A study led by Ming Tai-Seale, Ph.D., MPH, associate director of PAMFRI, received $5.8 million to assess the effectiveness of three different approaches to enhancing patient-doctor communication in a primary care setting.

“We want to enable patients to have a voice in their care from the beginning,” said Dr. Tai-Seale. “This project encourages patients to be better prepared and to engage in shared decision making so that they will get more out of their visit. And it will help doctors and patients choose the best treatment plan for the patient.’’

Dr. Ming Tai-Seale at a conference held by Health Affairs, a leading policy journal.

An award for $50,000 went to the Guzik Family Center for Geriatrics and Palliative Care at PAMF to advance the Fostering Successful Aging project. Established in 2014, Fostering Successful Aging has received funding from PCORI for three consecutive years. The project’s goal is to engage older people, the medical community, researchers and other stakeholders in studying effective strategies to help seniors maintain their health and independence for as long as possible.

“This work focuses attention on value-based preventive care for seniors by discovering how patients can help contribute meaningfully to improving care for seniors both now and in the future,” said Peter H. Cheng, M.D., founder of the project and leader of geriatric medicine at PAMF’s Guzik Center.

Targeting Senior Care

Dr. Cheng co-leads this project together with Cheryl D. Stults, Ph.D., a research sociologist at PAMFRI, and Jane David, a PAMF patient and former caregiver of a senior PAMF patient.

The PCORI funding will be used to develop a design that compares two approaches to care for seniors as well as to support documenting the work of patient ambassadors. The patient ambassadors are a group of volunteers, ages 66 to 88, who participate in the project by sharing experiences about needing and receiving preventive care as well as insights on successful aging. The patient ambassadors are also working with researchers, educators, and health care professionals to develop tools and processes to improve delivery of preventive care.

The project focuses on practices and outcomes in the Medicare Annual Wellness Visit and a series of group appointments known as Mind, Body, Soul Shared Medical Appointments (SMA).

“This project is all about the power of collaboration and giving patients a special opportunity to be valued stakeholders and partners,” David said.

PAMF patient Jane David connects with fellow Successful Aging Ambassadors.

Evaluating Doctor-Patient Communication

Dr. Tai-Seale’s study assesses the effectiveness of three different tools for supporting communications between a patient and a doctor in a primary care setting. Some of the tools were developed during an earlier PCORI-funded pilot study known as the Open Communication study. The communication tools that the current study assesses include:

• A booklet that patients use to write down priorities for their office visits and reminders about recommended treatments and behaviors. A trained patient-physician communication coach also helps prepare the doctor for questions patients may have.
• A questionnaire that patients receive through My Health Online, a digital portal that lets Sutter Health patients manage their health online. Patients list priorities for the appointment via My Health Online; doctors then review the list to be better prepared for the visit.
• A poster that reminds the patients and doctors to discuss three questions about options, benefits and risks of options, and the likelihood that they would occur.

The four-year study will involve over 2,600 patients at PAMF and Sutter East Bay Medical Foundation clinics. Patients and doctors with Reliant Medical Group in Massachusetts also will be part of the study as well as researchers from the University of Massachusetts Medical School at Amherst.

Each approach to communication will be assessed by multiple outcome measures. Patients will fill out surveys on how well doctors engaged with them; investigators will review a patient’s action plan and gauge the patient’s intention to adhere to recommendations and treatments; and investigators also will look at clinical indicators and the patient’s quality of life immediately after a primary care session, and again three-months and 12- months later.

In addition to helping the patient get more out of an appointment, effective communication between a patient and a doctor may make health care systems more effective, Tai-Seale said.

“If a patient has their most important issue addressed clearly, they may be less likely to call or email with questions after the visit and be more satisfied with their care,’’ she said.

A recent Palo Alto Medical Foundation Research Institute (PAMFRI) study looked at ways to improve patient-physician communication through a cluster randomized controlled trial of four primary care clinics at the Palo Alto Medical Foundation (PAMF). Funding for the study was provided by the Patient Centered Outcomes Research Institute (PCORI),

Researchers tested two approaches:

The first approach, called “Open Communication,” was co-developed by the PAMF Research Institute team with patients, physicians and clinic staff. It contained three components:

1. A Visit Companion booklet for patients write down the issues or questions that matter to them most, and bring to their doctor visit
2. A short animated video that encourages patients and physicians to communicate openly
3. Physician communication coaching from a standardized patient coach on how to use the booklet with their patients

The second approach was based on the AskShareKnow of the ASK Patient-Clinician Communication Model which prompts patients to ask their doctor three questions about their options and risks.

Study results indicate that the Open Communication intervention increased patient-reported engagement in care and improved patient satisfaction, whereas the ASK Patient-Clinician Communication approach improved patient reported engagement in care only.

“It can be overwhelming for patients to remember everything they want to ask their doctor during their visit,” said PAMF Research Institute Principal Investigator Ming Tai-Seale, Ph.D., MPH. “The Visit Companion booklet helps the patient remember what they want to discuss most with their doctor.”

The study found that when patients are more engaged in their care, and when physicians have practiced their communication with the patient coach, both patient satisfaction and experience and patient satisfaction significantly improved. “It is important to create a friendly, comfortable environment for our patients, and a key component to developing that relationship is making sure what matters most to the patient is addressed during the visit, and ensuring that the patient and physician are on the same page before the end visit ends,” said Dr. Tai-Seale.

The PAMF Research Institute is partnering with the Palo Alto Medical Foundation’s Quality Improvement Steering Committee to disseminate the successful approaches to Palo Alto Medical Foundation providers, patients and others.

Watch the study in action

[brightcove video=”4427538305001″ blog=”12″ /]

Much of the dietary information presented as fact is actually myth, according to an article co-authored by a researchers at the Palo Alto Medical Foundation Research Institute (PAMFRI), Stanford and Albert Einstein College of Medicine. An article describing the study findings, is published in the May 1 issue of  American Family Physician, the American Academy of Family Physician’s peer-reviewed and evidence-based clinical journal for physicians and others in primary care.

The researchers studied dietary myths about vitamins and minerals (micronutrients); carbohydrates, proteins, and fats (macronutrients); dietary fibers; and how calories relate to weight loss. They found that the best diets share common features and a consistent theme: limit ultra-processed foods and eat whole or minimally processed foods – as close to what occurs in nature as possible.

Lenny Lesser, M.D.

“Myths usually take a simplified view of eating, and emphasize a focus on select food constituents as opposed to whole foods,” said Lenard Lesser, M.D., MSHS,  a family medicine physician at the Palo Alto Medical Foundation (PAMF) and research physician at PAMFRI. “For instance, if people consume ultra-processed foods that are altered, to add calcium and fiber and/or to remove saturated fats and calories, they will not necessarily be healthier, as myths imply. What we conclude is that dietary myths may stand in the way of healthy dietary choices for patients.”

Among the findings discussed in the article are:

• Diets higher in fat may produce and sustain as much or more weight loss than lower-fat or calorie-restricted diets, and diets higher in saturated fat do not necessarily increase mortality.
• Fibers added to processed food do not have the health benefits of foods naturally high in fiber like fruits and vegetables.
• Eating 3,500 calories less per week will not result in losing a pound of body fat per week.

This new research supports recommendations for people to limit the consumption of ultra-processed foods and to eat whole or minimally processed foods – generally in a form that is as close to what occurs in nature as possible.

“Physicians can help dispel myths for patients and give sound nutritional advice by focusing on actual foods and broader dietary patterns,” said Dr. Lesser.

The research was conducted by Lenard Lesser, M.D., MSHS, PAMF Research Institute, Mary Carol Mazza, Ph.D., PAMF Research Institute and Stanford Clinical Excellence Research Center, and Sean Lucan, M.D., MPH, MS, Albert Einstein College of Medicine.

The study evaluated primary care patients at the Palo Alto Medical Foundation (PAMF) and assessed the impact of the expansion in coverage on utilization of preventive visits. Among Medicare fee-for-service beneficiaries, annual preventive visit rates increased by two-fold, from 17 percent in 2007 to 32 percent in 2013.

Sukyung Chung, Ph.D.

“Initially, uptake of Annual Wellness Visits was slow in the first months of new coverage, but ramped up quickly, and by 2013, 32 percent of PAMF patients with traditional Medicare received a preventive visit,” Dr. Chung said. “We anticipate that the rate may continue to rise because the rate for those people is still lower than seniors with private insurance (44 percent) or with Medicare Advantage (52 percent).”

The results of this study suggest that Welcome to Medicare visits and Annual Wellness Visits were used by patients who would not have made a preventive visit without the Medicare coverage expansion. The study shows that relatively straightforward changes in coverage like this can have important and rapid effects on the use of preventive services. Prior to the Medicare’s preventive visit coverage, a physician might try to address preventive and acute or chronic problems during a single non-preventive visit. As coverage for Annual Wellness Visits expanded, preventive issues could be fully addressed in the preventive visit and more chronic issues could be better handled during other problem-focused visits.

“One goal of Healthy People 2020 is a 10 percent increase in the proportion of older adults who receive a core set of preventive services,” Dr. Chung said. “To achieve this goal, providers and patients will have to take full advantage of the Medicare coverage for preventive visits. Our hope is that through education both providers and patients become more aware of available preventive services.”

Generic drugs can save millions in health care costs, while providing the same quality, safety and efficacy as brand medications. Yet many doctors still prescribe brand-name treatments for their patients. Why?

To find out, the Food and Drug Administration (FDA) has tapped a team at the Palo Alto Medical Foundation Research Institute (PAMFRI) and Johns Hopkins Medicine for a two-year study that will analyze factors that contribute to the underuse of generic drugs.

Robert Romanelli, Ph.D., MPH

“The FDA is interested in understanding why certain generic drug classes may be underutilized,” said Robert Romanelli, Ph.D., MPH, health services researcher and project director at PAMFRI. “One goal of this project is to use electronic medical record data from Sutter Health to understand provider and patient barriers to generic drug use.”

The study, “Effect of Therapeutic Class on Generic Drug Substitutions,” will analyze drug use both at Sutter Health and in the U.S. by therapeutic class. It will also examine patient-reported concerns about generic drugs to identify reasons patients might ask their doctors to prescribe brand-name drugs. Based on this data, the study will identify predictors to help determine when generic or brand medications are more likely to be used by patients. In addition, the study will develop a method to prioritize drug classes that would benefit from the development of generic drugs.

Generic drugs cost significantly less than brand-name drugs for both patients and insurance companies. In 2013, 86 percent of drugs prescribed in the United States were generic, according to the FDA, yet generic drugs accounted for just 29 percent of the nation’s prescription drug costs. Branded drugs accounted for 71 percent of U.S. prescription drug costs, or $232 billion. “If the societal goal is to allow patients to access worthy medications while containing costs within the health care system, we need to understand why there is differential acceptance of generic drugs,” said Jodi Segal, M.D., study principal investigator and associate professor of medicine at the Johns Hopkins School of Medicine.

Researchers will analyze electronic medical records from Sutter Health and insurance claims data from Truven Health Analytics. These large data sets will yield information about written and pharmacist-filled prescriptions, providing insights into the drugs that are prescribed as well as the ones patients actually used. In particular, investigators will look at differences in generic usage rates between different classes of therapeutic drugs, including medications for heart disease, epilepsy or asthma. They will also take into consideration such factors as the age and socioeconomic class of the patient.

The researchers will also analyze data from the FDA Adverse Event Reporting System, which collects patient-based complaints about drug-related adverse events. Investigators will focus on reports that discuss adverse results from switching to a generic product.

The final step in the study will be to convene a panel of colleagues and experts, including representatives of large generic drug manufacturing companies, to work together to develop a system for identifying and prioritizing drugs that are suitable for investment and development of a generic substitute, said Segal.

PAMFRI’s Romanelli is conducting the research in partnership with a team at Johns Hopkins, which includes Dr. Segal, study principal investigator and associate professor of medicine, and Sonal Singh, co-investigator and assistant professor of Medicine, Health, Policy and Management.

The  two-year study will be conducted with a grant of $400,000 from the FDA. (Grant # U01FD005267-01)

New Website Points Consumers to Healthiest Places to Eat Out

In a recent study, researchers at the Palo Alto Medical Foundation Research Institute (PAMFRI) ranked the healthiness of 150 national chain restaurants in the United States. The 2013 study was lead by Primary Investigator Lenny Lesser, M.D., MSHS, a family medicine physician at PAMFRI, and funded in part by The California Endowment. Dr. Lesser presented the team’s research – and the launch of a new interactive rating system and website for consumers that shares information on which chain restaurants are healthier than others – on November 19, 2014 at the American Public Health Association Annual Meeting in New Orleans.

“With this transparent data, consumers can see which chain restaurants are actually ‘healthier’ places to eat,” Dr. Lesser said in announcing the new Grellin website. “Restaurants often claim they are ‘healthy’ by adding one or two wholesome items on a menu filled with unhealthy food. The new Grellin Grade tells consumer what percent of the restaurant’s menu is actually healthy.”

Lenny Lesser, M.D.

According to Dr. Lesser, consumers can use the Grellin website to see where they can find a nutritious meal and judge the healthiest menu options. The rankings and information are available on the web via computer or mobile devices.

The Grellin Grade uses a combination of technology and nutrition science to compute the grades. The grades take into account both the nutrients (calories, sodium and fat) of the food and the estimated amounts of fruit and vegetable in the food.

Each food in Grellin gets ranked as unhealthy or healthy, based on its nutrient and food components. These foods are then summed up for each restaurant, with each restaurant getting a Grellin Grade from 0-100. A “100” means 100 percent of the items at that restaurant are healthy. Some restaurants that ranked a zero do not release enough information to the public so they could not be scored.

“The goal is to give people objective information about which restaurants are likely to be healthier for families and children,” said Dr. Lesser. “I hope that restaurants will compete for customers on their healthiness of their menu, rather than just the price. If a chain restaurant’s score is low, it begs the question: how can they provide healthier choices to their customers?”

Learn more about the PAMF Research Institute.

Learn more about Grellin Grade at www.grellin.org and follow Grellin on Twitter at @grellingrade.

The Palo Alto Medical Foundation Research Institute (PAMFRI) has launched a new research study to create a more user-friendly online tool to help older adults select Medicare Part D prescription drug plans. PAMFRI is looking for older adults to participate in the study and share their experiences in a focus group. The research project is funded by the Patient-Centered Outcomes Research Institute (PCORI).

Ming Tai-Seale, Ph.D., Senior Investigator, PAMF Research Institute

“Currently, Medicare beneficiaries often have to choose among more than 30 different Medicare Part D plans,” said Ming Tai-Seale, Ph.D., MPH, PAMFRI senior scientist. “This is a difficult and confusing task. Through this study we hope to create a more effective tool that is easier to use and will help individuals select their prescription drug plans. In order to build a better tool, we want to understand what it’s like for older adults to select a Medicare Part D plan.

“We are also seeking older adults who will allow researchers to see how they select their Medicare Part D plan using a decision tool during the Medicare Open Enrollment period, which runs October 15 through December 7, 2014.

The study is a joint effort led by co-principal investigators Tai-Seale and M. Kate Bundorf, Ph.D., associate professor at Stanford University. Co-investigators include Albert Chan, M.D., M.S., chief medical information officer at the Palo Alto Medical Foundation, and Cheryl Stults, Ph.D., research sociologist at PAMFRI.

For more information about participating in the study, please contact Cheryl Stults at (650) 853-2346 or stultsc@pamf.org.

Learn more about the PAMF Research Institute.

.

Sandra R. Wilson, Ph. D.

Many tools already exist to help physicians and scientists measure patients’ symptoms, physical limitations and emotional well-being. However, “These measures alone don’t tell physicians caring for patients or scientists developing new medical treatments how the patient feels their quality of life is being affected, says Sandra Wilson, Ph.D., PAMFRI senior scientist and the study’s principal investigator. “Getting that information requires a new type of measure.”

For example, two people with asthma might experience symptoms if they engage in strenuous physical activity. However, a grandmother whose priority is being able to play with her small grandchildren may not feel her asthma limits her life, while an Olympic athlete might feel that his asthma is preventing him from achieving his career goals.

In addition, measuring the effects of a disease on a person’s quality of life needs to include both the negative effects of the disease itself and any negative effects of its treatment. Some cancer treatments, for example, may prolong the patient’s life but at the cost of a worse quality of life.

Dr. Wilson and colleagues are evaluating a straightforward but very novel approach to measuring a disease’s Impact on Quality of Life (IQOL). Patients rate the extent of the negative effect of their disease and its treatment on each of 16 dimensions of quality of life. These dimensions include material and physical well-being, relationships with other people, social and community activities and personal development and fulfillment.

In the new study, patients with asthma who are receiving care from the Palo Alto Medical Foundation will complete the Asthma Impact on Quality of Life Scale (A-IQOLS) at two points in time. The research team also will collect information on these patients’ lung function, symptoms, asthma control, and functional limitations to find out how these affect A-IQOLS scores. Other members of the team include Sarah Knowles, Ph.D., and PAMF physicians Michael Mulligan, M.D., (allergy), Alan Chausow, M.D., and Estela Ayala, M.D., (pulmonary medicine).

Participants in three asthma treatment studies are also completing the A-IQOLS. Robert Wise, M.D., at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, coordinates two of these studies.  Mario Castro, M.D., at the Washington University School of Medicine in St. Louis, Missouri, leads the other. PAMFRI investigators will analyze data from these studies to learn how changes over time or differences in asthma status between treatment groups affect patients’ A-IQOLS scores.

The A-IQOLS fills a significant gap in the tools currently available to assess outcomes that matter to patients. If successful, it will directly benefit asthma research and asthma medical care, and will influence the measurement of the effects of other diseases on patients’ quality of life.

Researchers at the Palo Alto Medical Foundation Research Institute (PAMFRI) have been awarded a $3M grant from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) to study the benefits of strength training for people with type 2 diabetes who are at normal weight.

With type 2 diabetes, the body cannot use insulin properly to control blood sugar levels. Regular physical activity has been shown to help control blood sugar levels, and current guidelines emphasize aerobic exercise and weight loss for overweight individuals with type 2 diabetes. However, up to one in five people with type 2 diabetes are at normal weight, with a body mass index (BMI) under 25. They may not need to lose weight. For these individuals, best exercise regimen is not yet known. There is evidence that strength training, which improves muscle mass while decreasing body fat, may be more beneficial for normal weight diabetics than other types of exercise.

Latha Palaniappan, M.D., M.S.

The Strength Training Regimen for Normal Weight Diabetics (STRONG-D) study is a collaborative effort between PAMFRI and Pennington Biomedical Research Center. The study will be co-led by Latha Palaniappan, M.D., M.S., associate investigator at PAMFRI, and Timothy Church, M.D., MPH, PhD., professor at Pennington Biomedical Research Center.

“There is a lack of data on effective lifestyle recommendations for individuals with type 2 diabetes at normal weight,” said Dr. Palaniappan. “The current physical activity recommendations may not be appropriate.

“The STRONG-D study seeks to determine the best exercise regimen for normal weight individuals with type 2 diabetes. Different exercise programs will be tested in the study, including those that emphasize aerobic or strength training only.” The study will allow researchers to better understand the effects of different types of exercises on type 2 diabetes, and will help shape exercise guidelines for those people with type 2 diabetes who are at normal weight.

The study will enroll approximately 300 normal weight patients with type 2 diabetes. It is planned to start in September 2014.  If you are interested in participating, please email STRONG-D@pamfri.org for more information.

But do employee wellness programs actually work? The Palo Alto Medical Foundation Research Institute (PAMFRI) recently published a commentary in the American Journal of Preventive Medicine on this question.

Lenny Lesser, M.D., MSHS

According to Lenard Lesser, M.D., MSHS, PAMFRI Assistant Research Physician, while monetary incentives may help employees start to make changes, sustaining those changes in the long term is far more challenging.

“These programs do not address key factors that impact public health: marketing, pricing and the easy availability of unhealthy food,” said Dr. Lesser. “It also unfairly places the responsibility on individuals to change health indices over which they have little personal control. Ignoring environmental and biological forces that contribute to obesity can undermine a program’s ability to help people reach weight outcomes or change health behavior.”

But financial incentives are not all bad. “Employers should create and incentivize opportunities for employees to engage in healthy behavior in the workplace – subsidizing healthy meals, providing standing workstations and time and space for physical activity, and removing sugary beverages,” said Dr. Lesser.

These strategies prevent the stigmatization and ethical problems associated with incentivizing weight loss and provide ways to empower and support employees in their efforts to become healthier.

The commentary will appear in the April 2014 issue of the American Journal of Preventive Medicine.