Projects
Alternative Medicine Study
Burge SK, Albright T (formerly McCutchon), RRNeST Investigators. Complementary and alternative medicine use among family practice patients in south Texas: an RRNeST project. American Journal of Public Health 2002, 92(10): 1614-1616.
Objectives: To examine prevalence and predictors of complementary and alternative medicine (CAM) use among family practice patients in South Texas.
Methods: A cross-sectional survey of CAM use in the past year administered to 575 family practice patients.
Results: This sample was 80 percent Hispanic. Eighty-nine percent of patients used at least one CAM in the past year. NonHispanic Whites were more likely to use lifestyle strategies, mind-body treatments and manual healing, while Hispanics and NonHispanic Whites were equally likely to use herbs and folk remedies. The strongest predictor of CAM use was use of other medicines, both prescription and over-the-counter.
Conclusions: South Texas patients use many methods to improve their health. Physicians should routinely ask patients about CAM use to avoid adverse drug interactions.
Barriers to Diabetes Care Study
1. McCutchon TA, Parchman M, Burge SK, RRNeST Investigators. Predictors of self care behavior in adults with type 2 diabetes: an RRNeST Study. Family Medicine 2001; 33(5): 354-360.
Objective: Four factors have been linked with self-care behaviors in patients with type 2 diabetes: 1) patient demographics; 2) doctor-patient relationship; 3) stress; and 4) social context. The purpose of this study is to determine the impact of each of these factors on self-care behavior in diabetic family practice patients.
Participants: 397 consecutive adults with type 2 diabetes presenting for appointments with family practice faculty and residents over a 6-month time period.
Results: Among patients with diabetes for one year or more, 3.3% rarely took their medication, 33.4% rarely exercised, 14.2 rarely tested their blood sugar, and 11.2% rarely followed their diabetic diet. Self-care was related to age, patient satisfaction with their doctor-patient relationship, personal stress, and family context. Social context, as reflected by the question, “My family understands my diabetes,” was strongly associated with diet, exercise, and medication adherence. Multivariate analysis demonstrated that, after controlling for patient demographic characteristics and patient satisfaction, personal stress and family context were strongly associated with self-care, especially diet.
Conclusion: Of the four categories of factors associated with self-care behavior, the social context, specifically the family, appears to be most strongly associated with self-care behaviors. The perception of stress influenced compliance in diet and exercise recommendations.
2. Parchman ML, Burge SK, RRNeST Investigators. Continuity and quality of care in type 2 diabetes. A RRNeST Study. Journal of Family Practice 2002; 51(7): 619-624.
Objective: To evaluate the relationship between continuity of care and the quality of care received by patients with type 2 diabetes.
Study Design: Cross-sectional patient survey and medical record review.
Population: Consecutive patients with an established diagnosis of type 2 diabetes presenting to one of six clinics within the Residency Research Network of South Texas (RRNeST), a network of six family practice residencies affiliated with the University of Texas Health Science Center at San Antonio.
Outcomes Measure: Continuity was measured as the proportion of visits within the past year to the patients’ usual primary care provider. A quality of care score was computed based on the American Diabetes Association’s Provider Recognition Program criteria from data collected through medical record review and patient surveys. Each patient was awarded points based on the presence or absence of each criteria.
Results: The continuity score was significantly associated with the quality of care score in the anticipated direction. (r = 0.15, p = .04) Patients who had seen their usual provider within the past year were significantly more likely to have had an eye exam, a foot exam, two blood pressure measurements and a lipid analysis.
Conclusions: Continuity of care is associated with the quality of care received by patients with type 2 diabetes. Continuity of care may influence both provider and patient behaviors in ways that improve quality.
The Medication Compliance Intervention Study
1. Burge SK, White D, Bajorek E, Bazaldua O, et al. Correlates of Medication Knowledge and Compliance: Findings from RRNeST. Family Medicine 2005; 37 (10): 712-718.
Background: Medication adherence is a complex phenomenon, influenced by a variety of factors. Most adherence research focuses on one medicine and does not represent the realities of family medicine. This analysis examined factors associated with medication knowledge and adherence in family medicine patients with chronic conditions.
Methods: The Residency Research Network of South Texas (RRNeST) enrolled 150 patients with chronic disease who “sometimes have trouble taking medicines.” 75% were Latinos. This cross-sectional analysis used baseline survey data from an intervention study. Investigators correlated medication knowledge and adherence with known predictors - patient, health, medication, economic, and physician factors. New variables related to patients’ motivation to change treatment behaviors (“importance” and “confidence”) were also included.
Results: Linear regression analysis demonstrated that patient satisfaction, education level, and confidence were associated with better medication knowledge. Higher confidence, Spanish language, better functional and health status, and more prescription medicines were correlated with medication adherence.
Conclusions: We recommend that family physicians enhance medication adherence by providing good information about treatment and counseling strategies to build patients’ confidence. Our findings suggest that poor health status can be a barrier to, rather than a motivator for, treatment adherence.
2. Burge SK, Bazaldua O. Changes in chronic disease measures: the influence of patient characteristics and a brief intervention for medication adherence. Annual Meeting of the North American Primary Care Research Group, Quebec City. October 2005.
Context: Interventions to improve medication adherence generally focus on one medication or a single condition; however in primary care, physicians routinely manage multiple medications and comorbidities.
Objective: This analysis examined changes in chronic disease measures in poorly adherent patients, assessing the effect of a brief intervention while controlling for factors known to influence adherence.
Design: This nonrandomized controlled trial enrolled 91 patients (51 control, 40 treatment) from 18 family physicians in 6 residency programs. This analysis included medical record data collected one year prior to and one year following enrollment, and survey information collected on enrollment day.
<Participants: were adult outpatients who had hypertension, hyperlipidemia, and/or type 2 diabetes and “had trouble taking their medicines.”
Intervention: Physicians delivered a brief health behavior change intervention to improve medication adherence; telephone followup reinforced the message.
Main Outcome Measures: Examining pre- and post-enrollment measures of lipids, blood pressure, and HbA1c, investigators classified patients’ changes in chronic disease measures as “poor” (got worse or stayed bad) versus “satisfactory” (improved or remained good).
Results: In bivariable analyses, the intervention showed little effect on chronic disease outcomes. However, gender, ethnicity, income, patient satisfaction, and social desirability were associated with disease changes (p<.05). Logistic regression assessed significant predictors of changes in lipids, blood pressure, and HbA1c. The intervention variable was forced into each model. Lower income, higher social desirability, Hispanic ethnicity, female gender, and lower patient satisfaction predicted satisfactory changes in one or more conditions. Examining Hispanics only (77% of sample), the intervention and social desirability predicted satisfactory lipid changes. Being unmarried predicted satisfactory changes in HbA1c and all-conditions. Examining women only (70% of sample), self-reported adherence, Hispanic ethnicity, older age, and nonmarried status predicted satisfactory changes in one or more conditions.
Conclusion: Brief interventions for medication adherence had little influence on outcomes in this study. Instead, individual, family, and cultural factors were associated with important changes in chronic disease measures.
SAFE TEENS Study
White DG. SAFE TEENS: Preventive Care for Adolescents. Findings from RRNeST. Annual Scientific Assembly, American Academy of Family Physicians, Orlando FL. October 2004.
Context: Infrequent office visits from adolescents and competing demands of busy practice prevent physicians from providing optimal preventive care to teenagers.
Objective: To describe family physician preventive care with adolescents, and determine patient and visit characteristics that optimize that care.
Subjects: Physician volunteers completed data checklists on 316 consecutive visits with adolescents age 11-21 years old.
Measurement: The checklist assessed patient demographics, characteristics of the visit, and discussions of prevention topics, organized as SAFE TEENS: Sexuality, Accidents/abuse, Firearms/homicide, Emotions, Toxins, Environment, Exercise, Nutrition, and Shots.
Results: Patients were 16.1 years old, on average. Most were Latino (77 %) and female (68%). In 316 consecutive visits with adolescents, physicians had prevention discussions during 87% of those visits, addressing an average of 4.3 topics. Social environment, tobacco, alcohol and drugs, sexuality, and exercise were discussed in more than half of the visits. Logistic regression analysis showed that gender, parent presence, type of patient and type of visit predicted certain types of discussions. Discussions about sexuality and social environment were more frequent with girls than boys. Discussions about sexuality, emotions, substance abuse, and social environment were more likely when parents were present for part of the visit. The purpose of the visit was an important predictor. If the visit was for prevention purposes – such as sports physical – the odds that physicians would address prevention topics increased 3- to 22-fold (p<.05).
Conclusions. Findings demonstrated that prevention is more likely during visits scheduled for that purpose, and that parents have an important role to play. When parents are present for part of the visit, balancing parental involvement and respect for privacy, preventive care is more likely to occur.
Firearm Safety Intervention Study
Albright T, Burge SK. Improving firearm storage habits: the impact of brief office counseling by family physicians. Journal of the American Board of Family Practice 2003; 16:40-46.
Background: Firearm injury is the leading cause of injury-related death among youth, and second leading cause of injury-related death, overall, in the United States. Our objective is to determine the impact of brief office counseling by family physicians on patients’ firearm storage habits.
Methods: 1233 subjects completed enrollment surveys; 156 (13%) reported guns in their household and agreed to participate in the study. Post-intervention surveys were completed by 127 subjects for 81% follow-up. Participants received no counseling, verbal counseling alone, or with a gun safety brochure from their physician. Firearm storage habits were measured at baseline and 60-90 days after intervention.
Results: 46% and 49% of the ‘verbal counseling’ and ‘verbal plus written counseling’ groups, respectively, made a ‘safe change’ in gun storage compared to 29% of participants in the ‘no-intervention’ group (p=.031). A logistic regression model controlling for demographics and gun ownership showed that intervention participants were 2.2 times more likely to make ‘safe’ changes than controls.
Conclusions: Family physicians’ brief counseling efforts made a significant positive impact in the firearm storage habits of their patients. With a verbal or written recommendation, a significant improvement was observed in firearm storage.
Firearm Safety Survey
Weigle, David. Examining Firearm Storage Habits of Family Medicine Patients: An RRNeT Study, AnnualScientific Assembly, American Academy of Family Physicians San Francisco, September 2005.
Background: Firearm-related injuries are the second leading cause of injury-related death in the United States
Objective: to determine firearm storage habits of family medicine patients who own guns, and to evaluate risk factors that may guide family physicians’ injury prevention efforts.
Methods: 106 family medicine patients with guns in their household completed a survey assessing quantities, types, and purposes of firearms in their households, and the location and methods of storage.
Results: Respondents were about half Latino and half nonHispanic White. 53% were male, with average age of 51 years. Half had no children in the household. The median number of guns per household was two. Hunters owned more guns than nonhunters (4.6 vs 2.0, p=.000), and were more likely to own rifles and shotguns. Those who had guns for protection were more likely than others to own handguns. Thirty-eight percent reported triple-safe storage: firearms which were unloaded, locked up, and inaccessible to children. Logistic regression analysis showed that the strongest independent predictors of triple-safe firearm storage were: being Hispanic; being a handgun owner; using firearms for hunting; and a greater number of adults in the household. In general, subjects’ attitudes toward guns were favorable. 42% percent felt more safe with a gun, and 84-92% were unworried about accidental or intentional injury from firearms.
Conclusions: This brief survey demonstrated that only 38 percent of firearm-owning households in our practices stored their guns in a completely safe manner. We found that most were unworried about injury, and that many felt more safe with a gun in the house.
Four Health Behaviors Study
David Weigle PhD; Sandra Burge, PhD. Four Health Risk Behaviors in Family Medicine Patients: Correlates of Interest in Change. Annual Scientific Assembly, American Academy of Family Physicians Washington DC, September 2006
Background: Four health behaviors have a large influence on population health: smoking, alcohol misuse, physical inactivity, and diet.
Objective: In this study, we sought to examine prevalence of unhealthy behaviors in family medicine patients and examine predictors of patients’ interest in change.
Methods: In 2006, the Residency Research Network of Texas (RRNeT) surveyed 1171 patients to determine patients’ health behaviors, interest in change, and health and demographic correlates. We examined four groups of patients: smokers, “unsafe” drinkers, overweight inactive people, and overweight people with unhealthy diets.
Results: Across four health behaviors, age, health status, and ethnic background had consistent and significant influence on patients’ interest in healthy change. Seniors were less interested in change, while minorities and people with ill health were more interested.
Conclusion: Older age can be a barrier, but ill health can motivate people toward positive change. The interest in behavior change among minority patients suggests that physicians should tailor motivational messages to be consistent with patients’ cultural traditions and values.
Treating Chronic Nonmalignant Pain
John Whitham, Jerry Kizerian. Physicians’ Attitudes toward and Experiences with Chronic Nonmalignant Pain: the Effect of a Chronic Pain Clinic Curriculum. Study in Progress.
Background: Chronic nonmalignant pain is a common problem in family medicine. Many family physicians feel ill-equipped to treat chronic pain; some have biases against using opioids. One residency program in RRNeT is enhancing curricula about chronic pain by initiating a Chronic Pain Clinic using a multidisciplinary care team.
Objective: The aim of the study is to examine the effect of the new curriculum by comparing learners’ attitudes and experiences against residents in other programs with other types of chronic pain curriculum.
Methods: Residents and faculty in nine residency programs will be surveyed annually for three years to determine their experiences with and attitudes toward treating chronic nonmalignant pain. Changes over time will be assessed, comparing programs with Pain Clinics to programs without.
Early Results: 209 faculty and residents from 8 programs completed surveys in Year 1. 55% were male, with an average age of 35 years. 62% had lectures in residency, and 11% had participated in a Chronic Pain Clinic. The most common pain conditions seen by these respondents included peripheral neuropathy, headaches, and osteoarthritis. Respondents felt that opioids should play a major role in pain management only for sickle cell pain and malignant pain. For other conditions, they felt opioids could have an adjunct role or be used only as a “last resort”. The key barriers to use of opioids in managing pain included concerns about tolerance, dependence and addiction. Using a linear regression analysis, the significant predictors of positive attitudes toward opioid included: more lectures about pain management in residency; fewer lectures in medical school; fewer concerns about addiction; and more concerns about barriers such as cost and availability of opioid medicines.
Doctor-Patient Trust and Low Back Pain
David Schneider, Sandra Burge. Predictors of Health and Functional Status in Patients with Chronic Low Back Pain:The Role of Trust in the Doctor. Study in progress.
Background: The prevalence of low back pain in the population varies from 8 to 37 percent. For many with chronic low back pain (3 months duration or longer), opioid therapy can provide pain relief and restore daily functioning. Yet many physicians are hesitant to prescribe opioids because of the risk for addiction. They often distrust of patients who request opioid medicines for pain, which increases patients’ anxiety and demands, leading to further suspicion and resistance by the provider. A cycle of distrust and anxiety develops resulting in serious conflict between the providers and the patients.
Objective: This study will examine predictors of health and disability in patients with chronic low back pain in Texas, with a particular focus on trust in the doctor-patient relationship.
Methods: Medical student research assistants will identify, enroll, and survey 450 family medicine patients with chronic low back pain during a routine office visit to a family medicine residency clinic. Subjects will be adults with chronic low back pain of greater than 3 months duration who have visited the clinic more than one time. Students will administer surveys to patients and their doctors. Investigators will examine several sets of predictors: characteristics of the pain (severity, cause, duration); characteristics of the patient (age, gender, ethnic background, occupation); mediators of pain (trust in the doctor, length of the doctor/patient relationship, treatments for pain, and social support), and phenomena that may exacerbate pain (depression, anxiety, substance abuse, adverse childhood experiences, comorbidities, and social stress). Outcome measures will include health and functional status, as measured by the MOS Short-Form-36.