Library Watch - On Primary Care

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...on Primary Care

www.ProjectCork.org

Winter 2010

Smoking as a vital sign: Prompts to ask and assess increase cessation counseling.

McCullough A; Fisher M; Goldstein AO; Kramer KD; Ripley-Moffitt C. Journal of the American Board of Family Medicine 22(6): 625-632, 2009. (22 refs.)
Background: Strategies to improve smoking cessation counseling in clinical settings are critical to supporting smokers' attempts to quit. This study evaluates the impact of adding 2 smoking-related vital sign questions in an electronic medical records system on identification, assessment, and counseling for patients who smoke: "Current smoker?" and "Plan to quit?" Methods: Baseline data and data after intervention were collected through record review of 899 randomly selected patient visits across 3 outpatient clinics. Results: From before to after intervention, identification of smokers increased 18% (from 71% to 84%; P < .001), and assessment for a plan to quit increased 100% (from 25.5% to 51%; P < .005). Among all smokers, cessation counseling increased 26% (from 23.6% to 29.8%; P = .41). Significantly more smokers who received the assessment for a plan to quit received cessation counseling (46% vs. 14%, P < .001). Regression analysis showed that patients receiving an assessment for plan to quit were 80% more likely to receive cessation counseling (OR 0.209; 95% CI, 0.095-0.456). Conclusions: Physician-documented counseling rates are significantly higher when patients are asked about smoking and assessed for a plan to quit. Two questions that ask about smoking status and assess plans to quit may provide prompts to increase the likelihood that patients who smoke receive cessation counseling.

Best practices for smoking cessation interventions in primary care. (review).

McIvor A; Kayser J; Assaad JM; Brosky G; Demarest P; Desmarais P et al. Canadian Respiratory Journal 16(4): 129-134, 2009. (25 refs.)
BACKGROUND: In Canada, smoking is the leading preventable cause of premature death. Family physicians and nurse practitioners are uniquely positioned to initiate smoking cessation. Because smoking is a chronic addiction, repeated, opportunity based interventions are most effective in addressing physical dependence and modifying deeply ingrained patterns of beliefs and behaviour. However, only a small minority of family physicians provide thorough smoking cessation counselling and less than one-half offer adjunct support to patients. OBJECTIVE: To identify the key steps family physicians and nurse practitioners can take to strengthen effective smoking cessation interventions for their patients. METHODS: A Multidisciplinary panel of health care practitioners involved with smoking cessation from across Canada was convened to discuss best practices derived front international guidelines, including those from the United States, Europe, and Australia, and other relevant literature. The panellists subsequently refined their findings in the form of the present article. RESULTS: The present paper outlines best practices for brief and effective counselling for, and treatment of, tobacco addiction. By adopting a simple series of questions, taking 30 s to 3 min to complete, health care professionals can initiate smoking cessation interventions. Integrating, these strategies into daily practice provides opportunities to significantly improve the quality and duration of patients' lives. CONCLUSION: Tobacco addiction is the most important preventable cause of morbidity and mortality in Canada. Family physicians, nurse practitioners and other front-line health care professionals are well positioned to influence and assist their patients in quitting, thereby reducing the burden on both personal health and the public health care system.

Brief patient-centered clinician-delivered counseling for high-risk drinking: 4-year results.

Ockene JK; Reed GW; Reiff-Hekking S. Annals of Behavioral Medicine 37(3): 335-342, 2009. (19 refs.)
The purpose of this study is to determine the effect at 48 months of a screening and brief patient-centered physician- and nurse practitioner-delivered interven-tion implemented during a routine primary care visit on the reduction of alcohol consumption by high-risk drinkers. Participants seen in primary care practices previously randomized to special intervention (SI) or usual care (UC) were reconsented for long-term follow-up. From the initial cohort, 63% reconsented to participate and provided follow-up at 48 months between November 1996 and March 2002. The data for this paper were analyzed in June 2004. At 48 months, SI participants maintained significant reductions in drinks per week seen at 6 and 12 months. However, there were no longer significant differences in drinks per week, binges per month, percentage of low-risk drinking, relapse rates, and new quits between the SI and UC groups at 48 months that had been seen at earlier follow-up. There was a significant effect of prior low-risk drinking status at 12 months; those who were low-risk drinkers at 12 months were more likely to stay low-risk drinkers at 48 months regardless of treatment group. With a single brief intervention, SI participants had significantly greater reductions in their drinking levels at 6 and 12 months compared to UC participants and maintained the lower-risk levels at 48 months resulting in a reduction in health risk exposure time. However, the significant group differences in treatment effect seen in earlier follow-ups were not maintained.

Alcohol management strategies of college students with diabetes.

Ravert RD. Patient Education and Counseling 77(1): 97-102, 2009. (38 refs.)
Objective: Alcohol management strategies of college undergraduates with diabetes were Studied in order to identify which strategies were associated with decreased alcohol consumption and consequences. Methods: Data came from 450 undergraduates with diabetes who were among 90,000 students from 123 postsecondary institutions who completed the Spring, 2006 National College Health Assessment. Results: A majority of respondents (68.0%) reported alcohol use in the previous month, with 41.8% consuming five or more drinks in one sitting during the previous 2 weeks. High alcohol management strategy use in the past year was associated with fewer heavy drinking episodes and fewer alcohol-related consequences. Two strategies, avoiding drinking games and pacing one's drinking, were especially strong predictors of reduced consumption and consequences, and were More common among older students. Conclusion: Developing effective strategies to manage alcohol intake is especially important for students with diabetes due to short- and long-term hazards of excessive drinking. Practical implications: Alcohol use is a common aspect of college culture and may hold perceived social benefits for students. Healthcare clinicians should help students with diabetes to identify alcohol management strategies that are perceived as effective and feasible. Avoiding drinking games and pacing drinks appear to be strategies especially worthy of promotion.

General practitioners' management of psychostimulant drug misuse: Implications for education and training.

Alkhamis A; Matheson C; Bond C. Drugs: Education, Prevention and Policy 16(4): 343-354, 2009. (27 refs.)
Aims: To provide baseline data regarding GPs' knowledge, experience, and attitudes toward the management of PsychoStimulant Drug Misuse (PSDM) patients to inform future education and training initiatives. Methods: A structured cross-sectional postal questionnaire was developed following initial content setting interviews, piloted then sent to a sample of 250 GPs in north east Scotland. Findings: A 52.13% response rate was achieved after two reminders. Over 42% of GPs expressed uncertainty about their knowledge regarding PSDM. The majority were aware that some patients were using psychostimulant drugs (61.5%), and 62.7% thought this was increasing. More than half the GPs did not have experience in managing PSDM. Although 57% of respondents agreed that GPs should be involved over half (54.1%) were not personally willing to do so. Conclusion: GPs are aware of the rise in PSDM prevalence in their communities, but chose to keep their involvement minimal. The majority thought that the most suitable way to manage PSDM patients was primarily by specialist services with minimum input from them. A change in attitudes, education and guidance are necessary to encourage GPs to be more involved in the management of PSDM patients.

Attitudes, norms and controls influencing lifestyle risk factor management in general practice.

Ampt AJ; Amoroso C; Harris MF; McKenzie SH; Rose VK; Taggart JR. BMC Family Practice 10: e-59, 2009. (17 refs.)
Background: With increasing rates of chronic disease associated with lifestyle behavioural risk factors, there is urgent need for intervention strategies in primary health care. Currently there is a gap in the knowledge of factors that influence the delivery of preventive strategies by General Practitioners (GPs) around interventions for smoking, nutrition, alcohol consumption and physical activity (SNAP). This qualitative study explores the delivery of lifestyle behavioural risk factor screening and management by GPs within a 45-49 year old health check consultation. The aims of this research are to identify the influences affecting GPs' choosing to screen and choosing to manage SNAP lifestyle risk factors, as well as identify influences on screening and management when multiple SNAP factors exist. Methods: A total of 29 audio-taped interviews were conducted with 15 GPs and one practice nurse over two stages. Transcripts from the interviews were thematically analysed, and a model of influencing factors on preventive care behaviour was developed using the Theory of Planned Behaviour as a structural framework. Results: GPs felt that assessing smoking status was straightforward, however some found assessing alcohol intake only possible during a formal health check. Diet and physical activity were often inferred from appearance, only being assessed if the patient was overweight. The frequency and thoroughness of assessment were influenced by the GPs' personal interests and perceived congruence with their role, the level of risk to the patient, the capacity of the practice and availability of time. All GPs considered advising and educating patients part of their professional responsibility. However their attempts to motivate patients were influenced by perceptions of their own effectiveness, with smoking causing the most frustration. Active follow-up and referral of patients appeared to depend on the GPs' orientation to preventive care, the patient's motivation, and cost and accessibility of services to patients. Conclusion: General practitioner attitudes, normative influences from both patients and the profession, and perceived external control factors (time, cost, availability and practice capacity) all influence management of behavioural risk factors. Provider education, community awareness raising, support and capacity building may improve the uptake of lifestyle modification interventions.

Overview of interventions to enhance primary-care provider management of patients with substance-use disorders.

Anderson P. Drug and Alcohol Review 28(5): 567-574, 2009. (46 refs.)
Issues. Despite the evidence for the effectiveness and cost-effectiveness of interventions to manage substance use disorders, which are common presenting complaints in primary care, primary-care providers find managing substance use disorders a difficult business. This paper provides an overview of the evidence for interventions, including training and education programmes, in enhancing the management of alcohol- and tobacco-use disorders by health-care providers. Approach. The Cochrane Library and the database of the Cochrane Effective Practice and Organisation of Care Group were searched for answers to five questions: (i) Can education and training increase the involvement of primary care providers? (ii) Can education and training cause harm? (iii) Can education and training be enhanced with support and other organisational factors? (iv) Can finance systems change provider behaviour? and (v) Is political support needed? Key Findings. Education and training can increase the involvement of primary-care providers in managing alcohol- and tobacco-use disorders, with the impact enhanced by additional support and other organisational factors. There is some evidence that if education and training does not take account of providers' attitudes, then harm can be caused. There is limited evidence that finance systems can change provider behaviour, and that comprehensive policy, in which a health sector response is a part, can increase the potential of primary-care management of alcohol- and tobacco-use disorders. Conclusions. Tailored education and training programmes for the management of alcohol- and tobacco-use disorders need to be broadly implemented and embedded in overall comprehensive policies that provide the necessary organisational and financial incentives for enhancing provider behaviour. There is an urgent need to extend the evidence base on the impact of education and training and other strategies to increase the involvement of providers in managing substance-use disorders.

Smoking prevention and primary physician's and patient's characteristics.

Azuri J; Peled S; Kitai E; Vinker S. American Journal of Health Behavior 33(6): 710-717, 2009. (24 refs.)
Objective: To describe relationships between primary physician and patient characteristics and the approach to prevention and quitting of smoking. Methods: A questionnaire composed of descriptions of cases and clinic activities was given to primary physicians. Results: Fewer smoking physicians use written materials, yet former smokers more often recommend smoking cessation groups. Greatest efforts are invested in high-risk patients. However, former smokers invest greater efforts among youth and pregnant women. Workload and patient's main complaint exert great influence on raising the subject. Conclusions: The various attitudes of physicians emphasize the importance of physician education that should be according to their smoking habits.

The influence of gender on the doctor-patient interaction.

Bertakis KD. Patient Education and Counseling 76(3, Special Issue): 356-360, 2009. (23 refs.)
Objective: This paper discusses the research focused on gender issues in healthcare communication. Methods: The majority of papers discussed here are based on a research study in which 509 new adult patients were prospectively and randomly assigned to family practice or internal medicine clinics at a university medical center and followed for one year of care. Results: There are significant differences in the practice style behaviors of female and male doctors. Female doctors provide more preventive services and psychosocial counseling; male doctors spend more time on technical practice behaviors, such as medical history taking and physical examination. The patients of female doctors are more satisfied, even after adjusting for patient characteristics and physician practice style. Female patients make more medical visits and have higher total annual medical charges; their visits include more preventive services, less physical examination, and fewer discussions about tobacco, alcohol and other substance abuse (controlling for health status and sociodemographic variables). The examination of gender concordant and discordant doctor-patient dyads provides a unique strategy for assessing the effect of gender on what takes place during the medical visit. Conclusion: Doctor and patient gender can impact the physician-patient interaction and its outcomes. Practice implications: The development of appropriate strategies for the implementation of knowledge about physician and patient gender differences will be crucial for the delivery of high quality gender-sensitive healthcare.

Receipt of provider advice for smoking cessation and use of smoking cessation treatments among cancer survivors.

Coups EJ; Dhingra LK; Heckman CJ; Manne SL. Journal of General Internal Medicine 24(Supplement 2): 480-486, 2009. (35 refs.)
As the number of cancer survivors increases, the assessment and intervention for smoking among survivors are increasingly important. This study examined the extent to which cancer survivors reported being asked and advised about smoking by health-care providers and their use of smoking cessation treatments during quit attempts. The data were drawn from the 2005 National Health Interview Survey, an annual health survey of US adults. The participants were 1,825 individuals who reported being diagnosed with cancer at least 1 year previously and provided data regarding their current smoking status. Participants completed items assessing demographics, health and health-care factors, and smoking-related variables. More than three-quarters of participants (81.0%) reported that their smoking status was known by a health-care provider. Among current smokers (17.6%) who visited a health-care provider in the past year, 72.2% reported being advised to quit smoking by a provider. Factors associated with a higher rate of receiving advice to quit included greater cigarette consumption (P=0.008), more medical comorbidities (P= 0.001), high psychological distress (P= 0.003), and lack of health-care insurance (P = 0.03). Among current smokers who tried to quit in the last year, 33.5% used pharmacotherapy cessation treatment and 3.8% used an evidence-based behavioral treatment. This study reveals considerable missed opportunities for health-care providers to advise cancer survivors about smoking and provide evidence-based interventions. Systematic efforts are needed to increase the provision of smoking cessation advice and use of cessation treatments among cancer survivors.

Does gender matter? A vignette study of general practitioners' management skills in handling patients with alcohol-related problems.

Geirsson M; Hensing G; Spak F. Alcohol and Alcoholism 44(6): 620-625, 2009. (31 refs.)
Aims: The aims of this study were to analyse the perceptions of female and male primary care physicians (PCPs) of alcohol problems in male and female patients, their recommendations to reduce or abstain from alcohol, their referrals to treatment and their views of safe levels of drinking for male and female patients. These factors were related to the physicians' own alcohol consumption. Methods: A slightly adjusted version of the WHO Collaborative Study Questionnaire for General Practitioners was posted to all PCPs (n = 132) in the district of Skaraborg, Sweden, of whom 68 PCPs responded. In the questionnaire, the PCPs' perceptions of two patient vignettes were analysed. Results: Both the gender of the patients in the vignettes and of the PCPs influenced the advice and the referrals that the patients received: 83% of male excessive drinkers and 47% of female excessive drinkers were recommended to cut down on drinking. In 50% of cases, the male excessive drinker was not referred, compared with 25% for the female excessive drinker. This was statistically significant only for excessive drinkers. The odds ratio for referral to any treatment was 0.33 (CI = 0.12-0.93) for the male excessive drinker compared with the female excessive drinker. The male PCP referred the excessive drinker less often to any treatment than did the female PCP, odds ratio 0.26 (CI = 0.08-0.90). The upper limit of alcohol consumption before the PCPs would advise the patient to cut down was significantly higher for PCPs with the AUDIT-C score >= 3. The limit was 146 g/week for male patients and 103 g/week for female patients. Corresponding figures for PCP with the AUDIT-C score < 2 were 89 and 68 g/week. Conclusion: Male patients were less likely to be advised to stop drinking altogether than female patients and were less likely to be referred, according to this vignette study. Taking into account that male patients have a higher prevalence of alcohol problems, this may be of considerable importance for men's health outcomes. Implications of these findings are the need to increase awareness of male excessive drinking and that gendered perceptions might bias alcohol management recommendations.

Screening and brief interventions for hazardous and harmful alcohol use in primary care: A cluster randomised controlled trial protocol.

Kaner E; Bland M; Cassidy P; Coulton S; Deluca P; Drummond C et al. BMC Public Health 9(article 287), 2009. (47 refs.)
Background: There have been many randomized controlled trials of screening and brief alcohol intervention in primary care. Most trials have reported positive effects of brief intervention, in terms of reduced alcohol consumption in excessive drinkers. Despite this considerable evidence-base, key questions remain unanswered including: the applicability of the evidence to routine practice; the most efficient strategy for screening patients; and the required intensity of brief intervention in primary care. This pragmatic factorial trial, with cluster randomization of practices, will evaluate the effectiveness and cost-effectiveness of different models of screening to identify hazardous and harmful drinkers in primary care and different intensities of brief intervention to reduce excessive drinking in primary care patients. Methods and design: GPs and nurses from 24 practices across the North East (n = 12), London and South East (n = 12) of England will be recruited. Practices will be randomly allocated to one of three intervention conditions: a leaflet-only control group (n = 8); brief structured advice (n = 8); and brief lifestyle counselling (n = 8). To test the relative effectiveness of different screening methods all practices will also be randomised to either a universal or targeted screening approach and to use either a modified single item (M-SASQ) or FAST screening tool. Screening randomisation will incorporate stratification by geographical area and intervention condition. During the intervention stage of the trial, practices in each of the three arms will recruit at least 31 hazardous or harmful drinkers who will receive a short baseline assessment followed by brief intervention. Thus there will be a minimum of 744 patients recruited into the trial. Discussion: The trial will evaluate the impact of screening and brief alcohol intervention in routine practice; thus its findings will be highly relevant to clinicians working in primary care in the UK. There will be an intention to treat analysis of study outcomes at 6 and 12 months after intervention. Analyses will include patient measures (screening result, weekly alcohol consumption, alcohol-related problems, public service use and quality of life) and implementation measures from practice staff (the acceptability and feasibility of different models of brief intervention.) We will also examine organisational factors associated with successful implementation.