ABSTRACT
BACKGROUND: Health risk assessments (HRAs) have been implemented and studied for decades in various settings, but little is known about the effect of introducing HRAs on the dynamics and content of patient-clinician conversations during Medicare Annual Wellness Visits (AWVs) and whether the effective use of HRAs requires additional training and resources. METHODS: We used Conversation Analysis techniques to analyze 40 AWVs conducted in an academic family medicine residency practice. After a 3-month baseline period, a low-intensity intervention was implemented to explore improvements in the dynamics and content of conversations. Short exit interviews with patients and clinicians were evaluated by standard content analytic techniques. RESULTS: Six overarching themes emerged that described the dynamics of AWV conversations. Patients and clinicians sub-optimally utilized the HRA report and missed many opportunities for promoting behavior change. However, a low-intensity, multi-component intervention significantly decreased the proportion of clinician talk time per visit by 9% (P < .001), while it increased the proportion of patient talk time by 7% (P < .001), robustly increased the number and duration of "change talk" by 639% (P = .0007), increased the number of patient cut-ins by 237% (P = .04) and tended to increase the number and duration of clinician "advice talk" (P = .065). Patients felt more informed, empowered, and motivated by the HRA-enhanced wellness visit. Clinicians found that the process helped them construct a more effective visit agenda and it facilitated the convergence of patient goals with evidence-based recommendations. CONCLUSIONS: Our study suggests that HRAs introduced without proper framing, education, and additional resources may not allow patients and clinicians to leverage AWVs for effective health planning and improvement. A targeted, low-intensity intervention may help patients and clinicians improve the quality of HRA-guided health conversations during AWVs.
Subject(s)
Family Practice/organization & administration , Family Practice/statistics & numerical data , Physician-Patient Relations , Physicians, Family/psychology , Quality Improvement , Adult , Aged , Community Health Planning/organization & administration , Female , Humans , Male , Medicare , Middle Aged , Oklahoma , Pilot Projects , Risk Assessment , United StatesABSTRACT
Colon cancer is a major cause of cancer-related deaths worldwide. Adjuvant chemotherapy significantly reduces mortality in stage III colon cancer; however, it is only marginally effective in stage II patients. There is also increasing evidence that right-side colon cancer is different from left-side colon cancer. We have observed that the genes altered in expression between the poor and good prognosis tumors vary significantly depending on whether the malignancy originates on the right or left side of the colon. We have identified NADPH oxidase 4 (NOX4) to be highly predictive of relapse in stage II left-side colon cancer, whereas integrin alpha 3 beta 1 (ITGA3) is predictive of relapse in stage II right-side colon cancer. To investigate the underlying molecular mechanisms, we are analyzing the effect of ITGA3 and NOX4 silencing via RNA interference and pharmacological inhibition on global protein expression patterns via iTRAQ labeling and mass spectrometry in colon cancer cells. On the basis of bioinformatic analysis, the functions of these genes were assessed through phenotypic assays, revealing roles in cell migration and reactive oxygen species generation. These biomarkers for relapse risk are of clinical interest and lead to insight into how a tumor progresses to metastasis.
