Journal of Primary Care & Community Health

Introduction: Tobacco use is the leading behavioral cause of death among adults 25 years or older. American Indian (AI) and Alaska Native (AN) communities confront some of the highest rates of tobacco use and of its sequelae. Primary care–based screening of adolescents is an integral step in the reduction of tobacco use, yet remains virtually unstudied. We examined whether delivery of tobacco screening in primary care visits is associated with patient and provider characteristics among AI/AN adolescents. Methods: We used a cross-sectional analysis to examine tobacco screening among 4757 adolescent AI/AN patients served by 56 primary care providers at a large tribally managed health system between October 1, 2011 and May 31, 2014. Screening prevalence was examined in association with categorical patient characteristics (gender, age, clinic visited, insurance coverage) and provider characteristics (gender, age, tenure) using multilevel logistic regressions with individual provider identity as the nesting variable. Results: Thirty-seven percent of eligible patients were screened. Gender of both providers and patients was associated with screening. Male providers delivered screening more often than female providers (odds ratio [OR] 1.6, 95% confidence interval [CI] 0.7-3.9). Male patients had 20% lower odds of screening receipt (OR 0.8, 95% CI 0.7-0.9) than female patients, independent of patient age and provider characteristics. Individual provider identity significantly contributed to variability in the mixed-effects model (variance component 2.2; 95% CI 1.4-3.4), suggesting individual provider effect. Conclusions: Low tobacco screening delivery by female providers and the low receipt of screening among younger, male patients may identify targets for screening interventions.

Objectives: To determine the prevalence of frailty in patients with chronic lung diseases. Methods: We studied 120 patients with chronic lung disease using Fried’s criteria (gait speed, weight loss, exhaustion, grip strength, and physical activity). Results: The study population (56% women) had a mean age of 64 ± 13 years, mean body mass index of 31± 9 kg/m², and a mean FEV₁ (forced expiratory volume in 1 second) of 60% ± 25% of predicted. The average gait speed was 52.1 ± 14.3 m/min; 18% were frail, 64% prefrail, and 18% robust. Gait speed correlated with frailty status and decreased as frailty worsened (57 m/min in robust subjects and 41 m/min in frail subjects). Slow gait speeds (<60 m/min) had a 95% sensitivity and 34% specificity to predict frailty. Conclusions: Patients with chronic lung disease frequently meet Fried’s criteria for frailty. Gait speed can be used to screen these patients to determine if a more detailed evaluation is needed.

Objective: This study aimed to examine the impact of a Stop Smoking Before Surgery (SSBS) program in a health authority where responsibility for surgical services is shared by health professionals in regional centers and outlying communities. Methods: A between-subjects, pre-post mixed method program evaluation was conducted. Elective surgery patients at 2 Northern Canadian hospitals were recruited and surveyed at 2 time points: pre-SSBS implementation (n = 150) and 1 year post-SSBS implementation (n = 90). In addition, semistructured interviews were conducted with a purposeful sample of participants (n = 18). Results: Participants who received information about stopping smoking before surgery post-SSBS implementation were more likely than expected to have reduced their smoking, χ²(1, 89) = 10.62, P = .001, and had a significantly higher Awareness of Smoking-Related Perioperative Complications score than those that were advised to quit smoking prior to SSBS implementation (U = 1288.0, P < .001). Being advised by a health care professional was the second strongest predictor of whether or not participants reduced their smoking before surgery post-SSBS implementation. However, there was no significant change in the number of participants who reported being advised to quit smoking before surgery between groups. Conclusion: Providing surgery-specific resources to increase awareness of and support for surgery-specific smoking cessation had limited success in this rural context. Additional strategies are needed to ensure that every surgical patient who smokes receives information about the benefits of quitting for surgery and is aware of available cessation resources.

Objectives: This study surveyed Israeli primary care physicians’ attitudes and practice regarding postpartum depression (PPD). Methods: Participants included 224 pediatricians and family practitioners responding to an online survey (65% response rate). Results: Almost all respondents (98.0%) considered it important that they be able to recognize the signs of PPD. Most (89.8%) noted that if they suspected PPD, they would become somewhat involved: clarifying, keeping attentive, consulting with colleagues, and/or referring the woman to another professional. Six respondents—only family practitioners—stated that they would treat the case themselves (P = .01). Family practitioners were significantly more willing to screen for PPD than were pediatricians (91.2% vs 64.6%; P < .0001). There were no differences between physicians by region or between males and females when comparing all respondents, as well as when comparing within medical specialty (P < .05). Conclusions: There is a clear difference between considering the importance of recognizing signs of PPD and acting on it. Family practitioners had more favorable attitudes than did pediatricians, however screening in pediatric facilities is considered by many to be optimal. Hopefully future directions for medical education and health policy for family practitioners and pediatricians, as well as obstetrician/gynecologists, will meet the challenge of early identification and treatment of PPD for the benefit of women, infants and families.

Background: In August 2012, the Centers for Disease Control and Prevention released recommendations to screen persons born from 1945 to 1965 for hepatitis C virus (HCV). In September 2012, Warm Springs Health and Wellness Center (WSHWC) initiated a quality improvement (QI) project to conduct HCV screening among all patients in this birth cohort. Methods: Screening rates were tracked using a nationally standardized HCV screening measure in the Indian Health Service. At the end of the project period, WSHWC staff took a brief survey to review the impact of the HCV QI Project. Results: Screening for HCV among eligible patients at WSHWC increased from 5% (47/938) in September 2012 to 76% (593/785) in September 2014. Survey data indicated that clinicians felt increased screening for HCV had a positive impact on patient communication and care. Conclusions: Primary care clinics can successfully increase HCV screening in a relatively short time period. Age based screening recommendation may provide opportunities to increase communication with others at risk for HCV. As more patients are screened, it will be important to ensure appropriate linkage to care for HCV patients.

There are an estimated 3.5 million Muslims in North America. During the holy month of Ramadan, healthy adult Muslims are to fast from predawn to after sunset. While there are exemptions for older and sick adults, many adults with diabetes fast during Ramadan. However, there are risks associated with fasting and specific management considerations for patients with diabetes. We evaluated provider practices and knowledge regarding the management of patients with diabetes who fast during Ramadan. A 15-question quality improvement survey based on a literature review and the American Diabetes Association guidelines was developed and offered to providers at the outpatient primary care and geriatric clinics at an inner-city hospital in New York City. Forty-five providers completed the survey. Most respondents did not ask their Muslim patients with diabetes if they were fasting during the previous Ramadan. Knowledge of fasting practices during Ramadan was variable, and most felt uncomfortable managing patients with diabetes during Ramadan. There is room for improvement in educating providers about specific cultural and medical issues regarding fasting for patients with diabetes during Ramadan.

Missed appointments have been linked to adverse outcomes known to affect racial/ethnic minorities. However, the association of missed appointments with race/ethnicity has not been determined. We sought to determine the relationships between race/ethnicity and missed appointments by performing a cross-sectional study of 161 350 patients in a safety net health system. Several race/ethnicity categories were significantly associated with missed appointment rates, including Hispanic/Latino patients, American Indian/Alaskan Native patients, and Black/African American patients, as compared with White non-Hispanic patients. Other significant predictors included Mexico as country of origin, medical complexity, and major mental illness. We recommend additional research to determine which interventions best reduce missed appointments for minority populations in order to improve the care of vulnerable patients.

Objective: To assess relationships between primary care work conditions, physician burnout, quality of care, and medical errors. Methods: Cross-sectional and longitudinal analyses of data from the MEMO (Minimizing Error, Maximizing Outcome) Study. Two surveys of 422 family physicians and general internists, administered 1 year apart, queried physician job satisfaction, stress and burnout, organizational culture, and intent to leave within 2 years. A chart audit of 1795 of their adult patients with diabetes and/or hypertension assessed care quality and medical errors. Key Results: Women physicians were almost twice as likely as men to report burnout (36% vs 19%, P < .001). Burned out clinicians reported less satisfaction (P < .001), more job stress (P < .001), more time pressure during visits (P < .01), more chaotic work conditions (P < .001), and less work control (P < .001). Their workplaces were less likely to emphasize work-life balance (P < .001) and they noted more intent to leave the practice (56% vs 21%, P < .001). There were no consistent relationships between burnout, care quality, and medical errors. Conclusions: Burnout is highly associated with adverse work conditions and a greater intention to leave the practice, but not with adverse patient outcomes. Care quality thus appears to be preserved at great personal cost to primary care physicians. Efforts focused on workplace redesign and physician self-care are warranted to sustain the primary care workforce.

Background: Difficulty taking essential medications as prescribed is a prevalent problem among people living with chronic diseases. Numerous interventions to enhance medication adherence have been developed; the majority facilitated by health care professionals. Objective: This review examined medication adherence interventions delivered by peers (ie, lay individuals living with the same chronic disease) and reports what is known about the impact of peer-facilitated interventions. Data Sources: PubMed, CINAHL, Google Scholar, Google, and PsychInfo, and ancestry searches. Study Selection: Solely peers delivered the intervention and follow-up occurred for at least 24 weeks postintervention. Electronic databases were searched from their start date to December 31, 2014. Results: Eleven studies were located that reported 10 different interventions focused on 6 chronic disease conditions. Most interventions were delivered in clinical settings and grounded in a theoretical framework. Formats were evenly split between individual and group level, with one intervention using both. Length of training for the interventionists and the number of intervention sessions that subjects received varied across studies. Limitations: Self-report was frequently used as a measure of adherence. Biomarkers were sometimes used to assess medication adherence; however, lifestyle modification may have also affected biomarker levels. Conclusions: Overall, the interventions had positive effects and attrition was quite low. Peer-facilitated interventions appear to enhance medication adherence as well as other healthful behaviors, such as exercise.