External validity: we need to do more.
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Data Collection↗
Biomedical subjects
Michael G Goldstein
Publications and source records attributed to Michael G Goldstein.
Randomized controlled trial of physical activity counseling for older primary care patients.
BACKGROUND: Regular physical activity reduces the risk for chronic diseases among older adults. Older adults are likely to be seen by primary care clinicians who can play a role in promoting physical activity among their patients. DESIGN: In this randomized controlled trial (1998-2003; data analyzed 2004-2005), we compared the effects of brief advice to exercise from a clinician supplemented by telephone-based counseling by health educators (extended advice) to brief advice from a clinician alone (brief advice). SETTING/PARTICIPANTS: A total of 100 primary care patients (63.2% female, 14.7% minority, mean age=68.5 years) participated in the trial. INTERVENTIONS: The extended-advice intervention consisted of clinician advice plus exercise counseling via telephone provided by research staff, and the brief advice condition consisted of clinician advice alone. Both interventions focused on promoting moderate-intensity physical activity. MAIN OUTCOME MEASURES: Self-reported physical activity using the 7-Day Physical Activity Recall instrument and objective activity monitoring using Biotrainers were assessed at baseline, and at 3 and 6 months. RESULTS: Participants in the extended-advice arm reported significantly greater participation in moderate-intensity physical activity than the brief-advice group at 3 months (+57.69 minutes vs 12.45 minutes; 3.84 kcal/week vs 0.83 kcal/week) and 6 months (+62.84 minutes vs 16.60 minutes; 4.19 kcal/week vs 1.1 kcal/week). Objective activity monitoring also showed significantly increased physical activity among extended-advice versus brief-advice participants at both time points (+50.79 vs -11.11; +42.39 vs -24.18, respectively). CONCLUSIONS: These data indicate that clinician advice with follow-up counseling can promote adoption of moderate-intensity physical activity among older, primary care patients.
Aged↗
Translating what we have learned into practice. Principles and hypotheses for interventions addressing multiple behaviors in primary care.
BACKGROUND: The evidence base regarding what works in practice for helping patients change multiple risk behaviors is less developed than is the more basic literature on behavior change. Still, there is enough consistency of findings to present testable hypotheses for clinicians and administrators to evaluate and guide practice until more definitive evidence is available. METHODS: The behavior change principles known as the 5A's outline a sequence of support activities (assess, advise, agree, assist, arrange) that are effective for helping patients to change various health behaviors. These same principles also apply at the clinic level for designing activities to support behavior change. RESULTS: Successful practices promoting sustainable changes in multiple behaviors are patient centered, tailored, proactive, population based, culturally proficient, multilevel, and ongoing. Often a stepped-care model can be used to provide increasingly intensive (and costly) interventions for patients who are not successful at earlier intervention levels. CONCLUSIONS: Contextual factors are influential in determining success at both the patient and the office practice level. Therefore, greater attention should be paid to creating supportive family, healthcare system, and community resources and policies. We enumerate 15 hypotheses to be tested for improving patient-clinician interactions and for medical office change.
Behavior Therapy↗
Multiple behavioral risk factor interventions in primary care. Summary of research evidence.
BACKGROUND: An important barrier to the delivery of health behavior change interventions in primary care settings is the lack of an integrated screening and intervention approach that can cut across multiple risk factors and help clinicians and patients to address these risks in an efficient and productive manner. METHODS: We review the evidence for interventions that separately address lack of physical activity, an unhealthy diet, obesity, cigarette smoking, and risky/harmful alcohol use, and evidence for interventions that address multiple behavioral risks drawn primarily from the cardiovascular and diabetes literature. RESULTS: There is evidence for the efficacy of interventions to reduce smoking and risky/harmful alcohol use in unselected patients, and evidence for the efficacy of medium- to high-intensity dietary counseling by specially trained clinicians in high-risk patients. There is fair to good evidence for moderate, sustained weight loss in obese patients receiving high-intensity counseling, but insufficient evidence regarding weight loss interventions in nonobese adults. Evidence for the efficacy of physical activity interventions is limited. Large gaps remain in our knowledge about the efficacy of interventions to address multiple behavioral risk factors in primary care. CONCLUSIONS: We derive several principles and strategies for delivering behavioral risk factor interventions in primary care from the research literature. These principles can be linked to the "5A's" construct (assess, advise, agree, assist, and arrange-follow up) to provide a unifying conceptual framework for describing, delivering, and evaluating health behavioral counseling interventions in primary healthcare settings. We also provide recommendations for future research.
Adult↗
Addressing multiple behavioral risk factors in primary care. A synthesis of current knowledge and stakeholder dialogue sessions.
BACKGROUND: Addressing behavioral risk factors in primary care has become a pressing concern due to the increasing burden of behavioral risk factors on disease, healthcare costs, and public health. Risk factors considered include smoking, risky drinking, sedentary lifestyle, and unhealthy diet-singly or in combination. The already burdened primary care system needs a practical approach to efficiently and effectively address any combination of multiple risk factors. Multiple perspectives and broad insight are urgently needed to gain a deeper understanding of the interacting scientific, systems, and policy issues associated with multiple risk factor interventions (MRFIs). PURPOSE: This paper synthesizes findings from literature reviews, epidemiologic analyses, and structured interactive dialogue sessions, and includes a set of recommendations designed to stimulate further action. METHODS: Several papers were produced to document current knowledge, research evidence, and salient issues related to multiple risk factor assessment and intervention. Structured interactive dialogue sessions were then conducted with clinician, health system, and health policy leaders regarding what advantage or energy would be liberated by a multiple risk factor approach (rather than separate single risk factor approaches), and how to build a policy framework or constituency for MRFIs. This information is synthesized in this paper. RESULTS: There is a clear need to address MRFIs among multiple stakeholders, including patients, purchasers, payers, clinicians, health system leaders, and policy-level stakeholders. MRFIs need to bring with them a compelling value proposition for all stakeholders, and a vision of practical and systematic ways to make it a reality in already-pressed primary care practices. Involving stakeholders in dialogue aimed at helping them see the world through each other's eyes helps overcome discouragement and generates energy for jointly designing new approaches. Recommendations for further action include the creation of multistakeholder dialogue, creation of a policy agenda, development of a translation or integration agenda that connects researchers and practitioners in a two-way exchange, initiation of a series of demonstration projects around MRFIs, and support for research on multiple (rather than only single) risk factor interventions. CONCLUSIONS: The need to address multiple behavioral risk factors in primary care is increasingly urgent. Whereas stakeholders by themselves may be willing to address multiple risk factors, they agree that it can only be done successfully with a collaborative approach. Findings based on evidence reviews, hypotheses generation, and stakeholder dialogue provide guidance for appropriate further action that, based on what is known already, can be initiated right away.
Adult↗
Reliability of assessment and circumstances of performance of thorough skin self-examination for the early detection of melanoma in the Check-It-Out Project.
BACKGROUND: Thorough skin self-examination (TSSE) has substantial potential to reduce melanoma mortality by early detection. METHODS: We interviewed 2,126 patients before a scheduled routine visit with a primary care physician, at which participation in a randomized trial was offered as part of the Check-It-Out Project. We asked about skin examination behavior and related issues. RESULTS: By our a priori definition of TSSE, 18% of participants performed this activity, but other definitions led to widely varying estimates of 12% to 38%. Using a partner to assist in the examination was strongly associated with TSSE. That partner was generally the spouse, and wives were more likely to assist their husbands in these examinations than the reverse. The availability of a wall mirror was a particularly important predictor of TSSE performance. Visual impairment also affected performance. CONCLUSIONS: Estimates of TSSE performance vary substantially with the questions used to elicit this information. Partners, particularly spouses, appear to play a critical role in the conduct of TSSE, and wives appear more often and more effectively engaged in this process. Appropriate circumstances, such as availability of a wall mirror, are also important factors. These findings can be used to design interventions to increase TSSE performance with the ultimate aim of reducing melanoma mortality.
Female↗
Accuracy of recall of exercise counseling among primary care patients.
BACKGROUND: In evaluating the efficacy of health care provider counseling to encourage patients to modify health behaviors such as physical activity, it is important to be able to accurately measure the extent of health care provider counseling. METHODS: The Physical Activity Exit Interview (PAEI) is a brief measure of a patient's perception of the content of physical activity promotion counseling received during a visit with his or her physician. Forty-three primary care patients, and their physicians, completed a PAEI following a visit, which was compared to an audiotape of the visit that was coded to identify the physical activity counseling steps taken. RESULTS: Participants were 67% female, 81.7% white, and had a mean age of 47.1 years. Overall, there was good concordance in the overall number of counseling activities reported between patients and audiotapes (r = 0.47, P < 0.01), patients and physicians (r = 0.51, P < 0.01), and between physicians and audiotapes (r = 0.57, P < 0.01). Significant differences between the three measurement methods (patient exit interview, physician exit interview, audiotape) existed for only 4 of 12 items. CONCLUSIONS: The PAPEI was overall accurate in measuring the content of physical activity counseling, though accuracy differed between items. When discrepancy occurred, it was typically due to patient overreporting of counseling steps.
Adult↗
Feasibility of incorporating computer-tailored health behaviour communications in primary care settings.
BACKGROUND: We set out to investigate the feasibility of incorporating a computer-tailored health behaviour program into routine care in a group of primary care practices in Rhode Island. METHODS: Two existing computer programs (physical activity, smoking) that tailored text and graphical feedback to survey responses were combined and adapted for use in primary care directly by patients. Ten primary care practices were recruited and worked closely with project staff to develop a practice-specific plan for incorporating the program into the workflow and office routine. Feasibility was measured by the percentage of patients who used the program during the day of their visit. RESULTS: Only one of the ten offices was able to successfully incorporate the program into their office workflow and delivery of routine care. The main categories of barriers to incorporating the computer program into routine care included: the program was viewed overall as inconsistent with practice workflow, the staff was inexperienced with the program, technical problems with the computer and/or printer, the program placed an additional time burden on staff who already felt overworked. Suggestions for improving the program or the way that it was incorporated into routine care included: shortening the program, modifying the program's orientation to a target population (such as patients with hypertension) and incorporating decision-support feedback to help physicians manage the target condition, modifying the program to include other programs pertinent to primary care (for example, depression screening), selecting patients to use the program, rather than asking all patients to use it. CONCLUSIONS: After working closely with ten highly motivated primary care offices, we were unable to fully implement a point-of-care health behaviour computer system for patients and providers. Suggestions for disseminating computer-tailored health behaviour communications in primary care settings are discussed.
Feasibility Studies↗
Supporting self-management to improve diabetes care.
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Chronic Disease↗
An academic detailing intervention to disseminate physician-delivered smoking cessation counseling: smoking cessation outcomes of the Physicians Counseling Smokers Project.
BACKGROUND: Little is known about the effectiveness of interventions to disseminate smoking cessation interventions among a population of primary care physicians. This study's objective was to determine the effect of a community-based academic detailing intervention on the quit rates of a population-based sample of smokers. METHODS: This community-based, quasi-experimental study involved representative samples of 259 primary care physicians and 4295 adult smokers. An academic detailing intervention was delivered to physicians in intervention areas over a period of 15 months. Analyses were performed on the data from the 2346 subjects who reported at least one physician visit over 24 months. Multivariate regression analyses were conducted to determine the impact of the intervention on self-reported smoking quit rates, reported by adjusted odds ratios. RESULTS: Among smokers reporting a physician visit during the study period, there was a borderline significant effect for those residing in intervention areas versus control areas (OR = 1.35; 95% CI.99-1.83; P = 0.057). Among a subgroup of 819 smokers who reported a visit with an enrolled physician, we observed a significant effect for those residing in intervention areas (OR = 1.80; 95% CI 1.16-2.75; P = 0.008). CONCLUSION: An academic detailing intervention to enhance physician delivered smoking cessation counseling is an effective strategy for disseminating smoking cessation interventions among community-based practices.
Adult↗
Assessing the transtheoretical model of change constructs for physicians counseling smokers.
Baseline data from a population-based sample of 259 primary care physicians were used to examine the interrelations of 3 central constructs of the Transtheoretical Model of Change (TTM; stages of change, self-efficacy, and decisional balance) in regard to smoking cessation counseling behavior. In this article we explore the potential use of the TTM for future interventions to help understand and guide physicians' behavior change toward increasing adoption of smoking cessation interventions with their patients. It was hypothesized that self-efficacy and the decisional balance of counseling would be significantly related to physicians' stages of change, which in turn would be related to self-reported physician counseling behavior. Principal components analyses were conducted to examine the self-efficacy and decisional balance constructs. Coefficient alphas were.90 for self-efficacy and.84 and.78 for the pros and cons scales, respectively. Consistent with the TTM, analyses of variance revealed that later stages of physicians' readiness to provide smoking cessation counseling were associated with higher self-efficacy scores. Earlier stages showed significantly higher cons and lower pros of smoking cessation counseling. Structural equation modeling procedures supported the hypothesized path analysis model in which 3 constructs related to stage of readiness, which in turn related to reported physicians' counseling behavior.
Adult↗
The impact of the basic skin cancer triage curriculum on providers' skills, confidence, and knowledge in skin cancer control.
BACKGROUND: Primary care providers (PCPs) are in the unique position of being able to deliver preventive health care services to the majority of the general population. Early detection of skin cancer may reduce mortality, but many PCPs do not participate in skin cancer control activities due to lack of training and confidence. We sought to evaluate the effect of a 2-h, Basic Skin Cancer Triage (BSCT) curriculum in overcoming these barriers. METHODS: A convenience sample of 28 primary care providers participated in a 2-h training curriculum. Assessments included skills (evaluated by a 20-item slide quiz), confidence, knowledge, and attitudes measured pre- and post training. RESULTS: Provider ability to accurately diagnose and triage lesions significantly improved (46 to 64%, P < 0.0001, and 61 to 71%, P < 0.0001, respectively). The greatest improvement in triage ability occurred in providers ability to appropriately reassure patients about lesions (49 to 70%, P < 0.0001). There were also significant improvements in both knowledge of skin cancer control practices (68 to 74% correct answers, P = 0.026) and confidence in ability to provide skin cancer preventive services (2.95 to 4.13 on a 1 to 5 scale, P < 0.0001). CONCLUSIONS: Participation in the BSCT curriculum may improve providers' diagnostic and triage accuracy of skin cancer as well as increase their knowledge of skin cancer and confidence in their provision of skin cancer control activities. Defining the full potential impact of this curriculum requires further evaluation.
Adult↗
Negative mood, depressive symptoms, and major depression after smoking cessation treatment in smokers with a history of major depressive disorder.
Negative mood, depressive symptoms, and major depressive episodes (MDEs) were examined in 179 smokers with a history of major depression in a trial comparing standard smoking cessation treatment to treatment incorporating cognitive-behavioral therapy for depression (CBT-D). Early lapses were associated with relatively large increases in negative mood on quit date. Mood improved in the 2 weeks after quit date among those returning to regular smoking but not among those smoking moderately. Continuous abstinence was associated with short- and long-term reductions in depressive symptoms. MDE incidence during follow-up was 15.3% and was not associated with abstinence. Unexpected was that CBT-D was associated with greater negative mood and depressive symptoms and increased MDE risk. Results suggest complex bidirectional associations between affect and smoking outcomes.
Adolescent↗
Patterns of change in depressive symptoms during smoking cessation: who's at risk for relapse?
The authors examined patterns of change in depressive symptoms during smoking cessation treatment in 163 smokers with past major depressive disorder (MDD). Cluster analysis of Beck Depression Inventory (A. T. Beck, C. H. Ward, M. Mendelson, J. Mock, & J. Erbaugh, 1961) scores identified 5 patterns of change. Although 40% of participants belonged to clusters characterized by increasing depressive symptoms during quitting (rapid increasers, n = 31, and delayed increasers, n = 35), almost 47% were in clusters characterized by decreasing symptoms (delayed decreasers, n = 24, and rapid decreasers, n = 52). Both rapid and delayed increasers had especially poor smoking cessation outcomes. Results suggest that among smokers with an MDD history there is substantial heterogeneity in patterns of depressive symptoms during quitting and that patterns involving increased symptoms are associated with low abstinence rates.
Adult↗
Multicenter trial of fluoxetine as an adjunct to behavioral smoking cessation treatment.
The authors evaluated the efficacy of fluoxetine hydrochloride (Prozac; Eli Lilly and Company, Indianapolis, IN) as an adjunct to behavioral treatment for smoking cessation. Sixteen sites randomized 989 smokers to 3 dose conditions: 10 weeks of placebo, 30 mg, or 60 mg fluoxetine per day. Smokers received 9 sessions of individualized cognitive-behavioral therapy, and biologically verified 7-day self-reported abstinence follow-ups were conducted at 1, 3, and 6 months posttreatment. Analyses assuming missing data counted as smoking observed no treatment difference in outcomes. Pattern-mixture analysis that estimates treatment effects in the presence of missing data observed enhanced quit rates associated with both the 60-mg and 30-mg doses. Results support a modest, short-term effect of fluoxetine on smoking cessation and consideration of alternative models for handling missing data.
Adult↗
Academic profiling of tobacco-related performance measures in primary care.
Academic detailing and data feedback are two methods that have been used to change provider behavior. Academic profiling is proposed as an intervention that combines provider educational outreach and peer-comparison feedback of data generated from chart reviews and health plans. This project assessed the feasibility of academic profiling, using baseline measures to assess provider performance in identifying and treating patients who smoke. The pilot study was undertaken with four primary care practices in Maine. Two health plans shared administrative claims data on adult patients of participating providers. Two educational sessions were conducted: one including feedback of tobacco-related chart documentation and claims for nicotine replacement and bupropion (Zyban), and the other, coding for tobacco use (ICD-9 305.1) in adults enrolled in two health plans during 1998. A mailed survey assessed provider attitudes following the intervention. Among 24 providers, 80% attended the first session and 70% attended the second session. Provider documentation of tobacco status in the medical records varied from 68% to 100%. The frequency of tobacco pharmacotherapy claims for adult health plan enrollees having a provider visit in 1998 varied from 0% to 4.6% (mean 1.5%) by provider. The frequency of tobacco use diagnosis claims (ICD-9 305.1) varied from 0% to 19.8% by provider. More than 90% of the providers who reviewed the profiling graphs found the data were understandable, and 66% reported that the sessions helped them improve the ways they interact with patients who smoke. Practices vary in tobacco-related documentation, the prescribing of tobacco pharmacotherapy, and the coding for tobacco use. Providers are willing to participate in educational outreach using peer-comparison feedback, presenting opportunities to improve performance in the treatment of tobacco dependence.
Adult↗
Physician recruitment for a community-based smoking cessation intervention.
OBJECTIVE: Our goal was to describe a strategy to recruit a population-based sample of physicians into a trial to test an approach to disseminate physician-delivered smoking cessation interventions. STUDY DESIGN: The 3-phase population-based recruitment trial included: (1) a print-based promotional appeal, (2) in-person presentations with by the principal investigator (PI), and (3) follow-up calls by the PI and paid physician recruiters. Participation requirements were kept minimal to facilitate recruitment. POPULATION: All primary care physicians statewide were targeted; 3 counties were chosen as intervention areas and 2 counties as control areas. A subsample of physicians was targeted in the larger control areas through a matching process. OUTCOME MEASURED: We measured physician recruitment rate. RESULTS: Eighty-one percent (n=259) of all eligible physicians were successfully recruited into our study. CONCLUSIONS: The full multistep process was important in getting participation agreement. By using an intensive recruitment strategy and minimizing research demands, it is possible to recruit community-based primary care physicians for research projects that will help them enhance the preventive services they provide to their patients.
Health Services Research↗