Real-World Massage Therapy Produces Meaningful Effectiveness Signal for Primary Care Patients with Chronic Low Back Pain: Results of a Repeated Measures Cohort Study.

OBJECTIVE: While efficacy of massage and other nonpharmacological treatments for chronic low back pain is established, stakeholders have called for pragmatic studies of effectiveness in "real-world" primary health care. The Kentucky Pain Research and Outcomes Study evaluated massage impact on pain, disability, and health-related quality of life for primary care patients with chronic low back pain. We report effectiveness and feasibility results, and make comparisons with established minimal clinically important differences. METHODS: Primary care providers referred eligible patients for 10 massage sessions with community practicing licensed massage therapists. Oswestry Disability Index and SF-36v2 measures obtained at baseline and postintervention at 12 and 24 weeks were analyzed with mixed linear models and Tukey's tests. Additional analyses examined clinically significant improvement and predictive patient characteristics. RESULTS: Of 104 enrolled patients, 85 and 76 completed 12 and 24 weeks of data collection, respectively. Group means improved at 12 weeks for all outcomes and at 24 weeks for SF-36v2's Physical Component Summary and Bodily Pain Domain. Of those with clinically improved disability at 12 weeks, 75% were still clinically improved at 24 weeks ( P < 0.01). For SF-36v2 Physical and Mental Component Summaries, 55.4% and 43.4%, respectively, showed clinically meaningful improvement at 12 weeks, 46.1% and 30.3% at 24 weeks. For Bodily Pain Domain, 49.4% were clinically improved at 12 weeks, 40% at 24 weeks. Adults older than age 49 years had better pain and disability outcomes than younger adults. CONCLUSIONS: Results provide a meaningful signal of massage effect for primary care patients with chronic low back pain and call for further research in practice settings using pragmatic designs with control groups.

The Intersection of Massage Practice and Research: Community Massage Therapists as Research Personnel on an NIH-funded Effectiveness Study.

INTRODUCTION: Few NIH funded studies give community massage therapists the opportunity to become study personnel. A recent NIH/NCCAM-funded study investigating chronic low back pain (CLBP) recruited, trained, and utilized community massage practitioners (CMPs) as study personnel. This study's aim was to determine whether health-related outcomes for CLBP improve when patients are referred from primary care to select CAM modalities including massage therapy (MT). The purpose of this paper is to report the results of the study's three massage practice-driven study objectives which were to: 1) identify challenges and solutions to recruiting and retaining ample CMPs, 2) develop a practice-informed protocol reflecting real-world MT, and 3) determine the extent to which CMPs comply with rigorous research methodology in their clinical practices as study personnel. METHODS: Eligible CMPs in urban and rural Kentucky counties were identified through licensure board records, professional organizations, and personal contact opportunities. Interested CMPs completed 6 CE hours of research and Human Subjects Protection training and agreed to comply with a study protocol reflecting MT as practiced. Once trained, study CMPs were matched with study participants to provide and document up to 10 MT sessions per participant. RESULTS: Utilizing prominent MT community members proved invaluable to CMP recruitment and protocol development. CMP recruitment challenges included mixed interest, low number of available rural CMPs, busy clinic schedules, and compensation. Ethics CE credits were offered to encourage CMP interest. A total of 28 Kentucky licensed massage therapists with 5-32 years of experience completed study training. A total of 127 CLBP patients consented to participate (n = 104 for MT). Twenty-five CMPs were assigned CLBP patients and provided 1-10 treatments for 94 study participants. Treatment documentation was provided by CMPs for 97% of treatments provided. CONCLUSIONS: When recruitment, retention, and protocol compliance challenges are met, CMPs are valuable study personnel for practice-based research reflecting real-world MT practice.

Factors relating to patient visit time with a physician.

This study sought to identify factors that increase or decrease patient time with a physician, determine which combinations of factors are associated with the shortest and longest visits to physicians, quantify how much physicians contribute to variation in the time they spend with patients, and assess how well patient time with a physician can be predicted. Data were acquired from a modified replication of the 1997-1998 National Ambulatory Medical Care Survey, administered by the Kentucky Ambulatory Network to 56 primary care clinicians at 24 practice sites in 2001 and 2002. A regression tree and a linear mixed model (LMM) were used to discover multivariate associations between patient time with a physician and 22 potentially predictive factors. Patient time with a physician was related to the number of diagnoses, whether non-illness care was received, and whether the patient had been seen before by the physician or someone at the practice. Approximately 38% of the variation in patient time with a physician was accounted for by predictive factors in the tree; roughly 33% was explained by predictive factors in the LMM, with another 12% linked to physicians. Knowledge of patient characteristics and needs could be used to schedule office visits, potentially improving patient flow through a clinic and reducing waiting times.

Diabetes and cancer screening rates among Appalachian and non-Appalachian residents of Kentucky.

BACKGROUND: Having diabetes may increase the odds of late-stage breast cancer. In Kentucky, the rates of late-stage disease are higher in rural than in urban areas, particularly in rural Appalachia. The objectives of the study were to examine the relationship between diabetes and cancer screening and to determine whether Appalachia residence modifies this association. METHODS: One thousand thirty Kentucky adults responded to a 2008 telephone survey that measured whether they had diabetes; lived in Appalachia; had guideline-concordant screening for breast (mammogram, clinical breast examination), cervical (Papanicolaou), and colorectal (fecal occult blood test or sigmoidoscopy/colonoscopy) cancer; and whether they reported receiving mammograms regularly every 1 to 2 years. RESULTS: Of the subjects, 16% had diabetes, 21% were Appalachian, and 32% were men. In multivariate analysis, women with diabetes had about half the odds of "regular" mammography screening (odds ratio, 0.56) compared with those without diabetes. Men and women in Appalachia had about half the odds of colonoscopy or sigmoidoscopy within the past 10 years (odds ratio, 0.54) compared with those living outside Appalachia. CONCLUSIONS: Both having diabetes and living in Appalachia were negatively associated with current and regular cancer screening. Less screening may explain late-stage diagnosis among these populations.

Colorectal cancer screening: patients' and physicians' perspectives on decision-making factors.

While patient barriers to colorectal cancer (CRC) screening have been identified, how well this knowledge is utilized during the patient-physician interaction is not fully understood. This study aims to assess among primary care physicians the degree of consensus between perceived and actual patients' CRC screening decision-making influential factors. During 2004-2006, 30 patients were interviewed to identify factors influencing screening decisions and 66 physicians were interviewed to understand what factors they thought were important to patients. The factors were categorized using the PRECEDE-PROCEED framework, and perspectives were compared. The researchers found little consensus on CRC screening decision-making influential factors between family practitioners, general internists, and patients. The recommendations to reach consensus are provided on the individual (e.g., updating the contents of a physician's screening recommendation to proactively address patients' decision-making needs) and population (e.g., providing cross-cultural training to medical students enabling them to better understand their patients) levels.

Cancer risk assessment by rural and Appalachian family medicine physicians.

CONTEXT: Challenges to the identification of hereditary cancer in primary care may be more pronounced in rural Appalachia, a medically underserved region. PURPOSE: To examine primary care physicians' identification of hereditary cancers. METHODS: A cross-sectional survey was mailed to family physicians in the midwestern and southeastern United States, stratified by rural/non-rural and Appalachian/non-Appalachian practice location (n = 176). Identification of hereditary breast-ovarian cancer (BRCA1/2), hereditary non-polyposis colon cancer (HNPCC), and other hereditary cancers was assessed. FINDINGS: Less than half of physicians (45%) reported having patients with cancer genetic testing. Most (70%) correctly identified the BRCA1/2-relevant scenario; 49% correctly identified the HNPCC-relevant scenario. Factor analysis of psychosocial variables revealed 2 factors: Confidence (knowledge, comfort, confidence) and importance (responsible, important, effective, need) of identifying hereditary cancer. Greater confidence was associated with use of 3 generation pedigree in taking family history. Greater knowledge and access to genetic services were associated with use of genetic testing. More recent graduation year, greater knowledge, and greater confidence were associated with identifying the BRCA1/2-relevant scenario. Greater knowledge and confidence were associated with identifying the HNPCC-relevant scenario. CONCLUSIONS: Though rural Appalachian physicians do not differ in ability to identify high risk individuals, access barriers may exist for genetic testing. Interventions are needed to boost physician confidence in identifying hereditary cancer and to improve availability and awareness of availability of genetic services.

Cardiovascular risk education and social support (CaRESS): report of a randomized controlled trial from the Kentucky Ambulatory Network (KAN).

PURPOSE: Test a practice-based intervention to foster involvement of a relative or friend for the reduction of cardiovascular risk in patients with type 2 diabetes. 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.

Six-year update on the financial status of US Family Medicine Departments.

BACKGROUND: The financial climate for academic family medicine departments is increasingly threatened by reductions in federal funding and ever more competitive health care markets. OBJECTIVES: Our objective was to evaluate the financial status of US Departments of Family Medicine, comparing 1998 and 2004 data. METHODS: In 1999 and 2005, family medicine department chairs were surveyed for the Association of Departments of Family Medicine. Information reported about departments' financial status for 1998 and 2004 included department size, faculty compensation, revenue sources, expenditures, residents' salary support, payer mix, and department reserves. The 2005 survey data were compared to the 1999 survey reports. RESULTS: Eighty-five departments responded to the 2005 survey (69% of 124 departments). For 2004, the largest source of department revenue was clinical income; the median percent of revenue from clinical work increased from 32% in 1998 to 46% in 2004. The contributions of school/government support and hospital support decreased. Median expenditures for faculty salaries and fringe benefits increased (from 49% to 54%). Although the percentage of departments with reserves had increased (from 57% to 71%), 18% of departments reported debt in 2004. CONCLUSIONS: Family medicine departments increasingly rely on clinical income. They continue to be vulnerable to changes in support from government and hospital sources, since these sources constitute significant portions of department budgets but have declined in the past 6 years.

Patient safety in after-hours telephone medicine.

OBJECTIVES: This study analyzed our family medicine department's after-hours telephone medicine systems at an academic health center from a patient safety perspective. The research questions were (1) What are the threats to patient safety associated with after-hours telephone medicine and (2) What kinds of errors are made during after-hours telephone medicine? METHODS: Subjects were patients at the University of Kentucky family medicine practice who called in to the after-hours answering service. Telephone interviews were conducted with 64 patients over 10 weeks. During the interviews, patients described their telephone medicine experience, identified any problems, and reported potential or actual harm (patient-identified threats to patient safety). Two registered nurses and one physician analyzed the patient narratives to identify threats to patient safety (medical personnel-identified threats to patient safety). RESULTS: Sixty-three analyzable patient interviews identified four instances (6%) of temporary physical harm. Two separate after-hours calls (3%) involved four medical errors with potentially serious consequences to patient safety (wrong dose, serious illness not ruled out). Fourteen calls (22%) involved events that could have threatened patient safety. CONCLUSIONS: Situations that threaten patient safety occur frequently in telephone medicine. Although this study is too small to draw strong conclusions, it suggests that there are risks to patient safety associated with after-hours telephone medicine.

Patients, practices, and relationships: challenges and lessons learned from the Kentucky Ambulatory Network (KAN) CaRESS clinical trial.

The Cardiovascular Risk Education and Social Support (CaRESS) study is a randomized controlled trial that evaluates a social support intervention toward reducing cardiovascular risk in type 2 diabetic patients. It involves multiple community-based practice sites from the Kentucky Ambulatory Network (KAN), which is a regional primary care practice-based research network (PBRN). CaRESS also implements multiple modes of data collection. The purpose of this methods article is to share lessons learned that might be useful to others developing or implementing complex studies that consent patients in PBRNs. Key points include building long-term relationships with the clinicians, adaptability when integrating into practice sites, adequate funding to support consistent data management and statistical support during all phases of the study, and creativity and perseverance for recruiting patients and practices while maintaining the integrity of the protocol.

Communication about complementary and alternative medicine: perspectives of primary care clinicians.

BACKGROUND: People in the United States are using complementary and alternative medicine (CAM) increasingly while they are also receiving conventional care. National population-based surveys and studies in primary care settings have documented inadequate communication about CAM between patients and their conventional healthcare providers. Most studies about CAM communication have surveyed urban practices and focused on physicians. Information about how physicians and non-physician in rural areas clinicians communicate with their patients about CAM is needed to develop strategies for improving the quality of care for patients in rural areas. OBJECTIVE: To investigate how primary care clinicians in the Kentucky Ambulatory Network (KAN) communicate with patients about CAM and to determine interest in additional education about CAM. METHODS: A self-administered survey was mailed to 112 community clinicians in a research network of largely rural practices. KAN members include primary care physicians, nurse practitioners, certified nurse midwives, and physician assistants practicing in 32 counties in central and eastern Kentucky. RESULTS: Of 102 deliverable surveys, 65 (64%) were returned. Sixty-one (94%) clinicians reported patient CAM use. Few clinicians consistently asked patients about CAM. A positive attitude toward patient CAM use was associated with clinician comfort in advising patients. Most clinicians recommended CAM to patients. Seventy percent of KAN clinicians expressed interest in continuing education about CAM. CONCLUSIONS: Kentucky primary care clinicians are aware of their patients' CAM use and are motivated to learn more about CAM so that they can appropriately advise their patients. They need evidence-based, clinically relevant education about CAM to provide better patient care.

Information-seeking behaviors of practitioners in a primary care practice-based research network (PBRN).

OBJECTIVE: The aim of this study was to examine the information-seeking behaviors (e.g., information resource usage patterns, access to types of sources and to medical libraries, and use of particular information technologies) of members in a primary care practice-based research network (PBRN) to inform future efforts supporting primary care practitioners in their daily care of patients. METHODS: Every primary care practitioner who was a member of the Kentucky Ambulatory Network-including family practitioners, general practitioners, nurse practitioners, and physician assistants-was surveyed. The cross-sectional survey included twenty-six questions to investigate the information-seeking behavior of primary care practitioners. RESULTS: The response rate was 51% (59 of 116). Most practitioners (58%) stated they sought information to support patient care several times per week, and most (68%) noted they do this while the patient waited. Many practitioners (40%) never or almost never perform literature searches from online sources such as MEDLINE, although 44% said they did so a few times per month. A significant correlation between use of online sources and use of print sources suggests that those who seek online information more frequently than those who do not also seek information from print sources frequently, and vice versa. Access to medical libraries was also reported as high. CONCLUSIONS: Consistent with previous studies, the primary care practitioners in this rural PBRN reported more frequent use of print and interpersonal sources compared to online sources. There appeared to be, however, a clear difference between those practitioners who are more likely to seek information, regardless of format, and those who are less inclined. Future interventions will need to address such barriers as time, cost, and information-seeking skills.

Practices and Perceptions of Family Practice Residency Directors toward International Medical Graduate Applicants: A National Survey.

Purpose - International Medical Graduates (IMGs) are increasingly filling Family Medicine residency positions. (1) To what extent are residency programs recruiting and accepting IMG applicants? (2) What are program directors' perceptions of IMG applicants? (3) What program characteristics are associated with their practices and perceptions? Methods - A 2002 national survey of Family Medicine program directors assessed program demographics and directors' recruiting practices and perceptions regarding IMG applicants. Results - Although 88% of respondents would rank IMG applicants, only 40% agreed that they would perform as well as U.S. graduates. Programs with IMG faculty were more likely to have IMG residents (p˂0.01). Program directors with IMG faculty or more IMG residents reported more positive perceptions of IMG residents' performance (p˂0.01). Conclusion - More experience with IMGs, such as having IMG faculty or higher numbers of IMG residents, is associated with recruitment of IMG residents and may contribute to more positive beliefs about their performance.

How and why to study the practice content of a practice-based research network.

BACKGROUND: We describe the rationale, methods, and important lessons learned from doing a practice content study in a new practice-based research network (PBRN). METHODS: We performed a modified replication of the National Ambulatory Medical Care Survey (NAMCS) in the Kentucky Ambulatory Network (KAN). Network clinicians had input into focused modifications of the NAMCS protocol, including addition of data fields of special interest to them. Cross-sectional sampling of patient visits was done for a 1-year period, with each practice collecting data during 2 separate weeks. We used selected results to illustrate lessons learned and the value of this endeavor. RESULTS: Twenty-three KAN clinicians helped recruit 33 of their colleagues, and these 56 community-based primary care clinicians collected data on 2,228 office visits. Patient demographics (except race) and the top 10 diagnoses were similar to US NAMCS data. One third of visits addressed 3 or more diagnoses, and one fourth of the visits involved 4 or more medications. The top 10 primary diagnoses represented only one third of all primary diagnoses. Seventy percent of adult patients were either overweight (30%) or obese (40%). Rates of counseling on diet or exercise rose with increases in body mass index. CONCLUSION: This study helped us establish and activate our new PBRN, increasing its membership in the process. The descriptive data gained will stimulate, guide, and support our future research activities.

Current state of information technology use in a US primary care practice-based research network.

OBJECTIVES: To examine the current levels of information technology (IT) use in a primary care practice-based research network (PBRN) in order to inform future development of its infrastructure. PARTICIPANTS: Every primary care practitioner who is a member of the Kentucky Ambulatory Network (KAN),as well as the office managers of each practice. Practitioners included family practitioners, general practitioners, nurse practitioners and physician assistants. METHODS: A cross-sectional study using two survey instruments: one for office managers and one for practitioners. The office manager survey included questions related to the current state of IT within the practice, plans for enhancement and general IT issues from the perspective of managing a practice. The practitioner survey was designed to measure current IT use and attitudes of primary care practitioners. RESULTS: Response rates for the surveys were 46% (n = 68) for the office managers and 51% (n = 116) for practitioners. All but one practice had internet access; however, 43% had only dial-up service. Only 21% of practitioners use an electronic medical record (EMR), with dollar cost being the barrier reported most frequently (58%). More than half of the office managers were either 'somewhat interested' (45%) or 'very interested' (17%) in a low-cost, standardised EMR that was, at the time, to be sponsored by the American Academy of Family Physicians. For practitioners, 71% were either 'somewhat' or 'very' interested in such a system. Responses to other IT issues are reported. CONCLUSION: While interest in enabling information technologies was high in KAN, adoption was variable, with use of several key technologies reported as low.The results suggest that research in this network that would be dependent on or enhanced by IT might be impeded and, generally, greater attention should be given to enhancing the IT infrastructure in primary care.

Exploration of the relationship between continuity, trust in regular doctors and patient satisfaction with consultations with family doctors.

OBJECTIVE: To determine the influence of longitudinal continuity and trust in patients' regular family doctors on patient satisfaction with consultations. DESIGN: Observational questionnaire study. SETTING: Three family practice centres in the USA and four general practices in the UK. SUBJECTS: 418 patients in the USA and 650 in the UK who were consulting family doctors. MAIN OUTCOME MEASURES: A pre-consultation questionnaire sought information about the patient's experience of continuity and trust in their regular doctor; a post-consultation questionnaire measured satisfaction with the consultation. RESULTS: 78.8% of patients rated seeing the same doctor every time they had a health problem as important or very important. Trust in the regular doctor, consulting the regular doctor and country were the strongest predictors of satisfaction. Patients who had a high level of trust in their regular doctor and consulted that doctor had the highest levels of satisfaction with their consultations. Among patients with relatively low levels of trust in regular doctor, levels of satisfaction were similar whether or not they consulted their regular doctor. CONCLUSIONS: Consulting the regular doctor, trust and satisfaction with consultations are associated, and patients who consult a doctor they trust report the highest levels of satisfaction with consultations.