PURPOSE This study aimed to examine the contribution of competing demands to changes in hypoglycemic medications and to return appointment intervals for patients with type 2 diabetes and an elevated glycosylated hemoglobin (A 1c ) level. METHODSWe observed 211 primary care encounters by adult patients with type 2 diabetes in 20 primary care clinics and documented changes in hypoglycemic medications. Competing demands were assessed from length of encounter, number of concerns patients raised, and number of topics brought up by the clinician. Days to the next scheduled appointment were obtained at patient checkout. Recent A 1c values and dates were determined from the chart. RESULTSAmong patients with an A 1c level greater than 7%, each additional patient concern was associated with a 49% (95% confi dence interval, 35%-60%) reduction in the likelihood of a change in medication, independent of length of the encounter and most recent level of A 1c . Among patients with an A 1c level greater than 7% and no change in medication, for every additional minute of encounter length, the time to the next scheduled appointment decreased by 2.8 days (P = .001). Similarly, for each additional 1% increase in A 1c level, the time to the next scheduled appointment decreased by 8.6 days (P = .001). CONCLUSIONSThe concept of clinical inertia is limited and does not fully characterize the complexity of primary care encounters. Competing demands is a principle for constructing models of primary care encounters that are more congruent with reality and should be considered in the design of interventions to improve chronic disease outcomes in primary care settings. 2007;5:196-201. DOI: 10.1370/afm.679. Ann Fam Med INTRODUCTIONA lthough tight glucose control can prevent or delay the onset of complications in patients with type 2 diabetes mellitus, 1-3 optimal control is frequently not achieved. [4][5][6] Recently, poor glucose control has been attributed to so-called clinical inertia on the part of physicians, defi ned as "recognition of the problem, but failure to act." [7][8][9][10][11][12] Some have even proposed methods for a measure of clinical inertia as a quality of care indicator. 13 The phenomenon of clinical inertia has been diffi cult to study because of the paucity of data on the content of the patient-physician encounter. All published studies of clinical inertia to date have used administrative or medical record data.An alternative explanation for failure to intensify therapy despite poor glucose control is the presence of competing demands.14-18 Encounters are bounded by a time constraint within which multiple diagnoses, problems, and patient concerns compete with each other for a place on the agenda. Physicians and patients prioritize demands and only deal with the most pressing or symptomatic problem.14 Problems perceived to be less urgent, for example, intensifying medication therapy for poorly controlled glycosylated hemoglobin (A 1c 1. As the length of the encounter decreases, the likelihood of a change in hy...

BackgroundPractice facilitation (PF) is an implementation strategy now commonly used in primary care settings for improvement initiatives. PF occurs when a trained external facilitator engages and supports the practice in its change efforts. The purpose of this group-randomized trial is to assess PF as an intervention to improve the delivery of chronic illness care in primary care.MethodsA randomized trial of 40 small primary care practices who were randomized to an initial or a delayed intervention (control) group. Trained practice facilitators worked with each practice for one year to implement tailored changes to improve delivery of diabetes care within the Chronic Care Model framework. The Assessment of Chronic Illness Care (ACIC) survey was administered at baseline and at one-year intervals to clinicians and staff in both groups of practices. Repeated-measures analyses of variance were used to assess the main effects (mean differences between groups) and the within-group change over time.ResultsThere was significant improvement in ACIC scores (p < 0.05) within initial intervention practices, from 5.58 (SD 1.89) to 6.33 (SD 1.50), compared to the delayed intervention (control) practices where there was a small decline, from 5.56 (SD 1.54) to 5.27 (SD 1.62). The increase in ACIC scores was sustained one year after withdrawal of the PF intervention in the initial intervention group, from 6.33 (SD 1.50) to 6.60 (SD 1.94), and improved in the delayed intervention (control) practices during their one year of PF intervention, from 5.27 (SD 1.62) to 5.99 (SD 1.75).ConclusionsPractice facilitation resulted in a significant and sustained improvement in delivery of care consistent with the CCM as reported by those involved in direct patient care in small primary care practices. The impact of the observed change on clinical outcomes remains uncertain.Trial registrationThis protocol followed the CONSORT guidelines and is registered per ICMJE guidelines: Clinical Trial Registration Number: NCT00482768.

OBJECTIVE—The purpose of this study was to examine the relationship between A1C and the extent to which care delivered to patients with type 2 diabetes in primary care clinics is consistent with the chronic care model (CCM), after controlling for self-care behaviors. RESEARCH DESIGN AND METHODS—This was a cross-sectional, observational study of care provided to 618 patients with type 2 diabetes across 20 small, autonomous primary care clinics in South Texas. Subjects completed an exit survey. The medical record was abstracted for A1C values. Clinicians completed the Assessment of Chronic Illness Care (ACIC) survey, a validated measure of the extent to which care delivered is consistent with the CCM. RESULTS—There was a significant relationship between ACIC score and A1C, but this relationship varied according to self-care behavior for exercise and was strongest for those who did not adhere to exercise recommendations: for every 1-point increase in ACIC score, A1C was 0.144% lower (P &lt; 0.001). The relationship between ACIC score and A1C for those who adhered to their diet was similar to that for those who did not, after adjusting for exercise, but the overall level of control was better for those who adhered to their diet. CONCLUSIONS—Characteristics of the primary care clinic where one receives care are an important predictor of glucose control. If resources for implementing the CCM are limited, one might want to focus on clinics with low ACIC scores that serve a population of patients who are sedentary because this population may be likely to realize the most benefit from improved glucose control.

PURPOSE Interventions tailored to sociopsychological factors associated with health behaviors have promise for reducing colorectal cancer screening disparities, but limited research has assessed their impact in multiethnic populations. We examined whether an interactive multimedia computer program (IMCP) tailored to expanded health belief model sociopsychological factors could promote colorectal cancer screening in a multiethnic sample. METHODSWe undertook a randomized controlled trial, comparing an IMCP tailored to colorectal cancer screening self-efficacy, knowledge, barriers, readiness, test preference, and experiences with a nontailored informational program, both delivered before office visits. The primary outcome was record-documented colorectal cancer screening during a 12-month follow-up period. Secondary outcomes included postvisit sociopsychological factor status and discussion, as well as clinician recommendation of screening during office visits. We enrolled 1,164 patients stratified by ethnicity and language (49.3% non-Hispanic, 27.2% Hispanic/English, 23.4% Hispanic/Spanish) from 26 offices around 5 centers (Sacramento, California; Rochester and the Bronx, New York; Denver, Colorado; and San Antonio, Texas). RESULTSAdjusting for ethnicity/language, study center, and the previsit value of the dependent variable, compared with control patients, the IMCP led to significantly greater colorectal cancer screening knowledge, self-efficacy, readiness, test preference specificity, discussion, and recommendation. During the followup period, 132 (23%) IMCP and 123 (22%) control patients received screening (adjusted difference = 0.5 percentage points, 95% CI -4.3 to 5.3). IMCP effects did not differ significantly by ethnicity/language. CONCLUSIONS Sociopsychological factor tailoring was no more effective than nontailored information in encouraging colorectal cancer screening in a multiethnic sample, despite enhancing sociopsychological factors and visit behaviors associated with screening. The utility of sociopsychological tailoring in addressing screening disparities remains uncertain. 2014;204-214. doi: 10.1370/afm.1623. Ann Fam Med INTRODUCTIONC olorectal cancer screening is underutilized.1,2 Screening rates are particularly low among Hispanic persons, reflecting language and socioeconomic barriers. 1,3 Approaches to motivate more individuals to undergo colorectal cancer screening and lessen ethnic screening disparities are needed.Interventions tailored to sociopsychological factors that may influence behavior, such as self-efficacy, stage of readiness, barriers, and others, 4 show promise.5 Such interventions use responses elicited from individuals to match the content and amount of information to individual needs and sociopsychological factors, with the proximate goal of enhancing the factors. [6][7][8] Tailoring of information increases its perceived relevance, promotes deeper cognitive processing, and improves recall. 9 Further, in randomized controlled trials tailored interventions are more eff...