PURPOSE This study aimed to examine the contribution of competing demands to changes in hypoglycemic medications and to return appointment intervals for patients with type 2 diabetes and an elevated glycosylated hemoglobin (A 1c ) level. METHODSWe observed 211 primary care encounters by adult patients with type 2 diabetes in 20 primary care clinics and documented changes in hypoglycemic medications. Competing demands were assessed from length of encounter, number of concerns patients raised, and number of topics brought up by the clinician. Days to the next scheduled appointment were obtained at patient checkout. Recent A 1c values and dates were determined from the chart. RESULTSAmong patients with an A 1c level greater than 7%, each additional patient concern was associated with a 49% (95% confi dence interval, 35%-60%) reduction in the likelihood of a change in medication, independent of length of the encounter and most recent level of A 1c . Among patients with an A 1c level greater than 7% and no change in medication, for every additional minute of encounter length, the time to the next scheduled appointment decreased by 2.8 days (P = .001). Similarly, for each additional 1% increase in A 1c level, the time to the next scheduled appointment decreased by 8.6 days (P = .001). CONCLUSIONSThe concept of clinical inertia is limited and does not fully characterize the complexity of primary care encounters. Competing demands is a principle for constructing models of primary care encounters that are more congruent with reality and should be considered in the design of interventions to improve chronic disease outcomes in primary care settings. 2007;5:196-201. DOI: 10.1370/afm.679. Ann Fam Med INTRODUCTIONA lthough tight glucose control can prevent or delay the onset of complications in patients with type 2 diabetes mellitus, 1-3 optimal control is frequently not achieved. [4][5][6] Recently, poor glucose control has been attributed to so-called clinical inertia on the part of physicians, defi ned as "recognition of the problem, but failure to act." [7][8][9][10][11][12] Some have even proposed methods for a measure of clinical inertia as a quality of care indicator. 13 The phenomenon of clinical inertia has been diffi cult to study because of the paucity of data on the content of the patient-physician encounter. All published studies of clinical inertia to date have used administrative or medical record data.An alternative explanation for failure to intensify therapy despite poor glucose control is the presence of competing demands.14-18 Encounters are bounded by a time constraint within which multiple diagnoses, problems, and patient concerns compete with each other for a place on the agenda. Physicians and patients prioritize demands and only deal with the most pressing or symptomatic problem.14 Problems perceived to be less urgent, for example, intensifying medication therapy for poorly controlled glycosylated hemoglobin (A 1c 1. As the length of the encounter decreases, the likelihood of a change in hy...

BackgroundPractice facilitation (PF) is an implementation strategy now commonly used in primary care settings for improvement initiatives. PF occurs when a trained external facilitator engages and supports the practice in its change efforts. The purpose of this group-randomized trial is to assess PF as an intervention to improve the delivery of chronic illness care in primary care.MethodsA randomized trial of 40 small primary care practices who were randomized to an initial or a delayed intervention (control) group. Trained practice facilitators worked with each practice for one year to implement tailored changes to improve delivery of diabetes care within the Chronic Care Model framework. The Assessment of Chronic Illness Care (ACIC) survey was administered at baseline and at one-year intervals to clinicians and staff in both groups of practices. Repeated-measures analyses of variance were used to assess the main effects (mean differences between groups) and the within-group change over time.ResultsThere was significant improvement in ACIC scores (p < 0.05) within initial intervention practices, from 5.58 (SD 1.89) to 6.33 (SD 1.50), compared to the delayed intervention (control) practices where there was a small decline, from 5.56 (SD 1.54) to 5.27 (SD 1.62). The increase in ACIC scores was sustained one year after withdrawal of the PF intervention in the initial intervention group, from 6.33 (SD 1.50) to 6.60 (SD 1.94), and improved in the delayed intervention (control) practices during their one year of PF intervention, from 5.27 (SD 1.62) to 5.99 (SD 1.75).ConclusionsPractice facilitation resulted in a significant and sustained improvement in delivery of care consistent with the CCM as reported by those involved in direct patient care in small primary care practices. The impact of the observed change on clinical outcomes remains uncertain.Trial registrationThis protocol followed the CONSORT guidelines and is registered per ICMJE guidelines: Clinical Trial Registration Number: NCT00482768.

OBJECTIVE—The purpose of this study was to examine the relationship between A1C and the extent to which care delivered to patients with type 2 diabetes in primary care clinics is consistent with the chronic care model (CCM), after controlling for self-care behaviors. RESEARCH DESIGN AND METHODS—This was a cross-sectional, observational study of care provided to 618 patients with type 2 diabetes across 20 small, autonomous primary care clinics in South Texas. Subjects completed an exit survey. The medical record was abstracted for A1C values. Clinicians completed the Assessment of Chronic Illness Care (ACIC) survey, a validated measure of the extent to which care delivered is consistent with the CCM. RESULTS—There was a significant relationship between ACIC score and A1C, but this relationship varied according to self-care behavior for exercise and was strongest for those who did not adhere to exercise recommendations: for every 1-point increase in ACIC score, A1C was 0.144% lower (P &lt; 0.001). The relationship between ACIC score and A1C for those who adhered to their diet was similar to that for those who did not, after adjusting for exercise, but the overall level of control was better for those who adhered to their diet. CONCLUSIONS—Characteristics of the primary care clinic where one receives care are an important predictor of glucose control. If resources for implementing the CCM are limited, one might want to focus on clinics with low ACIC scores that serve a population of patients who are sedentary because this population may be likely to realize the most benefit from improved glucose control.

PURPOSE Interventions tailored to sociopsychological factors associated with health behaviors have promise for reducing colorectal cancer screening disparities, but limited research has assessed their impact in multiethnic populations. We examined whether an interactive multimedia computer program (IMCP) tailored to expanded health belief model sociopsychological factors could promote colorectal cancer screening in a multiethnic sample. METHODSWe undertook a randomized controlled trial, comparing an IMCP tailored to colorectal cancer screening self-efficacy, knowledge, barriers, readiness, test preference, and experiences with a nontailored informational program, both delivered before office visits. The primary outcome was record-documented colorectal cancer screening during a 12-month follow-up period. Secondary outcomes included postvisit sociopsychological factor status and discussion, as well as clinician recommendation of screening during office visits. We enrolled 1,164 patients stratified by ethnicity and language (49.3% non-Hispanic, 27.2% Hispanic/English, 23.4% Hispanic/Spanish) from 26 offices around 5 centers (Sacramento, California; Rochester and the Bronx, New York; Denver, Colorado; and San Antonio, Texas). RESULTSAdjusting for ethnicity/language, study center, and the previsit value of the dependent variable, compared with control patients, the IMCP led to significantly greater colorectal cancer screening knowledge, self-efficacy, readiness, test preference specificity, discussion, and recommendation. During the followup period, 132 (23%) IMCP and 123 (22%) control patients received screening (adjusted difference = 0.5 percentage points, 95% CI -4.3 to 5.3). IMCP effects did not differ significantly by ethnicity/language. CONCLUSIONS Sociopsychological factor tailoring was no more effective than nontailored information in encouraging colorectal cancer screening in a multiethnic sample, despite enhancing sociopsychological factors and visit behaviors associated with screening. The utility of sociopsychological tailoring in addressing screening disparities remains uncertain. 2014;204-214. doi: 10.1370/afm.1623. Ann Fam Med INTRODUCTIONC olorectal cancer screening is underutilized.1,2 Screening rates are particularly low among Hispanic persons, reflecting language and socioeconomic barriers. 1,3 Approaches to motivate more individuals to undergo colorectal cancer screening and lessen ethnic screening disparities are needed.Interventions tailored to sociopsychological factors that may influence behavior, such as self-efficacy, stage of readiness, barriers, and others, 4 show promise.5 Such interventions use responses elicited from individuals to match the content and amount of information to individual needs and sociopsychological factors, with the proximate goal of enhancing the factors. [6][7][8] Tailoring of information increases its perceived relevance, promotes deeper cognitive processing, and improves recall. 9 Further, in randomized controlled trials tailored interventions are more eff...

Background: Most patients with type 2 diabetes have suboptimal control of their glucose, blood pressure (BP), and lipids -three risk factors for diabetes complications. Although the chronic care model (CCM) provides a roadmap for improving these outcomes, developing theoretically sound implementation strategies that will work across diverse primary care settings has been challenging. One explanation for this difficulty may be that most strategies do not account for the complex adaptive system (CAS) characteristics of the primary care setting. A CAS is comprised of individuals who can learn, interconnect, self-organize, and interact with their environment in a way that demonstrates non-linear dynamic behavior. One implementation strategy that may be used to leverage these properties is practice facilitation (PF). PF creates time for learning and reflection by members of the team in each clinic, improves their communication, and promotes an individualized approach to implement a strategy to improve patient outcomes.

BackgroundLittle is known as to whether primary care teams’ perceptions of how well they have implemented the Chronic Care Model (CCM) corresponds with their patients’ own experience of chronic illness care. We examined the extent to which practice members’ perceptions of how well they organized to deliver care consistent with the CCM were associated with their patients’ perceptions of the chronic illness care they have received.MethodsAnalysis of baseline measures from a cluster randomized controlled trial testing a practice facilitation intervention to implement the CCM in small, community-based primary care practices. All practice “members” (i.e., physician providers, non-physician providers, and staff) completed the Assessment of Chronic Illness Care (ACIC) survey and adult patients with 1 or more chronic illnesses completed the Patient Assessment of Chronic Illness Care (PACIC) questionnaire.ResultsTwo sets of hierarchical linear regression models accounting for nesting of practice members (N = 283) and patients (N = 1,769) within 39 practices assessed the association between practice member perspectives of CCM implementation (ACIC scores) and patients’ perspectives of CCM (PACIC). ACIC summary score was not significantly associated with PACIC summary score or most of PACIC subscale scores, but four of the ACIC subscales [Self-management Support (p < 0.05); Community Linkages (p < 0.02), Delivery System Design (p < 0.02), and Organizational Support (p < 0.02)] were consistently associated with PACIC summary score and the majority of PACIC subscale scores after controlling for patient characteristics. The magnitude of the coefficients, however, indicates that the level of association is weak.ConclusionsThe ACIC and PACIC scales appear to provide complementary and relatively unique assessments of how well clinical services are aligned with the CCM. Our findings underscore the importance of assessing both patient and practice member perspectives when evaluating quality of chronic illness care.Trial registrationNCT00482768

Improving health among people living in poverty often transcends narrowly focused illness care. Meaningful success is unlikely without confronting the complex social origins of illness. We describe an emerging community of solution to improve health outcomes for a population of 6000 San Antonio, Texas, residents enrolled in a county health care program. The community of solution comprises a county health system, a family medicine residency program, a metropolitan public health department, and local nonprofit organizations and businesses. Community-based activities responding to the needs of individuals and their neighborhoods are driven by a cohort of promotores (community health workers) whose mission encompasses change at both the individual and community levels.

Objective Tailoring to psychological constructs (e.g. self-efficacy, readiness) motivates behavior change, but whether knowledge tailoring alone changes healthcare preferences - a precursor of behavior change in some studies - is unknown. We examined this issue in secondary analyses from a randomized controlled trial of a tailored colorectal cancer (CRC) screening intervention, stratified by ethnicity/language subgroups (Hispanic/Spanish, Hispanic/English, non-Hispanic/English). Methods Logistic regressions compared effects of a CRC screening knowledge-tailored intervention versus a non-tailored control on preferences for specific test options (fecal occult blood or colonoscopy), in the entire sample (N = 1164) and the three ethnicity/language subgroups. Results Pre-intervention, preferences for specific tests did not differ significantly between study groups (experimental, 64.5%; control 62.6%). Post-intervention, more experimental participants (78.6%) than control participants (67.7%) preferred specific tests (P <0.001). Adjusting for pre-intervention preferences, more experimental group participants than control group participants preferred specific tests post-intervention [average marginal effect (AME) = 9.5%, 95% CI 5.3-13.6; P <0.001]. AMEs were similar across ethnicity/language subgroups. Conclusion Knowledge tailoring increased preferences for specific CRC screening tests across ethnic and language groups. Practice Implications If the observed preference changes are found to translate into behavior changes, then knowledge tailoring alone may enhance healthy behaviors.