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PURPOSE Studies have often shown low rates of preventive counseling in primary care, and interventions aimed at improving counseling rates have had disappointing results. Using obesity as a case study, we looked for factors that infl uence clinicians' decisions to include preventive counseling in the brief primary care encounter.METHODS A sequential, mixed methods study was conducted among clinicians in RIOS (Research Involving Outpatient Settings) Net, a Southwestern US practice-based research network. Thirty primary care clinicians participated in in-depth interviews or analytic focus groups, and 75% of 195 network members responded to a survey used to estimate the frequency of factors infl uencing decisions to undertake preventive counseling. RESULTSClinicians described a complex set of factors that infl uence decisions to provide preventive counseling for obesity. These can be grouped into 2 sets of factors: (1) relatively stable factors that "set the stage" for the encounter, such as the clinician's life values, defi nitions of success, and the availability of community resources; and (2) factors that are more dynamic, exerting their infl uence "as the door opens" into the examination room. These factors include the patient's agenda and receptivity to the proposed counseling, as well as the presence of teachable moments. Clinician, patient, and external factors are found in both groups.CONCLUSIONS Clinician decisions to include obesity and other types of preventive counseling in the brief encounter refl ect the art and complexity of management of the encounter. Future efforts to enhance the delivery of preventive counseling will need to move beyond linear models of behavior change to recognize this complex environment. Ann Fam Med 2006;4:327-333. DOI: 10.1370/afm.566. INTRODUCTIONP reventive counseling services are an essential component of primary care. Nevertheless, research has consistently shown low rates of preventive services counseling in everyday primary care practice.1-6 Several well-documented barriers to preventive counseling delivery in the brief clinical encounter include lack of clinician self-effi cacy and knowledge, limited time, and poor reimbursement for preventive services. [7][8][9][10] Most interventions that have been tested in an attempt to improve the frequency of preventive counseling delivery have targeted these same barriers.11-13 Surprisingly, these interventions have had, in general, disappointing results.14-17 Indeed, even a strong inclination by the clinician to provide preventive counseling care does not ensure its delivery. 18 In light of these disappointing results and with the continued growth in importance of behavior-related conditions for which preventive counseling has an important role, the need to better understand the process of preventive counseling in the primary care encounter, as well as the reasons for its limited delivery, has become compelling. PR E V ENT IV E COUNSEL ING DECISIONAn important step toward understanding the process of preventive counse...

Limited health literacy is a common but often unrecognized problem associated with poor health outcomes. Well-validated screening tools are available to identify and provide the opportunity to intervene for at-risk patients in a resource-efficient manner. This is a multimethod study describing the implementation of a hospital-wide routine health literacy assessment at an academic medical center initiated by nurses in April 2014 and applied to all adult inpatients. Results were documented in the electronic health record, which then generated care plans and alerts for patients who screened positive. A nursing survey showed good ease of use and adequate patient acceptance of the screening process. Six months after hospital-wide implementation, retrospective chart abstraction of 1,455 patients showed that 84% were screened. We conclude that a routine health literacy assessment can be feasibly and successfully implemented into the nursing workflow and electronic health record of a major academic medical center.

The new rounding system has the potential to reduce waste and improve the quality of patient care while improving caregiver satisfaction and medical student teaching. Adaptive leadership skills will be required to overcome resistance to change. The use of athletic analogies can improve teamwork and facilitate the adoption of a systems approach to the delivery of patient care.

PURPOSEThe advent of Web-based survey tools has provided the investigator with an alternative to paper-based survey methods that in many instances may be less expensive to implement than traditional paper-based surveys. Newer technology, however, does not diminish the importance of obtaining an adequate response rate. METHODSWe analyzed response rate data obtained from a survey implemented across 3 practice-based research networks (PBRNs) in which the survey was fi rst implemented electronically with 5 rounds of electronic solicitation for an Internet-based questionnaire and then by 2 rounds of a paper-based version mailed only to nonresponders.RESULTS Overall, 24% of the total survey responses received were in the paper mode despite intense promotion of the survey in the electronic phase.CONCLUSIONS Our results suggest there is still an important role for the use of paper-based methods in PBRN survey research. Both hard copy and electronic survey collection methods may be required to enhance clinician response rates in PBRNs. INTRODUCTIONR esearch using surveys for data collection is common in practicebased research networks (PBRNs). The continuing growth of electronic communications, potential for cost savings, and more rapid results has created interest in Internet-based survey designs. Regardless of the method or technology used in performing a survey, it is clear that an adequate response rate is still critical to the scientifi c validity of survey fi ndings.1 Several investigators have shown that the mode of the survey measurably affects response rates in various biomedical venues.2 Our objective was to ascertain the value of a paper follow-up to an electronically based survey conducted on clinicians across 3 PBRNs . METHODSWe performed a secondary, retrospective analysis on data obtained from a completed survey on clinician attitudes toward the screening and treatment of hepatitis C. The survey was conducted in the Primary Care Multi-Ethnic Research Network (PRIME Net).3 At the time of this study, PRIME Net was a collaboration of W EB -BA SED A ND M A IL SURV E Y SThe survey instrument 7 consisted of 28 questions exploring clinicians' approaches to hepatitis C in their practices and available resources for care of patients infected with the hepatitis C virus.Invitations to participate in the survey were sent to all 805 active clinician members of the 3 PRIME Net PBRNs for whom a valid e-mail and postal address was available. Before the survey began, clinicians received 1 or more advance e-mail messages from their home PBRN describing the purpose of the survey and requesting participation.At the start of the survey, each clinician received a personalized e-mail solicitation from his or her home PBRN with a link to the Web-based version of the survey. The customized link had the target's unique identifying code embedded to provide automatic log-in and response identifi cation. We repeated the e-mail solicitation to nonresponders at intervals of 1 to 2 weeks for a total of 5 e-mail solicitations. ...

BackgroundThe recommendations of the American Board of Internal Medicine Foundation’s “Choosing Wisely®” initiative recognize the importance of improving the appropriateness of testing behavior and reducing the number of duplicate laboratory tests.ObjectiveTo assess the effectiveness of an electronic medical record Best Practice Alert (BPA or “pop up”) intervention aimed at reducing duplicate laboratory tests and hospital costs.DesignComparison of the number of duplicated laboratory tests performed on inpatients before and after the intervention.SettingUniversity of Florida Health Shands Hospital, Gainesville, FL, USA, during 2014–2017.InterventionThe electronic medical record intervention was a BPA pop-up alert that informed the ordering physician if a recent identical order already existed along with the “ordering time”, “collecting time”, “resulting time”, and the result itself.Main outcome measuresPercentage change in the number of inpatient duplicate orders of selected clinical biochemistry tests and cost savings from reduction of the duplicates. Student’s t-test and beta-binomial models were used to analyze the data.ResultsResults from the beta-binomial model indicated that the intervention reduced the overall duplicates by 18% (OR=0.82, standard error=0.016, P-value<0.000). Percent reductions in 9 of the 17 tests were statistically significant: serum hemoglobin A1C level, vitamin B12, serum erythrocyte sedimentation rate, serum folate, serum iron, lipid panel, respiratory viral panel, serum thyroid stimulating hormone level, and Vitamin D. Additionally, important cost savings were realized from the reduction of duplicates for each lab test (with the exception of CRP) with an estimated overall savings of $72,543 over 17 months in the post-intervention period.ConclusionsThe present study included all hospital inpatients and covered 17 clinical laboratory tests. This rather simple and low-cost intervention resulted in significant reductions in percentage duplicates of several tests and resulted in cost savings. The study also highlights the role of hospitalists in quality improvement.

ObjectiveTo estimate the prevalence of hypertension, diabetes and chronic kidney disease and their risk factors in a rural and urban region of Haiti.Setting and participantsCommunity health workers enumerated 2648 households (909 rural and 1739 urban) via a multistage cluster random sampling method from July 2015 to May 2016, completed 705 rural and 1419 urban assessments for adults aged 25–65 years.Outcome measuresWe performed a WHO STEPS based questionnaire, measured two blood pressure values, weight, height, abdominal circumference and point of care test finger stick blood sample for haemoglobin A1c, creatinine and cholesterol (total, high density lipoprotein (HDL) and triglycerides).ResultsAfter adjusting for age and sex, the overall prevalence rates of hypertension, diabetes and chronic kidney disease were 15.6% (±2.93%), 19.7% (±1.57%) and 12.3% (±2.72%), respectively. Of the three non-communicable diseases (NCDs), only diabetes showed a significant difference between rural and urban sites (p=0.000), with the rural site (23.1%) having a higher prevalence than the urban site (16.4%). When comparing male and female participants, females were significantly more likely than males to have an NCD (p≤0.011). Females had a higher prevalence of most of the risk factors when compared with males. The urban location had a higher prevalence than the rural location for four risk factors that showed a significant difference between location (p≤0.037).ConclusionsWomen in Haiti had significantly higher prevalence rates of most NCDs and risk factors than men, and urban populations frequently, but not always, had higher rates of NCDs risk factors than the rural population. Further, it was shown that using point of care blood tests combined with community health workers, it is feasible to screen for NCDs and risk factors in remote areas which otherwise have limited access to healthcare.