Masahito Jimbo

A meta-analysis of pedometer-based walking interventions and weight loss

PURPOSE Cross-sectional studies show that individuals who walk more tend to be thinner than those who walk less. This does not mean, however, that the association between higher step counts and lower weight is causal or that encouraging sedentary individuals to increase step counts helps them lose weight. METHODS In this meta-analysis, we searched 6 electronic databases and contacted pedometer experts to identify pedometer-based walking studies without a dietary intervention that reported weight change as an outcome. We included randomized controlled trials and prospective cohort studies published after January 1, 1995, in either English or Japanese, with 5 or more adult participants and at least 1 cohort enrolled in a pedometer-based walking intervention lasting at least 4 weeks. RESULTS Nine studies met the study inclusion criteria. Cohort sample size ranged from 15 to 106, for a total of 307 participants, 73% of whom were women and 27% of whom were men. The duration of the intervention ranged from 4 weeks to 1 year, with a median duration of 16 weeks. The pooled estimate of mean weight change from baseline using a fixed-effects model and combining data from all 9 cohorts was −1.27 kg (95% confidence interval, −1.85 to −0.70 kg). Longer intervention duration was associated with greater weight change. On average, participants lost 0.05 kg per week during the interventions. CONCLUSION Pedometer-based walking programs result in a modest amount of weight loss. Longer programs lead to more weight loss than shorter programs.

Using pharmacy data to identify those with chronic conditions in Emilia Romagna, Italy.

Background and objectives: Automated pharmacy data have been used to develop a measure of chronic disease status in the general population. The objectives of this project were to refine and apply a model of chronic disease identification using Italian automated pharmacy data; to describe how this model may identify patterns of morbidity in Emilia Romagna, a large Italian region; and to compare estimated prevalence rates using pharmacy data with those available from a 2000 Emilia Romagna disease surveillance study. Methods: Using the Chronic Disease Score, a list of chronic conditions related to the consumption of drugs under the Italian pharmaceutical dispensing system was created. Clinical review identified medication classes within the Italian National Therapeutic Formulary that were linked to the management of each chronic condition. Algorithms were then tested on pharmaceutical claims data from Emilia Romagna for 2001 to verify the applicability of the classification scheme. Results: Thirty-one chronic condition drug groups (CCDGs) were identified. Applying the model to the pharmacy data, approximately 1.5 million individuals (37.1%) of the population were identified as having one or more of the 31 CCDGs. The 31 CCDGs accounted for 77% (E556 million) of 2001 pharmaceutical expenditures. Cardiovascular diseases, rheumatological conditions, chronic respiratory illness, gastrointestinal diseases and psychiatric diseases were the most frequent chronic conditions. External validation comparing rates of the diseases found through using pharmacy data with those of a 2000 Emilia Romagna disease surveillance study showed similar prevalence of illness. Conclusions: Using Italian automated pharmacy data, a measure of population-based chronic disease status was developed. Applying the model to pharmaceutical claims from Emilia Romagna 2001, a large proportion of the population was identified as having chronic conditions. Pharmacy data may be a valuable alternative to survey data to assess the extent to which large populations are affected by chronic conditions.

Reasons patients with a positive fecal occult blood test result do not undergo complete diagnostic evaluation.

PURPOSE Screening for fecal occult blood reduces colorectal cancer mortality by identifying patients with positive results for complete diagnostic evaluation (CDE). CDE rates are suboptimal, however. We sought to determine common reasons for nonperformance of a CDE as recorded by the primary care physician. METHODS We undertook a descriptive analysis of reasons reported by physicians for nonperformance of CDE in a nested sample of patients with positive fecal occult blood test (FOBT) results from a randomized controlled trial designed to evaluate the impact of a physician intervention (CDE reminder-feedback and educational outreach) on recommendation and performance rates in primary care practices. Inspection of administrative data for 1,468 patients with positive results showed that 661 (45%) did not undergo CDE. We reviewed patient follow-up forms, which were completed by physicians for patients who did not have a CDE, to identify reasons for nonperformance. RESULTS Nonperformance of CDE was due to physician decision for 217 patients (33%). In 123 patients (19%), reasons for nonperformance were compatible with the guidelines, and in 94 patients (14%), they were not. Reasons wholly or partially due to factors other than physician decision were noted in 212 patients (32%); physician action was considered to be appropriate in these patients. For the 232 patients (35%) without a clearly documented reason for CDE nonperformance, the appropriateness of the physicians’ action could not be determined. CONCLUSIONS Decision making by primary care physicians had a major effect on nonperformance of CDE after a positive FOBT result. Colorectal cancer screening programs should include guidance for physicians about when a CDE should and should not be performed.

Impact of a Generalizable Reminder System on Colorectal Cancer Screening in Diverse Primary Care Practices: A Report From the Prompting and Reminding at Encounters for Prevention Project

Background:Computerized reminder systems (CRS) show promise for increasing preventive services such as colorectal cancer (CRC) screening. However, prior research has not evaluated a generalizable CRS across diverse, community primary care practices. We evaluated whether a generalizable CRS, ClinfoTracker, could improve screening rates for CRC in diverse primary care practices. Methods:The study was a prospective trial to evaluate ClinfoTracker using historical control data in 12 Great Lakes Research In Practice Network community-based, primary care practices distributed from Southeast to Upper Peninsula Michigan. Our outcome measures were pre- and post-study practice-level CRC screening rates among patients seen during the 9-month study period. Ability to maintain the CRS was measured by days of reminder printing. Field notes were used to examine each practices cohesion and technology capabilities. Results:All but one practice increased their CRC screening rates, ranging from 3.3% to 16.8% improvement. t tests adjusted for within practice correlation showed improvement in screening rates across all 12 practices, from 41.7% to 50.9%, P = 0.002. Technology capabilities impacted printing days (74% for high technology vs. 45% for low technology practices, P = 0.01), and cohesion demonstrated an impact trend for screening (15.3% rate change for high cohesion vs. 7.9% for low cohesion practices). Conclusions:Implementing a generalizable CRS in diverse primary care practices yielded significant improvements in CRC screening rates. Technology capabilities are important in maintaining the system, but practice cohesion may have a greater influence on screening rates. This work has important implications for practices implementing reminder systems.

Information Technology and Cancer Prevention

Information technology is rapidly advancing and making its way into many primary care settings. The technology may provide the means to increase the delivery of cancer preventive services. The aim of this systematic review is to examine the literature on information technology impacts on the delivery of cancer preventive services in primary care offices. Thirty studies met our selection criteria. Technology interventions studied to date have been limited to some type of reminder to either patients or providers. Patient reminders have been mailed before appointments, mailed unrelated to an appointment, mailed after a missed appointment, or given at the time of an appointment. Telephone call interventions have not used technology to automate the calls. Provider interventions have been primarily computer‐generated reminders at the time of an appointment. However, there has been limited use of computer‐generated audits, feedback, or report cards. The effectiveness of information technology on increasing cancer screening was modest at best. The full potential of information technology to unload the provider‐patient face‐to‐face encounter has not been examined. There is critical need to study these new technologic approaches to understand the impact and acceptance by providers and patients.

Evaluation and management of hematuria.

Causes of hematuria can range from benign conditions such as urinary tract infection to serious conditions such as bladder cancer. In evaluating a patient with hematuria, 3 questions must be answered by the primary care physician: (1) Is it really hematuria? (2) Should this patient with hematuria be worked up, and if so, how? (3) Should this patient with hematuria be referred, and if so, to which specialty? This article addresses these questions. Because uniformly high-quality studies are lacking, the recommendations included in this article are mostly based on expert consensus.

Communication preference moderates the effect of a tailored intervention to increase colorectal cancer screening among African Americans

OBJECTIVE Test the impact of tailoring CRC screening messages for African Americans (AAs) using novel theoretical variables and to examine moderating effect of communication preferences. METHODS Participants were randomized to receive two minimally tailored or two enhanced tailored print newsletters addressing CRC. The enhanced intervention was tailored on Self-Determination Theory and other novel psychological constructs. Minimal tailoring only used information available in the patients EHR. The primary outcome was CRC screening based on EHR. Participants were AA members aged 50-74 of an integrated health care delivery system not up to date on CRC screening. RESULTS We enrolled 881 participants. CRC screening participation rates at 1-year follow up were 20.5% and 21.5% in the minimally and enhanced tailored groups, respectively. Communication preferences moderated the impact of the intervention. Specifically, among those with an autonomous communication preference, screening rates in the minimally and enhanced tailored groups were 17.1% and 25.9%, respectively, while no intervention effect was evident among those with a directive preference. CONCLUSION Future research is needed to explore the impact of communication preference tailoring for other health behaviors and among other populations. PRACTICE IMPLICATIONS Tailored communications should consider communication style preference to help guide the content and tone of messages.

Diagnosis and office-based treatment of urinary incontinence in adults. Part two: treatment.

Urinary incontinence is a common problem in both men and women. In this review article we address treatment of the various forms of incontinence with conservative treatments, medical therapy, devices and surgery. The US Preventive Services Task Force, The Cochrane Database of Systematic Reviews, and PubMed were reviewed for articles focusing on urinary incontinence. Conservative therapy with education, fluid and food management, weight loss, timed voiding and pelvic floor physical therapy are all simple office-based treatments for incontinence. Medical therapy for incontinence currently is only available for urgency incontinence in the form of anticholinergic medication. Condom catheters, penile clamps, urethral inserts and pessaries can be helpful in specific situations. Surgical therapies vary depending on the type of incontinence, but are typically offered if conservative measures fail.

Diagnosis and Office Based Treatment of Urinary Incontinence in Adults: Part One Diagnosis and Testing

Urinary incontinence is a common problem in both men and women. This review article addresses its prevalence, risk factors, cost, the various types of incontinence, as well as how to diagnose them. The US Preventive Services Task Force, the Cochrane Database of Systematic Reviews, and PubMed were reviewed for articles focusing on urinary incontinence. Incontinence is a common problem with a high societal cost. It is frequently underreported by patients so it is appropriate for primary-care providers to screen all women and older men during visits. A thorough history and physical examination combined with easy office-based tests can often yield a clear diagnosis and rule out other transient illnesses contributing to the incontinence. Specialist referral is occasionally needed in specific situations before embarking on a treatment plan.

Perceived Barriers and Facilitators of Using a Web-Based Interactive Decision Aid for Colorectal Cancer Screening in Community Practice Settings: Findings From Focus Groups With Primary Care Clinicians and Medical Office Staff

Background Information is lacking about the capacity of those working in community practice settings to utilize health information technology for colorectal cancer screening. Objective To address this gap we asked those working in community practice settings to share their perspectives about how the implementation of a Web-based patient-led decision aid might affect patient-clinician conversations about colorectal cancer screening and the day-to-day clinical workflow. Methods Five focus groups in five community practice settings were conducted with 8 physicians, 1 physician assistant, and 18 clinic staff. Focus groups were organized using a semistructured discussion guide designed to identify factors that mediate and impede the use of a Web-based decision aid intended to clarify patient preferences for colorectal cancer screening and to trigger shared decision making during the clinical encounter. Results All physicians, the physician assistant, and 8 of the 18 clinic staff were active participants in the focus groups. Clinician and staff participants from each setting reported a belief that the Web-based patient-led decision aid could be an informative and educational tool; in all but one setting participants reported a readiness to recommend the tool to patients. The exception related to clinicians from one clinic who described a preference for patients having fewer screening choices, noting that a colonoscopy was the preferred screening modality for patients in their clinic. Perceived barriers to utilizing the Web-based decision aid included patients’ lack of Internet access or low computer literacy, and potential impediments to the clinics’ daily workflow. Expanding patients’ use of an online decision aid that is both easy to access and understand and that is utilized by patients outside of the office visit was described as a potentially efficient means for soliciting patients’ screening preferences. Participants described that a system to link the online decision aid to a computerized reminder system could promote a better understanding of patients’ screening preferences, though some expressed concern that such a system could be difficult to keep up and running. Conclusions Community practice clinicians and staff perceived the Web-based decision aid technology as promising but raised questions as to how the technology and resultant information would be integrated into their daily practice workflow. Additional research investigating how to best implement online decision aids should be conducted prior to the widespread adoption of such technology so as to maximize the benefits of the technology while minimizing workflow disruptions.