Methods: The sample included diabetic patients, aged 40 years and older, from the Central district of Clalit Health Service in Israel, with at least one HbA1c measure greater than 9.5 mg% during 2001. They were divided into 2 categories according to their HbA1c levels in 2003, well controlled (HbA1c <7.5 mg%) and poorly controlled (HbA1c >9.5 mg%). Patients with 7.5< HbA1c <9.5 in 2003 were excluded from analysis.

Results: Two thousand sixty-two diabetic patients met the inclusion criteria and care was provided by one of 249 primary care physicians. Of these patients, 1232 (41.6%) had well-controlled diabetes and 1760 (58.4%) had poorly controlled diabetes in 2003. The well-controlled group had fewer patients with low socioeconomic status (30.3% vs 41.9%; P < .001) and more men (52% vs 43.8%; P < .001). The individual primary care physician was the most significant predictor of good glycemic control. Total patient costs in 2004 were 8% lower among the group with well-controlled diabetes.

Conclusion: The primary care physician has an important role in the patient's chances of achieving glycemic control. Further investigation of how and why some primary care physicians achieve better diabetes control in their patients would be worthwhile.

Methods: We analyzed the National Health and Nutrition Examination Survey, 1999 to 2004, a nationally representative sample of the noninstitutionalized US population. Among adults (aged ≥20 years of age) who were not problem drinkers, we examined hepatitis B and C antibodies and the liver enzymes aspartate aminotransferase (AST), alanine aminotransferase (ALT), and glutamyl transaminase (GGT) with impaired fasting glucose and undiagnosed diabetes (unweighted, n = 5234; weighted, n = 172,626,805). Logistic regression models were computed controlling for major risk factors that drive diabetes screening, including age, gender, race, diagnosed hypertension, diagnosed hypercholesterolemia, and obesity.

Results: In unadjusted analyses 51% of individuals with undiagnosed diabetes have elevated GGT versus 20% of individuals without diabetes or impaired fasting glucose (P = .01). Similarly, 43% of individuals with undiagnosed diabetes have elevated ALT versus 23% of individuals without diabetes or impaired fasting glucose (P = .01). AST and Hepatitis C antibodies were not associated with undiagnosed diabetes. In adjusted analyses, elevated GGT (odds ratio, 2.15; 95% CI, 1.44–3.20) and ALT (odds ratio, 1.84; 95% CI, 1.06–3.20) are associated with undiagnosed diabetes. Similarly, in adjusted analyses, elevated GGT (odds ratio, 1.23; 95% CI, 1.00–1.53) and ALT (odds ratio, 1.44; 95% CI, 1.15–1.79) are associated with impaired fasting glucose. Hepatitis antibodies, reporting a current liver problem, or AST were associated with having undiagnosed diabetes in adjusted analyses.

Conclusions: Liver function is associated with undiagnosed diabetes and impaired fasting glucose and may justify further investigation as a risk stratification variable for undiagnosed diabetes or impaired fasting glucose.

Methods: We reviewed the screening records for service members who completed health risk assessments at Fort Lewis in Tacoma, WA, in 2004. The prevalence of hypertension and prehypertension were estimated from single recorded blood pressure readings and subjects’ reported use of blood pressure medications. Study subject characteristics associated with hypertension and prehypertension were examined by ² tests and multivariate logistic regression.

Results: Thirteen percent of the 15,391 subjects met the study definition for hypertension; 62% met the study definition for prehypertension. Increasing age and body mass index, male sex, black race/ethnicity, and senior rank were associated with hypertension; only body mass index, male sex, and senior rank were associated with prehypertension.

Conclusion: Hypertension and prehypertension are more prevalent in the US Armed Forces than has been previously reported, and prehypertension may be more common in the US Armed forces than in the general population. The high prevalence of prehypertension found in this young, fit population suggests a need to better define the risks and benefits associated with the diagnosis and treatment of prehypertension in low-risk populations.

Methods: This was a retrospective, time series analysis of 27 provider groups and managed care organizations from 1998 through 2006. Patients with hypertension were identified from more than 4000 physicians. Medical charts were collected and clinical data were evaluated using prevailing JNC criteria during the time period before and after JNC 7.

Results: A total of 19,258 patients were identified with hypertension: 15,258 included in the before-JNC 7 cohort and 4,000 in the after-JNC 7 cohort. BP control in the before-JNC 7 cohort was 40.8% compared with 49.3% in the after-JNC 7 cohort (P < .0001). After controlling for demographic and clinical covariates, patients in the before-JNC 7 cohort were 45% less likely to achieve BP control compared with the after-JNC 7 cohort (odds ratio, 0.551; P < .0001).

Conclusion: Although findings indicate BP control is improving, a significant need for further improvement remains.

Methods: Using a combination of practice enhancement assistants, computer decision-making support, and academic detailing, we sought to increase physician awareness and care of CKD in 2 inner-city practices. Using these 3 modalities, a rapid-cycle quality improvement process was implemented.

Results: One hundred eighty-one patients met the inclusion criteria of having a glomerular filtration rate <60. This represented a 100% sample of patients with CKD at baseline. Recognition of CKD improved significantly from 30 (21%) to 114 (79%) (P < .001). Diagnosis of anemia also increased significantly from 26 (33%) to 53 (67%) (P < .001). Angiotensin-converting enzyme inhibitor and aspirin use did not change significantly (P = .31 and P = .233, respectively). Changes in medications that did show significance were metformin use, which decreased 50% from 12 to 6 patients (P < .001), and nonsteroidal anti-inflammatory drug use, which decreased 41% from 23 to 14 patients (P < .001). Mean glomerular riltration rate increased significantly from 45.75 to 47.34 (P < .001).

Discussion: Recognition and treatment of CKD and its complications can be markedly improved in primary care offices using a combination of practice enhancement assistants, computer decision-making support, and academic detailing. A significant rise in glomerular riltration rate, although small, was a surprising and encouraging result. Larger studies in a more geographically spread region are needed to confirm these preliminary results.

Methods: This is a retrospective case series of 339 ESTs performed in a family medicine center from July 2001 to April 2005. EST results were classified as positive, negative, or equivocal. Outcomes studied from a review of outpatient and inpatient electronic medical record data and telephone follow-up included myocardial infarction, cardiac catheterization with angioplasty and stenting, coronary artery bypass grafting, a new diagnosis of coronary artery disease, and cardiac death. Mean duration of follow-up was 47 months, with a range of 27 to 72 months.

Results: Nearly all patients had low to intermediate risk pretest probability. Five tests were positive, 32 were equivocal, and 302 were negative. There were 2 false-positive tests, both in female patients. There were 2 false-negative tests, both of which were treated with good outcomes. Two of 32 equivocal results had cardiac outcomes. Considering equivocal tests as positive, the overall sensitivity in this series was 71.4%; specificity was 90.4%. The positive predictive value was 13.5% and the negative predictive value was 99.3%.

Conclusions: The high negative predictive value for EST in this outpatient family medicine population is noteworthy and reassuring. EST is a cost-effective strategy for triaging the common complaint of chest pain in low- to intermediate-risk patients in primary care practices and should be included in the services offered to family medicine patients.

Methods: We developed a questionnaire based on eating behaviors associated with overweight and obesity. After pilot testing and revision, we administered the questionnaire to patients in 2 primary care clinics from the Utah Health Research Network. We analyzed the relationship between measured body mass index, demographic factors, and responses to screening questions about eating behaviors and physical activity.

Results: We collected 261 completed questionnaires with weight and height measurements. With regression analysis, questions about consumption of beverages with sugar added, fruits and vegetables, and full portions served at restaurants as well as questions about physical activity were associated with body mass index and being overweight and/or obese.

Conclusions: We suggest that future research about eating behaviors focus on the questions regarding typical consumption of beverages with sugar added, fruits and vegetables, and full portions served at restaurants to further develop a tool for clinical screening.

Methods: We used a secondary analysis of the Panel Study of Income Dynamics, Child Development Supplement, a multigenerational, genealogical, prospective cohort study of the US population. Self-report height and weight data from adults and measured height and weight data for children were used to calculate BMI. The prevalence of child overweight was calculated for different possible combinations of parental and grandparental BMI status, including missing status.

Results: The sample included 2591 children aged 5 to 19 years, for whom parental BMI data were available for 94% and grandparental BMI data were available for 61%. Prevalence of childhood overweight (18.6%) in the sample was comparable with contemporaneous measured national data from other sources. Among children with normal-weight parents and normal-weight grandparents, 7.9% were overweight. In contrast, among children with overweight parents (BMI 25–29.9) and normal-weight grandparents, 17.9% were overweight, and among children with obese parents (BMI ≥30) and normal-weight grandparents, 31.9% were overweight (P < .0001). Importantly, when parents were normal weight, if grandparents were obese, then the prevalence of child overweight was 17.4% (P < .0001). The prevalence of child overweight was similarly elevated (16.4%) when parents were normal weight and grandparental BMI was missing.

Conclusions: This is the first national study to find an association of child weight status with grandparental obesity, distinct from parental obesity. Primary care physicians may find it helpful to consider grandparents’ weight status in judging risk of childhood overweight for their patients, especially when parents’ weight is normal.

Methods: Survey data were obtained from overweight and obese adolescents in the Youth Risk Behavioral Survey (YRBS) in Delaware. Cross tabulations were used to determine the frequency of accurate perception, recent action, and current intention regarding weight loss. Multivariable analysis identified factors associated with recent action to lose weight.

Results: From 2728 records, 482 overweight adolescents and 398 obese adolescents were identified. Most obese (83%) and overweight (79%) adolescents reported recent action to lose weight. Most obese (75%) and overweight (65%) adolescents intended to lose weight. Obese and overweight adolescents who reported a current intention to lose weight were more likely to have taken recent action to lose weight (odds ratio [OR], 11.6 and 6.6, respectively).

Conclusions: The percentage of obese and overweight adolescents who have an accurate perception of weight, intend to lose weight, and have taken recent action to lose weight suggests that this group is highly engaged in weight-related behavior change. Compared with their obese peers, overweight adolescents seem less engaged in weight change behavior. There is a strong association in both groups between intention and recent action, and this association indicates that obese and overweight adolescents are highly motivated to change their weight.

Methods: All couples receiving treatment from 2 NPT-trained family physicians between February 1998 and January 2002 were studied. The main outcome was live birth, and secondary outcomes included conceptions and multiple births. Crude proportions and adjusted life-table proportions were calculated per 100 couples.

Results: A total of 1239 couples had an initial consult for NPT, of which 1072 had been trying for at least a year to conceive and initiated treatment. The average female age was 35.8 years, the mean duration of attempting to conceive was 5.6 years, 24% had a prior birth, and 33% had previously attempted treatment with assisted reproductive technology (ART). All couples were taught to identify the fertile days of the menstrual cycle with the Creighton Model FertilityCare System, and most received additional medical treatment, including clomiphene (75%). In life-table analysis, the cumulative proportion of first live births for those completing up to 24 months of NPT treatment was 52.8 per 100 couples. The crude proportion was 25.5. Younger couples and couples without previous ART attempts had higher rates of live birth. Among live births, there were 4.6% twin births.

Conclusion: NPT provided by trained general practitioners had live birth rates comparable to cohort studies of more invasive treatments, including ART. Further studies are warranted to compare NPT directly to other treatments.

Methods: We performed a retrospective cohort study of Medicaid enrollees in Oregon using administrative data. Infants were determined to have family continuity if they received well-baby care at the same clinic as that in which their mothers received prenatal care.

Results: Of the 1591 infants identified for participation in this study, 749 (47.1%) had family continuity. Infants had a mean of 4.55 well-child visits, 1.23 emergency department visits, and 0.17 hospitalizations in the first 13 months of life. Multivariate analyses found that infants with family continuity had increased numbers of well-child visits (relative risk, 1.05; P = .041), increased numbers of emergency department visits (relative risk, 1.36; P < .0001), and no difference in the number of hospitalizations (relative risk, 0.85; P = .282) when compared with infants without family continuity.

Conclusions: Family continuity, when measured at the clinic level, is associated with a variable effect on infant health service use. This finding suggests that clinic-level continuity is not sufficient for achieving all the benefits of continuity.

Methods: We used a prospective cohort study of 1223 adults with diabetes that obtained self-reported depression symptoms from a survey. Medication use was obtained from claims data, and pharmacy and clinical data were obtained by manual review of paper medical records.

Results: Diabetes patients with depression symptoms were less likely to be at their glucose goal (43% vs 50%; P = .0176) but more likely to be at their blood pressure goal (57% vs 51%; P = .0435). The association between lipids and depression symptoms was related to a lower rate for low-density lipoprotein testing (56% vs 68%; P < .0001). Treatment with antidepressants resulted in a greater percentage achieving glucose and blood pressure goals but not lipid goals.

Conclusions: Depression seems to have a variable impact on achieving these clinical goals, perhaps because the goals have differing measurement logistics and biological profiles. Further research is needed to learn whether better treatment of depressive symptoms leads to improvements in meeting diabetes clinical goals.

Methods: We used the Patient Health Questionnaire plus a posttraumatic stress disorder screen to measure 6 common mental health conditions. In a sample of 367 patients recruited from 3 urban family medicine practices affiliated with Boston University Medical Center, we measured self-reported health care utilization of primary care provider visits, emergency department visits, nonpsychiatric hospitalizations, and outpatient mental health visits. We determined the association between screening positive for the mental health conditions and health care utilization using both multivariable logistic regression and Poisson regression methods while controlling for sex, age, race, income, insurance status, marital status, educational level, and the presence of chronic medical conditions.

Results: After controlling for potential confounders, generalized anxiety disorder, panic disorder, and posttraumatic stress disorder were statistically significantly associated with more PCP visits, ED visits, and nonpsychiatric hospitalizations. Neither major nor minor depression were associated with more PCP visits, ED visits, or nonpsychiatric hospitalizations, except that minor depression was associated with 103% increase in PCP visits (P < .001). Alcohol use disorder was associated with 16% fewer PCP visits (P = .01) but 238% more nonpsychiatric hospitalizations (P < .001).

Conclusions: After controlling for confounders we found that mental health conditions among a sample of family medicine patients were associated with increased use of ED services, nonpsychiatric hospitalizations, and, to a lesser extent, PCP visits.

Methods: We analyzed data from the Atherosclerosis Risk in Communities Study (ARIC), a longitudinal cohort of people 45 to 64 years old at entry (1986 to 1989 through 2001). FRSs were calculated for participants in the ARIC cohort (3901 men, 5406 women) at baseline (visit 3) and 3 and 6 years before. Using Cox regressions we evaluated the risk of CHD development for the FRS 6 years from baseline and then evaluated whether the addition of the change in FRS assessments from 3 and 6 years before the baseline improved the predictive ability of the FRS. Areas under the receiver operating characteristic (AUROC) curves were compared.

Results: The addition of the difference between the baseline FRS (eg, in 1995) and the FRS from 6 years earlier (eg, in 1989) to predict CHD development by 2001 for the entire cohort yielded an AUROC of 0.730, which was a significant improvement over just using the baseline FRS (P < .05). The effect was located primarily among women, with the AUROC curve improving from 0.667 to 0.709 (P < .05). There was no improvement for CHD risk prediction in men when the earlier FRS assessments were taken into account. Men seem to have less change in some risk factors over time.

Conclusions: Accounting for an individual's history improves risk assessments based on current measures.

Methods: Five hundred sixty participants attending a primary care clinic, aged 50 to 80 years, and of African-American, Hispanic, or non-Hispanic white race/ethnicity were interviewed. The goal was to assess the contribution of sociodemographic characteristics, knowledge, beliefs about CRC, and the health care experience with their primary care doctor to racial/ethnic differences in CRC screening. The outcome variable was self-reported screening. All analyses were weighted; bivariate testing and multivariate logistic regression was conducted.

Results: The response rate was 55.7%, with no sociodemographic differences noted between respondents and nonrespondents. Respondents were African-American (n = 194), Hispanic (n = 162), and non-Hispanic white (n = 204); 64.5% were aged 50 to 64 years; 63.1% were women; 96.9% were insured; and over half reported a total annual income of less than $25,000. Overall 62.5% were current with CRC screening: 67.5% of non-Hispanic whites, 54.3% of African-Americans, and 48.6% of Hispanics (P < .001). A doctor's recommendation (odds ratio, 3.86); awareness of screening (odds ratio, 3.32); older age (odds ratio, 2.88); greater education (odds ratio, 2.02); and perceived susceptibility (odds ratio, 1.74) contributed to racial/ethnic differences in CRC screening.

Conclusions: Interventions to address CRC screening disparities among racial/ethnic groups should focus on the health care setting and patient education about CRC screening; differences in attitudes and beliefs seem to be less important.

Methods: Standard literature databases, including PubMed, and Internet sites of numerous professional associations, government agencies, business groups, and private health organizations identified over 200 references, reports, and books evaluating the medical home and patient-centered primary care.

Findings: Evaluations of several patient-centered medical home models corroborate earlier findings of improved outcomes and satisfaction. The peer-reviewed literature documents improved quality, reduced errors, and increased satisfaction when patients identify with a primary care medical home. Patient autonomy and choice also contributes to satisfaction. Although industry has funded case management models demonstrating value superior to traditional fee-for-service reimbursement adoption of the medical home as a basis for medical care in the United States, delivery will require effort on the part of providers and incentives to support activities outside of the traditional face-to-face office visit.

Conclusions: Evidence from multiple settings and several countries supports the ability of medical homes to advance societal health. A combination of fee-for-service, case management fees, and quality outcome incentives effectively drive higher standards in patient experience and outcomes. Community/provider boards may be required to safeguard the public interest.

Methods: Cross-sectional analyses of nationally representative data from the 2002 Medical Expenditure Panel Survey. Among adults with a health care visit in the past year (n = ~16,700), we measured independent associations between having a USC and patient perceptions of health care communication. Second, among respondents with a USC (n = ~18,000), we assessed the independent association between various demographic factors and indicators of patients’ perceptions of their autonomy in making health care decisions.

Results: Approximately 78% of adults in the United States reported having a USC. Those with a USC were more likely to report that providers always listened to them, always explained things clearly, always showed respect, and always spent enough time with them. Patients who perceived higher levels of decision-making autonomy were non-Hispanic, had health insurance coverage, lived in rural areas, and had higher incomes.

Conclusions: Patients with a USC were more likely to perceive positive health care interactions. Certain demographic factors among the subgroups of Medical Expenditure Panel Survey respondents with a USC were associated with patient perceptions of greater decision-making autonomy. Efforts to ensure universal access to a USC must be partnered with broader awareness and training of USC providers to engage patients from various demographic backgrounds equally when making health care decisions at the point of care.

Methods:All 200 of the written notes and e-mails to a single family physician retiring after 42 years in practice were examined using content analysis for general themes and meaning. No phone or personal verbal responses were included.

Results: Seven themes emerged with regards to what patients appreciated in their family physician relationship. These included "being there," caring, medical expertise, personal characteristics, multiple roles/anything goes, family, and continuity.

Conclusion: Analyzing comments from actual patients at the end of a long-term relationship with an individual physician confirms beliefs of what patients consider important based on theoretical models, surveys, and interviews.

Methods: In this double-blind, controlled clinical trial, 27 patients were sequentially assigned to receive either a 9-day tapering course of prednisone (n = 13) or placebo (n = 14) within 1 week of developing sciatic symptoms. Patients and investigators were blinded to the drug administered. Follow-up assessment was done weekly for 1 month and then monthly for 5 months.

Results: Prednisone and control groups showed no statistically significant differences in physical findings, use of nonsteroidal anti-inflammatory drugs or narcotic medications, or rates of patients returning to work at any time interval studied. Compared with controls, patients who received prednisone had more rapid rates of improvement from baseline in pain, mental well-being, and disability scores. These changes were subtle but statistically significant. Patients who received prednisone tended to receive fewer epidural injections for pain.

Conclusions: Early administration of oral steroid medication in patients with acute sciatica had no significant effect on most parameters studied. It did, however, lead to slightly more rapid rates of improvement in pain, mental well-being, and disability scores. The impact of oral steroids on other outcomes is suggested by this study, but its small sample size limited its statistical power.

Methods: We used medical records of pediatric patients seen in a large group practice in Minnesota in the first 2 months of 2008. A retrospective analysis of electronic patient records was performed on 2 groups of patients: those using the retail clinic (n = 200) and a comparison group using a same-day acute family medicine clinic in a medical office (n = 200). Two measures of early return visits were used as dependent variables: office visits within 2 weeks for any reason and office visits within 2 weeks for the same reason. Multiple logistic regression analysis was used to adjust for case mix differences between groups. Trained medical records abstractors reviewed electronic medical records to obtain the data.

Results: After adjustment for baseline differences in age, acuity, and number of office visits in the previous 6 months, no significant differences in risk of early return visits were found among clinic types.

Conclusions: Retail clinic visits were not associated with early return visits.

Methods: Nonpregnant women aged 18 to 64 years who required ≥3 days oral antibiotics for nongynecological diseases were recruited from a family medicine office. Age-matched (±5 years) women seen in the same clinic for noninfectious problems were recruited as controls. The main outcomes are incidence of symptomatic VVC and prevalence of positive vaginal Candida culture 4 to 6 weeks after antibiotics.

Results: Eighty (44 in antibiotic group) women were recruited; 14 of 79 (95% CI, 0.11–0.28) had asymptomatic vaginal Candida cultures positive at baseline. During follow-up, 10 of 27 (95% CI, 0.22–0.56) women in antibiotic group were Candida culture positive. In contrast, 3 of 27 (95% CI, 0.04–0.28) women in the control group were Candida culture positive (relative risk, 3.33; P = .03). Meanwhile, 6 of 27 (95% CI, 0.11–0.41) women in antibiotic group developed symptomatic VVC whereas none (95% CI, 0–0.12) of the women in the control group developed vaginal symptoms (relative risk, ; P = .02). Baseline Candida culture did not predict subsequent symptomatic VVC after antibiotics.

Conclusion: In this pilot study, the use of short courses of oral antibiotics seems to increase prevalence of asymptomatic vaginal Candida colonization and incidence of symptomatic VVC. Larger cohort studies are needed to confirm these findings.

Methods: We enrolled in a randomized controlled trial 199 patients and 108 support persons (SPs) from 18 practices within a practice-based research network. All patient participants had type 2 diabetes with suboptimal blood pressure control and were prepared to designate a SP. A subset of the patients also had dyslipidemia. All study visits were conducted at the practice sites where staff took standardized blood pressure measurements and collected blood samples. All patients completed one education session and received newsletters aimed at improving key health behaviors. Intervention group patients included their chosen SP in the education session and the SPs received newsletters.

Results: After 9 to 12 months, the intervention had no significant effect on systolic blood pressure, HbA1C, health-related quality of life, patient satisfaction, medication adherence, or perceived health competence. Power was insufficient to detect an effect on low-density lipoprotein cholesterol. Baseline cardiovascular risk values were not very high, with mean systolic blood pressure at 140 mm Hg; mean HbA1C at 7.6%; and mean low-density lipoprotein at 137 mg/dL. Patient health care satisfaction was high.

Conclusion: This practice-based intervention to foster social support for chronic care management among diabetics had no significant impact on the targeted outcomes.

Methods: We studied clinical decision making through a mixed-method approach using obesity counseling as an example of preventive counseling. We conducted in-depth interviews and focus groups with 30 primary care clinicians in RIOS Net, a Southwestern US practice-based research network and distributed a survey, which was completed by 75% of 195 network members. We then used the components of SDT autonomy, competence, and relatedness to organize the factors that clinicians identified as most influential in their preventive counseling decisions.

Results: We found that SDT provides an organizing structure for understanding some of the psychology of clinicians' decisions to provide preventive counseling in the brief primary care encounter. In the specific case of obesity counseling clinicians expressed a high degree of autonomy, but barriers to competence and generally low levels of relatedness with professional colleagues seemed to limit their delivery of preventive counseling.

Conclusion: SDT provides a new perspective on factors that impact preventive counseling delivery, with a focus on the psychology of clinical decision making. Further research testing the predictive value of SDT may open new avenues for enhancing the delivery of preventive services.

Methods: Surveys were self-administered by 185 women, ages 20 to 64, presenting consecutively for care at 6 suburban community-based family medicine practices within the Cleveland Clinic Ambulatory Research Network (CleAR-eN). We compared demographic characteristics, health beliefs, and health behaviors of those women who reported never using calcium supplements with those who presently took calcium supplements. Women who never took calcium were also queried about reasons for non-use and whether physician recommendation would influence their adoption of calcium supplementation.

Results: Multivitamin use, self-perceived risk of osteoporosis, and age were independent predictors of calcium supplement use. Leading barriers for never-users were lack of knowledge about the need/importance of increasing calcium intake, lack of motivation to start supplements, and the belief that their dietary calcium intake alone was sufficient. Ninety-six percent of never-users reported that they would consider taking a calcium supplement if recommended by their physician.

Conclusions: Many patient-identified barriers to calcium supplementation seem amenable to focused and brief office-based interventions that could increase the number of women meeting calcium intake guidelines.

Methods: We mailed a questionnaire to 700 hypertensive patients enrolled in a practice-based research network cohort from 24 practices in North Carolina. We determined percentages of respondents (total and by subgroups) incorrectly answering each of 6 questions pertaining to various aspects of high BP. We then examined bivariate and multivariate associations with answering 2 or more items incorrectly ("lower hypertension knowledge").

Results: We received 530 completed surveys (76% response rate). Twenty-six percent (95% CI, 22–30) of respondents did not know that most of the time people with high BP do not feel it. Twenty-two percent (95% CI, 18–26) either were not sure whether anything could be done to prevent high BP or believe that there is nothing that can be done. Nineteen percent (95% CI, 16–22) either believe taking medications will cure high BP or are not sure whether it will.

Twenty-two percent (95% CI, 19–26) of respondents had overall lower hypertension knowledge. Independent associations with lower hypertension knowledge were African-American race (odds ratio, 1.77; 95% CI, 1.10–2.86), having less than high school education (odds ratio, 2.43; 95% CI, 1.34–4.41), and history of stroke/mini-stroke (odds ratio, 1.94; 95% CI, 1.00–3.75).

Conclusions: Patients may need to be taught the difference between curing hypertension and treating it with medications. Efforts to educate the public that lifestyle modifications can prevent hypertension and that it usually causes no symptoms need to continue. It seems especially important to develop messages that reach African-Americans and people with less education.

Methods: Patients in 37 primary care practices in 3 practice-based research networks completed a survey to elicit the prevalence of underinsurance among those who had insurance for a full 12 months, including private insurance, Medicare, and Medicaid. Being underinsured was based on patients reporting the delay or omission of recommended care because of their inability to afford it.

Results: Of those with insurance for a full year, 36.3% were underinsured. Of those who were underinsured, 50.2% felt that their health suffered because they could not afford recommended care, a rate similar among those who were uninsured.

Conclusions: When evaluating underinsurance in primary care offices, using an experiential definition based on self-reports of patients about their inability to pay for recommended health care despite having insurance, the prevalence is quite high. It is important for the primary care physician to understand that a substantial percentage of their patients may not follow through with their recommendations because of cost, despite having insurance. This also has significant implications when considering health care reform, particularly considering that these patients reported that their health suffered at a rate equal to that of the uninsured.

Methods: Cross-sectional assessments at 15 weeks' gestation (n = 414), 30 weeks' gestation (n = 334), and 6 to 16 weeks postpartum (n = 193) among women from a diverse set of races/ethnicities, participating in the IMPLICIT maternal care quality improvement network. The Edinburgh Postnatal Depression Scale score (≥13) was used as the criterion measure for the PHQ-2.

Results: A positive 2-item screen had sensitivity of 93%, 82%, and 80% and specificity of 75%, 80%, and 86% for Edinburgh Postnatal Depression Scale score of ≥13 for assessment at 15 and 30 weeks gestational age and postpartum, respectively. The positive/negative predictive values for the PHQ-2 were 44/98, 24/91, and 30/98 for each time point, respectively. Areas under the receiver operating characteristic curve analysis suggested that 2-item assessments at each time point had approximately equal diagnostic validity.

Conclusions: Two questions were efficient to rule out depression and reduced the need for further screening of approximately 60% to 80% of women, depending on the point in pregnancy or postpartum. A diagnostic interview follow-up of women screening positive is still required.

Methods: A total of 16 practices participated; 8 were assigned to intervention and 8 to usual care. Pre- and post-audits of mammography rates were conducted. Intervention practices received feedback with benchmarking, academic detailing, and the assistance of a practice enhancement assistant to help with practice redesign over a 9-month period.

Results: The groups differed significantly for both the proportion of mammograms offered to eligible patients (P = .043) and for the proportion of patients with current mammograms (P < .015). For the control group, 38% of eligible women were offered a mammogram and 202 (35% of those eligible) actually did have documentation that a mammogram had been performed. Fifty-three percent of the eligible patients in the intervention group were offered a mammogram and 52% of those eligible (n = 332) did have documentation in the chart that the mammogram had been completed.

Conclusion: The results suggest that these interventions can improve mammography rates in a range of practice settings. These findings are consistent with other studies that have tested multicomponent interventions.

Methods: A 6-month randomized, controlled trial comparing a multicomponent quality improvement intervention to feedback and benchmarking. One clinician/nurse team from each of 24 practices was randomly assigned to one of 2 study arms. Intervention practices received performance feedback, peer-to-peer education (academic detailing), a practice facilitator, and computer (information technology) support. Implementation of the 3 targeted processes was determined by a blinded 3-clinician panel that reviewed transcribed clinician interviews before and after intervention using performance definitions. Rates of delivery of selected preventive services were determined by chart audit.

Results: Intervention practices implemented more of the processes than control practices overall (P = .003), for adults (P = .05), and for children (P = .04). They were also more likely to implement at least one of the processes for children (P = .04) and to implement standing orders for either children or adults (P = .02). Mammography rates increased significantly. Neither clinician and practice characteristics nor clinician readiness to change predicted implementation.

Conclusions: A multicomponent implementation strategy consisting of feedback, benchmarking, academic detailing, facilitation, and IT support increased implementation of evidence-based processes for delivering preventive services to a greater extent than performance feedback and benchmarking alone.

Methods: This was a cross sectional study of 7 group practices (2 urban and 5 rural groups comprising 22 clinic sites) throughout New Mexico that had RIOS Net member and nonmember practicing clinicians.

Results: The 22 clinics employed 95 clinicians, of which 43% were RIOS Net members (21 of 59 MDs, 8 of 18 Nurse Practitioners, 9 of 15 Physician Assistants and 3 of 3 others). RIOS Net members had a significantly longer mean employment time (7.0 years; SD, 6.8 years; median, 5.0 years), compared with non-RIOS Net members (4.0 years; SD, 5.0 years; median, 2.3 years; P = .003). Similar results were found when analyzed by length of time in practice with cutoffs of 2 and 5 years.

Discussion: Being a member of a practice-based research network may be a determinate of staying in rural practice longer. This is a hypothesis-generating study and needs confirmation from larger studies whose analysis stratifies clinician demographics and practice type.

Methods: Using coding data from an electronic medical record to identify all adults with an underlying diagnosis of hyperlipidemia enrolled to this PBRN, children at risk for dyslipidemia were identified.

Results: Enrolled to this network were 189,282 patients, including 55,252 children aged 2 to 18 years. The prevalence of physician-coded hyperlipidemia in the adult population was 1.5%. Two percent of the children enrolled to this PBRN were at risk for dyslipidemia.

Conclusion: Using technology within electronic medical records allowed for the identification of children at risk for dyslipidemia and to create clinical reminders that will allow us to improve the efficiency of screening efforts.

Methods:An anonymous survey (n = 285) of hypertensive patients cared for at 2 offices within the Ohio State University Primary Care Practice-Based Research Network. Survey questions included demographics, recommendations for diet, and exercise lifestyle modification for reducing blood pressure. Questions were phrased as multiple choice or based on Prochaska and DiClemente's readiness to change model.

Results:Of the 244 respondents, 57% were women and 43% were African-American. The income of African-Americans was significantly lower than that of whites. Exercise and increased fruit/vegetable consumption were the preferred lifestyle modifications and did not differ by race. Race and exercise were associated; a majority of whites were engaged in exercise whereas this was not so for African Americans.

Conclusions:Although exercise as a preferred lifestyle modification habit does not differ by race, implementation of such a behavior does. This may be related to differing income levels. When counseling patients, physicians must be prepared to ask what may hinder the adoption of such behavior and be prepared to offer possible solutions to overcoming such factors.

Design: Cross-sectional, clinic-based study in a practice-based research network.

Methods: One hundred seventy-one parents or adults accompanying children aged 5 to 17 years to a primary care visit in 4 family medicine centers completed a questionnaire. Parent/adult overweight status and attitudes were compared with child overweight status.

Results: Forty-eight percent of children were overweight or obese (BMI ≥ the 85th percentile) as were 56% of mothers and 77% of fathers (BMI ≥ 25 kg/m²). Child and parent overweight were significantly associated, as were mother overweight and beliefs about child overweight status. Children aged 5 to 13 years were more likely to be overweight than those aged ≥14 years.

Conclusions: Parents of overweight children are often overweight and many do not recognize that their children are overweight. Suggestions are made for primary care physicians to engage parents of overweight children in family weight control efforts.

Methods: Analysis was performed of the Atherosclerosis Risk in Communities study, a cohort of middle aged and elderly adults. We examined the association of a reported history of hay fever to the development of stroke.

Results: There were 9272 participants meeting our criteria, of which 125 had strokes. Of those with a history of hay fever, 2.2% had a stroke. Of those without a history of hay fever, 1.25% had a stroke. Participants with a history of hay fever had an unadjusted hazard ratio of 1.72 (95% CI, 1.08–2.27) for stroke versus participants without hay fever. Risk of stroke remained significant (hazard ratio, 1.87 [95% CI, 1.17–2.99]) after controlling for age, sex, race, smoking status, body mass index, diabetes, hypertension, alcohol use, and hyperlipidemia.

Conclusion: A history of hay fever seems to be a risk factor for stroke, and this association may be an area for future research and intervention.

Methods: To determine the optimal time for teens to start prenatal care, we conducted a cost-benefit analysis from the perspective of Medicaid, the predominant payer for pregnancy-related services for teens. Cost projections were based on current recommended prenatal care testing, the cost of vaginal and cesarean deliveries, and the estimated costs for care of the child in the first year of life. We then compared average cost per person and performed sensitivity analyses based on when prenatal care would have started.

Results: Compared with no prenatal care, any prenatal care saves between $2,369 and $3,242 per person, depending on when care is initiated. All savings are related to reductions in the cost of caring for low-birth weight babies. We found no cost advantage to starting prenatal care earlier compared with later months.

Conclusion: If prenatal care does reduce the rate of low-birth weight babies, prenatal care is cost beneficial. If a program was developed to improve access for teens and applied to all pregnant teens not in care by 6 months' gestation, the program would have to average $95 or less per person to be cost beneficial if it reduced the number of low-birth weight deliveries by 50%.

Methods: Multivariate analyses were performed on cross-sectional data from the National Survey of Children's Health collected in 2003 to 2004.

Results: Analyses found that overweight children