PubMed Health⌕ Search

Biomedical subjects

Kurt C Stange

Publications and source records attributed to Kurt C Stange.

At least 19 recordsLinked to original sources
PubMed2006

Validation of a self-administered, computerized tool for collecting and displaying the family history of cancer.

PURPOSE: A detailed family history is important for cancer risk assessment, but obtaining it is time consuming and infrequently accomplished in practice. The Genetic Risk Easy Assessment Tool (GREAT) conducts a computer-administered family history interview and immediately generates a pedigree diagram in digital form. The purpose of this study was to validate family cancer histories produced by patients using the computer tool in comparison with pedigrees made by genetic counselors. METHODS: Patients scheduled for genetics consultation recorded their family histories using the GREAT, separate from their genetic counseling session. The presence of each relative; presence, type, and age at diagnosis of cancers; and cancer geneticist's risk assessment were compared for 120 pairs of pedigrees produced by counselors versus computer tool. RESULTS: The automated telephone interview took a mean of 33.5 minutes and was highly acceptable to respondents. Ninety-four percent of first-degree relatives, 67% of second-degree relatives, and 38% of third-degree relatives were identical on paired pedigrees; computer-generated pedigrees included additional relatives. Sixty-three percent of all cancers were identified by both family histories, with 90% agreement on the type of cancer. There was very good agreement (kappa = 0.70; correlation = 0.77) between the geneticist's breast cancer risk assessments based on computer versus counselors' pedigrees. In a subsample of 61 users, test-retest reliability for the computer-administered questionnaire was high (phi = 0.94 for cancers in first-degree and phi = 0.91 in second-degree relatives). CONCLUSION: The GREAT computer-administered questionnaire provides an acceptable, reliable, and valid way of collecting an unverified but extensive family history of cancer and displaying it as a pedigree, in an entirely automated process.

Data Collection↗
PubMed2006

A sense of priorities for the healthcare commons.

Limited resources make it impossible to deliver all healthcare services to all people. Therefore, it is vital for the nation to adopt rational methods for setting priorities. The work of the National Commission on Prevention Priorities takes such an approach in ranking the relative importance of effective preventive services, and it carries important implications for policymakers, clinicians, and patients. The crisis facing health care requires society to function as a community to use limited resources in ways that maximize the public good.

Health Policy↗
PubMed2006

Recruiting minority primary care practices into practice-based research.

BACKGROUND: A potentially fruitful strategy for increasing enrollment of minority patients in research is to engage minority clinicians. However, little attention has been paid to unique challenges and effective strategies for engaging practices with minority physicians. OBJECTIVE: The objective of this study was to provide a model for recruiting community-based primary care practices with minority physicians into research studies. RESEARCH DESIGN: Practices were recruited using a 3-step process that included telephone contact, on-site meetings, and follow-up discussions. Strategies used to recruit 18 New Jersey community-based primary care practices with minority physicians for a quality improvement intervention study were assessed. RESULTS: Twelve of 18 practices (67%) were successfully recruited into the study. Effective recruitment strategies included building rapport using a multiethnic/multidisciplinary team led by a minority physician recruiter and stressing study benefits for the practice. We attempted to match recruiters and key practice members by race, underrepresented minority status of the lead recruiter, gender, career stage, experience in urban practice, and experience in clinical instruction. Practices that were successfully recruited had more characteristics in common between recruiters and key practice members than unsuccessfully recruited practices (mean number of characteristic matches = 3.75 vs. 1.83, P = 0.020). Study benefits cited by participants as motivators for participation included a general desire to provide good patient care by understanding their practices' strengths and challenges (92%) and improving their practice (85%). CONCLUSIONS: Our experience suggests that a staged, tailored, and iterative recruitment process emphasizing communication and relationship building can be successful in recruiting community-based primary care minority physicians into practice-based research.

Clinical Trials as Topic↗
PubMed2006

Using complexity theory to build interventions that improve health care delivery in primary care.

Previous observational research confirms abundant variation in primary care practice. While variation is sometimes viewed as problematic, its presence may also be highly informative in uncovering ways to enhance health care delivery when it represents unique adaptations to the values and needs of people within the practice and interactions with the local community and health care system. We describe a theoretical perspective for use in developing interventions to improve care that acknowledges the uniqueness of primary care practices and encourages flexibility in the form of intervention implementation, while maintaining fidelity to its essential functions.

Community Health Services↗
PubMed2005

Physicians' attitudes and preventive care delivery: insights from the DOPC study.

BACKGROUND: Interventions that modify physician attitudes to enhance preventive service delivery are common, yet other factors may be relatively more important in determining whether these services are provided. We assessed associations between physicians' attitudes and delivery of preventive care, compared with factors related to the patient, visit, or practice. METHODS: One hundred twenty-eight primary care physicians rated the importance of five preventive services and their effectiveness at delivering them. We assessed whether their patients had received cervical smears, prostate-specific antigen (PSA) testing, smoking cessation advice, recommendation to use aspirin to prevent myocardial infarction, or weight-maintenance counseling, when appropriate. Multilevel models assessed associations between physician attitudinal characteristics and a patient's likelihood of being up to date for each service. RESULTS: Importance of PSA screening and tobacco cessation counseling were weakly associated with patients' receipt of preventive care; no association between attitudes and other services was observed. Factors such as having a visit for well care and use of prevention flowcharts were associated with delivery of preventive services to a greater extent. CONCLUSIONS: Physicians' attitudes toward prevention are necessary, but not sufficient in ensuring the delivery of preventive services. Future interventions should address visit- and practice-specific factors more closely associated with preventive care.

Adult↗
PubMed2005

Facilitating practice change: lessons from the STEP-UP clinical trial.

BACKGROUND: The Study To Enhance Prevention by Understanding Practice (STEP-UP) clinical trial (1997-2000) resulted in sustainable increases in preventive service delivery in primary care practices. However, the process by which practice change can be facilitated has not been well described. METHODS: Comparative case studies were conducted of eight STEP-UP practices with the largest increases in preventive service delivery rates and compared to seven practices with the lowest increases. A multidisciplinary team (research nurse, nurse facilitator, physician principal investigator) used an editing analysis approach to create individual case studies. Then, using an immersion-crystallization approach, the team identified pragmatic lessons for people working to improve primary care practice, and validated these lessons with a participating practice and an additional facilitator. RESULTS: It is not always possible to predict which practices will change based on understanding initial practice conditions. "Malleable moments" can be identified during which practices become open to change. It is important to tie change strategies with existing motivations, or to develop new motivation among potential change agents. Motivation can be developed by discrepant information that challenges self-image, aligning change plans with existing values, or identifying feasible ways of responding to outside pressures or internal demands. Instrumental interventions (such as office systems, tools, new processes) are useful when motivation to change exists, and can build motivation when they meet a perceived need. Disruption in previously workable approaches, either by purposeful information seeking or unanticipated changes, promotes openness to change. CONCLUSIONS: Despite limited ability to predict which practices will change and when, understanding practices' initial conditions and evolution can identify opportunities to craft individualized approaches to positive change.

Clinical Trials as Topic↗
PubMed2005

How complexity science can inform a reflective process for improvement in primary care practices.

BACKGROUND: Quality improvement processes have sometimes met with limited success in small, independent primary care settings. The theoretical framework for these processes uses an implied understanding of organizations as predictable with potentially controllable components. However, most organizations are not accurately described using this framework. Complexity science provides a better fit for understanding small primary care practices. METHODS: The Multimethod Assessment Process (MAP)/Reflective Adaptive Process (RAP) is informed by complexity science. This process was developed in a series of studies designed to understand and improve primary care practice. A case example illustrates the application and impact of the MAP/RAP process. RESULTS: Guiding principles for a reflective change process include the following: an understanding of practices' vision and mission is useful in guiding change, learning and reflection helps organizations adapt to and plan change, tension and discomfort are essential and normal during change, and diverse perspectives foster adaptability and new insights for positive change. DISCUSSION: A reflective change process that treats organizations as complex adaptive systems may help practices make sustainable improvements.

Organizational Case Studies↗
PubMed2005

Clinical genetics issues encountered by family physicians.

PURPOSE: To describe the genetics-related clinical issues encountered by family physicians, and the medical problems they referred to genetics consultants. METHODS: Questionnaires were mailed to a nationwide, random sample of 498 practicing family physicians, asking how many times in the past year they discussed genetic information about 19 familial or genetic conditions with patients and what proportion of the families with each genetic condition were referred for genetics consultation. Factor analysis was used to group the conditions. RESULTS: The response rate was 38% (n = 190). Respondents were similar to non-respondents except that more were women. Most family physicians reported discussing the genetics of common cancers, cardiovascular disease, and Alzheimer's disease with two or more patients in the past year. Thirteen percent had referred families for genetics assessment of breast-ovarian cancer but only two made genetics referrals for cardiovascular disease or dementia. 25% to 50% of family physicians had addressed genetic issues in at least one family with hemoglobinopathy, a blood clotting disorder, hemochromatosis, mental illness, vision loss or deafness, chromosome abnormality, infertility or pregnancy loss, congenital anomalies, mental retardation, and neurofibromatosis. Most cases were not referred to geneticists. Of respondents, 23% said that genetics consultation is very difficult to obtain or unavailable and 18% listed ethical and social dilemmas related to pursuing genetic diagnosis. CONCLUSION: Nationwide, family physicians address a variety of genetics issues with patients, most frequently consulting geneticists for perinatal conditions and familial cancers. Access to genetics consultation is more difficult in rural areas. These data may be used in organizing genetics services and in planning professional education programs for primary care clinicians.

Genetics, Medical↗
PubMed2005

Features of medical records in community practices and their association with preventive service delivery.

BACKGROUND: Medical records are important for facilitating the process and quality of care. However, little is known about their current state in primary care practices. This article describes features of medical record systems in diverse practices and examines their association with preventive service delivery rates. METHODS: Medical records were reviewed from a consecutive sample of outpatients seen by 198 family physicians in 79 community-based practices in Northeast Ohio. The physicians were participants in a clinical trial designed to increase preventive service delivery. Research nurses performed baseline medical record reviews and used ethnographic field notes and a practice environment checklist to provide global assessments of features of medical records. RESULTS: In 79 practices, 3462 medical records were reviewed. Medical records were rated as highly easy to use in 52% of practices; outpatient visit notes were dictated in 54%. Nine percent of practices grouped individual charts by family. Patient notes were computerized in 1% of practices, although several practices had previously tried and abandoned computerized systems. Flow sheets for immunization, screening, and counseling were present on 71%, 63%, and 16% of charts and were used on 34%, 33%, and 3% of charts, respectively. The presence and use of flow sheets were associated with higher preventive service delivery rates. CONCLUSION: Medical record organization, completeness, and use vary widely, and computerized records remain rare. The association of flow sheet presence and use with preventive service delivery rates shows the potential importance of medical records for enhancing the process and outcome of patient care.

Adolescent↗
PubMed2004

Direct observation and patient recall of health behavior advice.

BACKGROUND: Patient recall of health behavior change discussions with physicians is an important intermediate outcome to adherence with recommendations and subsequent behavior change. This study reports patient recall of health behavior discussions during outpatient visits and tests patient and visit characteristics associated with recall. METHODS: In a cross-sectional study of 2670 adult outpatients visiting 138 family physicians in 84 practices, provision of health behavior advice was measured by direct observation. Patient recall of discussion of each health behavior topic was assessed by patient survey. RESULTS: Patient recall rates ranged from 11% for substance use assessment to 75% of smokers recalling smoking cessation advice. Patient demographics were not associated with recall. In multivariable models, the strongest predictor of patient recall of diet and exercise advice was the duration of the advice. Advice provided during well care visits was more likely to be recalled by patients than during illness visits, but presence of a health behavior-relevant diagnosis during an illness visit was associated with a 2-fold increase in patient recall. CONCLUSIONS: Patient recall of health behavior advice is enhanced by longer duration of advice and by linking advice to visit contexts that represent teachable moments.

Diet↗
PubMed2004

Gender differences in time spent during direct observation of doctor-patient encounters.

BACKGROUND: Despite increasing recognition of women's health needs, little is known about how primary care physicians spend time with women. Therefore, we examined differences in time use and preventive service delivery during outpatient visits by male and female patients. METHODS: As part of a multimethod study of 138 family physicians, 3384 outpatient visits by adults were directly observed, medical records were reviewed, and patient surveys were performed. Time use was assessed by the Davis Observation Code, which classifies every 15 seconds into 20 behavioral categories. Receipt of health habit counseling recommended by the U.S. Preventive Services Task Force was assessed by direct observation, and eligibility was determined by chart review. Logistic regression and multivariate analysis of variance (ANOVA) were used to compare time use and preventive service delivery in visits by women vs. men. RESULTS: Sixty-four percent of adult visits were from women. Women reported poorer physical health, had higher rates of anxiety (12.5% vs. 7.4% in men), and depression (21.9% vs. 8.4% in men), a higher percent of visits for well care (10.2% vs. 8.8% in men), and more drugs prescribed (64.8% vs. 61% in men) and raised more emotional issues than men (14.7% vs. 7.5%). After controlling for visit and patients characteristics, visits by women had a higher percent of time spent on physical examination, structuring the intervention, patient questions, screening, and emotional counseling. Visits by men involved a higher percent of time spent on procedures and health behavior counseling. More eligible men than women received exercise, diet, and substance abuse counseling. Patients of female physicians exhibited gender differences in only one category of how time was spent (substance abuse), whereas among patients of male physicians, gender differences were noted in 10 of the 20 categories. CONCLUSIONS: Outpatient visits by women differ from those of men in ways that reflect women's unique healthcare needs but also raise concern about unequal delivery of health habit counseling for diet and exercise.

Adult↗
PubMed2004

A comparison of the National Ambulatory Medical Care Survey (NAMCS) measurement approach with direct observation of outpatient visits.

BACKGROUND: The National Ambulatory Medical Care Survey (NAMCS) informs a wide range of important policy and clinical decisions by providing nationally representative data about outpatient practice. However, the validity of the NAMCS methods has not been compared with a reference standard. METHODS: Office visits of 549 patients visiting 30 family physicians in Northeastern Ohio were observed by trained research nurses. Visit content measured by direct observation was compared with data reported by physicians using the 1993 NAMCS form. RESULTS: Outpatient visit physician reports of procedures and examinations using the NAMCS method showed generally good concordance with direct observation measures, with kappas ranging from 0.39 for ordering a chest x-ray to 0.86 for performance of Pap smears. Concordance was generally lower for health behavior counseling, with kappas ranging from 0.21 for alcohol counseling to 0.60 for smoking cessation advice. The NAMCS form had high specificity (range, 0.90-0.99) but variable (range, 0.12-.84) sensitivity compared with direct observation, with the lowest sensitivities for health behavior counseling. The NAMCS physician report method overestimated visit duration in comparison with direct observation (16.5 vs. 12.8 minutes). CONCLUSIONS: Compared with direct observation of outpatient visits, the NAMCS physician report method is more accurate for procedures and examinations than for health behavior counseling. Underreporting of behavioral counseling and overreporting of visit duration should lead to caution in interpreting findings based on these variables.

Adolescent↗
PubMed2003

Use of indoor tanning facilities by white adolescents in the United States.

CONTEXT: Indoor tanning is a risk factor for skin cancer, but the population-based prevalence of this behavior among adolescents is not clearly known. OBJECTIVES: To describe the prevalence of tanning booth use among white US adolescents and to assess its association with sociodemographic factors, health behaviors, and appearance. DESIGN, SETTING, AND PARTICIPANTS: A nationally representative sample of 6903 non-Hispanic white adolescents, aged 13 to 19 years, who participated in Wave II (between April 1, 1996, and August 31, 1996) of the National Longitudinal Study of Adolescent Health. MAIN OUTCOME MEASURE: Frequency of lifetime use of indoor artificial tanning facilities. RESULTS: With the data weighted to national levels, 36.8% of the white female adolescents and 11.2% of the white male adolescents have used a tanning booth at least once in their life, while 28.1% and 6.9% of the female and male adolescents, respectively, reported tanning booth use 3 or more times. The percentage of female adolescents using tanning booths 3 or more times increased with age, from 11.2% of the 13- to 14-year-olds to 47.0% of 18- to 19-year-olds and also increased with greater tanning ability, from 12.6% of the poor tanners to 38.1% of those with a strong tan response. After multivariate adjustment, those residing in the Midwest (adjusted odds ratio [aOR], 2.38; 95% confidence interval [CI], 1.53-3.68) or South (aOR, 2.91; 95% CI, 1.89-4.53), attending a rural high school (aOR, 1.80; 95% CI, 1.09-2.98), and reporting the use of 2 or 3 substances (aOR, 3.06; 95% CI, 2.44-3.82) were more likely to use indoor tanning facilities, as were dieters (aOR, 1.26; 95% CI, 1.01-1.57) regardless of their body mass index. Decreased odds of indoor tanning were observed among those with a college-educated mother (aOR, 0.68; 95% CI, 0.51-0.90) and greater cognitive ability (per 10-point score increase; aOR, 0.89; 95% CI, 0.82-0.96) while routine participation in physical activity significantly lowered the odds of indoor tanning only among female adolescents. CONCLUSIONS: Indoor tanning is prevalent, particularly among female adolescents, and aligns with other risk behaviors, appearance-related factors, and intentional sunbathing. The risks of artificial tanning need increased emphasis among adolescents, especially in the Midwest and South where extremes in the availability of natural light appear to send intentional tanners indoors.

Adolescent↗
PubMed2003

Tools, teamwork, and tenacity: an examination of family practice office system influences on preventive service delivery.

BACKGROUND: Most research examining primary care office characteristics and preventive service delivery (PSD) has evaluated preventive service aids and equipment, while generally overlooking the complex interactions among multiple office systems where multiple factors influence the overall practice. We test a theoretical model of practice influences on PSD that accounts for Tools (preventive service aids/equipment), Teamwork (office organization), and Tenacity (prevention delivery attitudes). METHODS: Office characteristics and 4454 patient visits were observed for 138 family physicians in northeast Ohio. Utilizing U.S. Preventive Services Task Force recommendations, age- and gender-specific PSD summary scores were computed for each patient and then averaged per physician. Multivariate analysis of variance tested office characteristic associations with PSD scores. RESULTS: Tools were common, but most were not significantly associated with PSD scores. The Teamwork indicators of clear staff role expectations and shared vision among physician and staff existed, respectively, for 80 and 73% of physicians. A high average reported practice focus on prevention existed, despite low staff involvement in PSD (22.2%). Compared with Tools, more Teamwork and Tenacity characteristics were associated with the PSD scores. CONCLUSION: Teamwork and Tenacity appear to be more important than Tools in delivering preventive services in primary care practices.

Adult↗
PubMed2003

Sustainability of a practice-individualized preventive service delivery intervention.

BACKGROUND: The long-term effect of most interventions has not been studied. Changes due to interventions to improve patient care may revert to baseline after the intervention stimulus ends. This analysis reports the 24-month follow-up of a practice-tailored intervention to increase preventive service delivery rates. DESIGN: Group randomized clinical trial with 24-month follow-up of intervention sites. SETTING/PARTICIPANTS: Seventy-seven community family practices in northeast Ohio. INTERVENTION: Practice-individualized facilitation of implementation of tools and approaches. MAIN OUTCOME MEASURES: Summary scores of health habit counseling, screening, and immunization services recommended by the U.S. Preventive Services Task Force that were up to date for consecutive patients during randomly selected chart review days. RESULTS: Previously reported increases in global preventive service delivery rates, health habit counseling, and screening rates at 12 months were sustained after 24 months. CONCLUSIONS: A practice-individualized approach can result in sustainable increases in rates of preventive service delivery, even 1 year after the outside intervention stimulus ends. Tailoring of approaches to the unique characteristics of each practice may result in institutionalization of changes.

Counseling↗
PubMed2003

Time use during acute and chronic illness visits to a family physician.

OBJECTIVE: To identify differences in time use during acute and chronic care visits. POPULATION: Patients coming to outpatient offices of physician members of a practice-based research network in Ohio. MEASURES: Direct observation and coding of physician activities during acute and chronic care visits. RESULTS: Time use varied by visit type with more time spent on compliance assessment, negotiation, and nutrition advice during chronic care visits. Acute care visits included more time for procedures, physical examination, feedback on test results and health education. CONCLUSION: Physicians structure their use of time to fit the differing goals of acute and chronic care visits.

Acute Disease↗
PubMed2003

Does time use in outpatient residency training reflect community practice?

BACKGROUND: The degree to which the ideals practiced during residency training persist amidst the pressures of community practice is unknown. Therefore, this paper compares time use during outpatient visits to family practice residents and experienced family physicians. METHODS: Visits of 244 new adult outpatients to 33 second- and third-year residents in a university clinic in Northern California were compared to 277 new adult outpatient visits to 92 community family physicians in Northeast Ohio, using the Davis Observation Code (DOC). The DOC uses observation to classify visit time into 20 different behavioral categories, reflecting different physician styles of interaction with patients. RESULTS: Controlling for patient mix, residents had longer visits, a less technical focus, and spent a greater percent of the visit on efforts to promote health behavior change, patient activation, preventive services, discussion of substance abuse, and counseling. CONCLUSIONS: Experienced family physicians provide more technical and less preventive and psychosocially oriented care than residents. This may reflect differences in patient mix, practice setting, physician experience, and the time and financial pressures of community practice. These findings may be used to modify residency training to better reflect actual community practice and to guide future studies of the effects of experience and different practice environments on physician style with patients.

Ambulatory Care↗