PAs Do More Biopsies, Find Less Early Melanoma than Dermatologists

MedicalResearch.com Interview with:

Laura Korb Ferris, MD, PhD Associate Professor, University of Pittsburgh Clinical and Translational Science Institute Director of Clinical Trials, Department of Dermatology University of Pittsburgh Medical Center

Dr. Laura K. Ferris

Laura K. Ferris MD, PhD
Associate Professor, University of Pittsburgh Clinical and Translational Science Institute
Director of Clinical Trials, UPMC Department of Dermatology
University of Pittsburgh

MedicalResearch.com: What is the background for this study? What are the main findings? 

Response: Dermatology is one of the greatest utilizers of physician extenders, including physician assistants (PAs) in medicine. The scope of practice of PAs has also expanded over time from a role in assisting the dermatologist to taking a more independent role and many PAs now do skin cancer screening examinations and make independent decisions about which lesions are suspicious for skin cancer and need to be biopsied.

Our main findings were that, overall, in comparison to board-certified dermatologists, PAs were more likely to perform biopsies of benign lesions. For every melanoma that they found, PAs biopsied 39 benign lesions whereas dermatologists biopsied 25.

In addition, PAs were less likely than dermatologists to diagnose melanoma in situ, the earliest and most curable, but also hardest to identify and diagnose, form of melanoma. However, PAs had a similar rate of diagnosing the more clinically-obvious forms of skin cancer, including invasive melanoma, basal cell carcinoma, and squamous cell carcinoma.

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Should Blood Pressure Measurement Be Repeated During Primary Care Visit?

MedicalResearch.com Interview with:
“Doctors” by Tele Jane is licensed under CC BY 2.0Doug Einstadter, MD, MPH

Center for Health Care Research and Policy
MetroHealth System and Case Western Reserve University 

MedicalResearch.com: What is the background for this study?  

Response: Despite the recognized importance of blood pressure (BP) control for those with hypertension, based on national surveys only 54% of patients with hypertension seen in primary care have their BP controlled to less than 140/90 mm Hg.

Blood pressure measurement error is a major cause of poor BP control. Reducing measurement error has the potential to avoid overtreatment, including side effects from medications which would be intensified or started due to a falsely elevated blood pressure. One way to reduce measurement error is to repeat the BP measurement during an office visit. The American Heart Association recommends repeating a blood pressure at the same clinic visit with at least 1 minute separating BP readings, but due to time constraints or lack of evidence for the value of repeat measurement, busy primary care practices often measure BP only once. Repeating the BP at the same office visit when the initial blood pressure measurement is high has the potential to improve clinical decision-making regarding BP treatment. Several studies have described the effect of a repeat BP measurement in the inpatient setting, but there are little data available to characterize the effect of repeating blood pressure measurement in an outpatient primary care setting.

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PCPs Need More Training In Assessing and Treating Irritability in Children

MedicalResearch.com Interview with:
Anna Scandinaro
Medical student
Penn State College of Medicine

MedicalResearch.com: What is the background for this study? What are the main findings? 

Response: Dr. Usman Hameed, a child and adolescent psychiatrist, and Dr. Dellasega wrote a previous paper called “What is irritability?” which examined the idea and concept of what irritability in school aged children can encompass. After considering possible definitions of irritability, we wanted to see how the concept manifested in clinical practice, especially with the controversy around the new diagnosis of Disruptive Mood Dysregulation Disorder (DMDD) in the DSM 5.

The main findings of this study are that primary care providers (PCP)​identified a need for more training and education in how to assess irritability in pediatric and adolescent populations.

In contrast, the child and adolescent psychiatrists we interviewed thought more triage from PCPs who care for school aged children with irritability would be helpful.  Continue reading

Study Suggests Tamiflu Does Not Increase Risk of Suicide

MedicalResearch.com Interview with:

James W. Antoon, MD, PhD, FAAP Assistant Professor of Clinical Pediatrics University of Illinois at Chicago Associate Medical Director, Pediatric Inpatient Unit Children's Hospital, University of Illinois Hospital & Health Sciences System Chicago, IL 60612 

Dr. Antoon

James W. Antoon, MD, PhD, FAAP
Assistant Professor of Clinical Pediatrics
University of Illinois at Chicago
Associate Medical Director, Pediatric Inpatient Unit
Children’s Hospital, University of Illinois Hospital & Health Sciences System
Chicago, IL 60612 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Oseltamivir, commonly known as Tamiflu, is the only commercially available medication FDA approved to treat the flu.  Since the 2009 H1N1 flu epidemic pediatric prescriptions for Tamiflu have soared.  In the United States, about 40% of Tamiflu prescriptions are given to children less than 16 years of age.  Following reports of abnormal behavior, such as hallucinations, self-injury and suicide attempts in adolescents on Tamiflu, the FDA placed a new warning about these neuropsychiatric symptoms on the drug label.  Whenever the FDA puts out label warning about a drug, doctors and the public take notice. Whether Tamiflu truly causes these side effects is unclear.  For this study we chose to focus on the most consequential of those reports: suicide.

The potential link between a drug and suicide is a particularly difficult topic to study for a number of reasons. There are things that happen together or at the same time that can influence someone to attempt suicide and it is very difficult to know which thing is actually having an affect. In our study, other things that can influence suicide are socioeconomic status, mental health, trauma, abuse, among others.  Separating the effects of these confounders can be difficult. It is also possible that the disease itself, which in this case is the flu, causes the effect of suicide. Finally, and luckily, suicide is rare. Our database had 12 million children per year and over five year 21,000 attempted suicide. Of those, only 251 were taking Tamiflu.

To get past these issues, we took advantage of a growing drug safety research collaboration between the Departments of Pediatrics and Pharmacy at our institution.  Previous studies have compared those on Tamiflu to those not on Tamiflu to see if there are more side effects in the Tamiflu group.  Our team utilized a novel study method called a case-crossover design. What’s different about this study is that we used each patient as their own comparison.  In other words, we compared each patient to themselves rather than a different group of people.  We essentially studied how patients behaved when the Tamiflu was in their system compared to other l periods where they were not on Tamiflu.  This allowed use to account for the personal differences noted above like mental health and socioeconomic status.   We also compared those children with flu who got Tamiflu and those with flu who did not get Tamiflu to see if the infection itself could be associated with increased suicide.

After accounting for all these variables, we did not find any an association between Tamiflu exposure and suicide. Our findings suggest that Tamiflu does NOT increase the risk of suicide in children or teenagers.

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Are Routine Digital Rectal Exams Helpful In Detecting Asymptomatic Prostate Cancer?

MedicalResearch.com Interview with:

Dr. Jason Profetto, MD, CCFP Family and Academic Medicine Chair, Clinical Skills Undergraduate Medical Education McMaster University

Dr. Jason Profetto

Dr. Jason Profetto, MD, CCFP
Family and Academic Medicine
Chair, Clinical Skills
Undergraduate Medical Education
McMaster University

MedicalResearch.com: What is the background for this study?

 Response: The main reason that prompted me to investigate the issue of digital rectal exams in primary care for prostate screening was that it appeared to be rather dogmatic practice (continually practiced by many despite updated data suggesting a lack of benefit).  I was very curious to see if there was any data that suggested the digital rectal exams was indeed a useful indicator in primary practice (ie. Family Medicine) in detecting prostate cancer in asymptomatic men.  Intuitively, I didn’t believe the DRE was accurate mainly because in medical school it’s generally under-represented in clinical skills teaching and poorly taught and assessed (not just in Ontario, but also Canada).  As a result, it seemed bizarre to me that this specific clinical skills was being used as a routine measure in family medicine to screen for prostate cancer.  Also, for me this was a big issue as many men in my practice were used to having yearly “rectal exams” done and I thought it was time to really take a closer look at the research to see whether or not we can support this practice.

MedicalResearch.com: What are the main findings?

Response: The main findings suggest that the digital rectal exam is not helpful/accurate in detecting prostate cancer in asymptomatic men in family practice or primary care.

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UK Study Finds Pulmonary Rehab for COPD Underutilized

MedicalResearch.com Interview with:

Dr Jennifer K Quint MSc PhD FHEA FRCP Clinical Senior Lecturer Respiratory Epidemiology Respiratory Epidemiology, Occupational Medicine and Public Health National Heart and Lung Institute Imperial College London

Dr. Quint

Dr Jennifer K Quint MSc PhD FHEA FRCP
Clinical Senior Lecturer Respiratory Epidemiology
Respiratory Epidemiology, Occupational Medicine and Public Health
National Heart and Lung Institute
Imperial College
London 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: We were commissioned by the Chartered Society of Physiotherapy in the UK to undertake a piece of work to show the value of pulmonary rehabilitation in reducing exacerbations in COPD patients so that they could create a web based tool that would show cost savings if GPs actually referred people for pulmonary rehabilitation.

Previous systematic reviews have found that pulmonary rehab can reduce hospital admissions but those groups are often small and not very generalizable so we decided to look at what happens in a primary care COPD population. Our main finding is that people who are eligible for referral are not being referred  – less than 10% eligible were actually referred.

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Declining Medicaid Fees Translates To Fewer Available Primary Care Appointments

MedicalResearch.com Interview with:

Molly Candon, PhD Postdoctoral Fellow, Leonard Davis Institute of Health Economics Center for Mental Health Policy and Services Research University of Pennsylvania

Dr. Candon

Molly Candon, PhD
Postdoctoral Fellow
Leonard Davis Institute of Health Economics
Center for Mental Health Policy and Services Research
University of Pennsylvania

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: We conducted a secret shopper study in 2012, 2014, and 2016 in which simulated Medicaid patients called primary care practices and attempted to schedule an appointment. When Medicaid fees were increased to Medicare levels in 2013 and 2014, primary care appointment availability increased. Once the federally-funded program ended in 2015, most states returned to lower fees. As expected, provider participation in Medicaid declined as well.

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Coordination Program Reduced ER Visits and Readmissions in Medicaid Population

MedicalResearch.com Interview with:

Roberta Capp MD Assistant Professor Director for Care Transitions in the Department of Emergency Medicine University of Colorado School of Medicine Medical Director of Colorado Access Medicaid Aurora Colorado

Dr. Capp

Roberta Capp MD
Assistant Professor
Director for Care Transitions in the Department of Emergency Medicine
University of Colorado School of Medicine
Medical Director of Colorado Access Medicaid
Aurora Colorado

 

 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Medicaid clients are at highest risk for utilizing the hospital system due to barriers in accessing outpatient services and social determinants.

We have found that providing care management services improves primary care utilization, which leads to better chronic disease management and reductions in emergency department use and hospital admissions.

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Diabetes In Elderly May Be Overtreated Leading To Hypoglycemia

MedicalResearch.com Interview with:

Matthew L. Maciejewski, PhD Professor in Medicine Division of General Internal Medicine, Department of Medicine Center for Health Services Research Primary Care Durham VA Medical Center Duke University

Dr. Maciejewski

Matthew L. Maciejewski, PhD
Professor in Medicine
Division of General Internal Medicine, Department of Medicine
Center for Health Services Research Primary Care
Durham VA Medical Center
Duke University

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Treating diabetes requires balancing the risks of long-term harm from under-treatment with the short-term and long-term harm from potential over-treatment. Randomized trials have shown that the benefits of aggressive glycemic control only begin after at least 8 years of treatment. Yet, the harms of aggressive glycemic control –  hypoglycemia, cardiovascular events, cognitive impairment, fractures, and death – can happen at any time.

In some older people, “deintensification” of diabetes treatment may be the safer route, because of the risks that come with too-low blood sugar. The American Geriatrics Society (AGS) specifically states that medications other than metformin should be avoided when an older patient’s hemoglobin A1c is less than 7.5%, because the risks of hypoglycemia are larger and the potential benefits of treatment are smaller for older adults with diabetes.  Most attention in prior work has focused on undertreatment of diabetes and there has been only limited investigation of patient characteristics associated with overtreatment of diabetes or severe hypoglycemia.

Since the elderly are therefore at greatest risk of overtreatment and Medicare is the primary source of care of the elderly, we examined rates of overtreatment and deintensification of therapy for Medicare beneficiaries, and whether there were any disparities in these rates.  We found that almost 11 percent of Medicare participants with diabetes had very low blood sugar levels that suggested they were being over-treated. But only 14 percent of these patients had a reduction in blood sugar medication refills in the next six months.

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USPSTF: Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Cardiovascular Risk Factors

MedicalResearch.com Interview with:

Carol M. Mangione, MD, MSPH, FACP Barbara A. Levey, MD, and Gerald S. Levey, MD Endowed chair in medicine David Geffen School of Medicine University of California, Los Angeles Professor of public health at the UCLA Fielding School of Public Health

Dr. Mangione

Carol M. Mangione, MD, MSPH, FACP
Barbara A. Levey, MD, and Gerald S. Levey, MD
Endowed chair in medicine
David Geffen School of Medicine
University of California, Los Angeles
Professor of public health at the UCLA Fielding School of Public Health

MedicalResearch.com: What is the background for this study?

Response: Americans can experience several health benefits from consuming healthy foods and engaging in physical activity. The Task Force recommends that primary care professionals work together with their patients when making the decision to offer or refer adults who are not obese and do not have hypertension, high cholesterol, high blood sugar, or diabetes to behavior counseling to promote healthful diet and physical activity. Our focus was on the impact of a healthful diet and physical activity on cardiovascular risk because this condition is the leading cause of premature morbidity and mortality. The Task Force evaluates what the science tells us surrounding the potential benefits and harms of a particular preventive service. In this case, the Task Force found high quality evidence focusing on the impact a healthful diet and physical activity can have on a patient’s risk of cardiovascular disease. Relying on this evidence, the Task Force was able to conclude that there is a positive but small benefit of behavioral counseling to prevent cardiovascular disease.

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Better Coordination Needed Between Hospital Physicians and Home Health Care Providers

MedicalResearch.com Interview with:

Christine D. Jones, MD, MS, Assistant professor Director of Care Transitions, Hospital Medicine Group University of Colorado School of Medicine

Dr. Jones

Christine D. Jones, MD, MS
Assistant professor
Director of Care Transitions, Hospital Medicine Group
University of Colorado School of Medicine

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The background for this study is that referrals to home health care at hospital discharge have increased over recent years.  Yet, care coordination including information exchange and communication is often suboptimal between the hospital and home health care and may contribute to medication list discrepancies and even hospital readmissions.

We spoke with focus groups of home health nurses and our main findings were that improvements in key areas could care coordination after hospital discharge.

Specific solutions included:

1) Clearly defining the accountability for home health orders after discharge between hospitalists and primary care providers

2) Changes to insurance requirements that currently only allow physicians to write home health orders so that nurse practitioners and physician assistants can also write home health orders

3) Enhancing access for home health agencies to hospital electronic health records and direct phone lines

4) Encouraging liaisons from home health agencies to meet patients in the hospital to align clinician and patient expectations

5) Direct coordination between home health nurses and clinicians or pharmacists to resolve medication discrepancies

6) Ensuring that detailed information about cognitive and behavioral health is included in information provided to home health from referring hospitals

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Primary Care Practice Interventions Helped Maintain Adherence to Opioid Prescription Guidelines

MedicalResearch.com Interview with:

Jane M. Liebschutz, MD, MPH Associate Professor of Medicine Section of General Internal Medicine Boston University School of Medicine Boston, Massachusetts

Dr. Liebschutz

Jane M. Liebschutz, MD, MPH
Associate Professor of Medicine
Section of General Internal Medicine
Boston University School of Medicine
Boston, Massachusetts

MedicalResearch.com: What is the background for this study?

Response: The number of patients receiving opioids for chronic pain has risen over the past 2 decades in the US, in parallel with an increase in opioid use disorder. The CDC and professional medical societies have created clinical guidelines to improve the safety of opioid prescribing, yet individual prescribers can find them onerous to implement.

We developed an intervention to change clinical practice to support primary care physicians who prescribe the majority of opioids for chronic pain. The intervention included 4 elements- a nurse care manager to help assess, educate and monitor patients, an electronic registry to keep track of patient data and produce physician level reports, an individualized educational session for the physician by an opioid prescribing expert based on the physician-specific practice information and online resources to help with decision-making for opioid prescribing (www.mytopcare.org). We tested whether the intervention would improve adherence to guidelines, decrease opioid doses and decrease early refills, as a marker of potential prescription opioid misuse among 985 patients of 53 primary care clinicians in four primary care practices.

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American Academy of Family Physicians Foundation Launches Highlight on VACCINATIONS 4 TEENS to Help Address Teen Under-Vaccination

 

MedicalResearch.com Interview with:

Hughes Melton, MD, MBA, FAAFP AAFP Foundation president

Dr. Melton

S. Hughes Melton, MD, MBA, FAAFP
AAFP Foundation president

MedicalResearch: What is the background for this initiative? What are the main vaccinations that teens should have?

 Response: The Centers for Disease Control and Prevention (CDC) recommends adolescents receive four immunizations – two of which are administered as multi-dose series – to help protect against meningococcal meningitis caused by serogroups A, C, W and Y; human papillomavirus (HPV); tetanus, diphtheria and pertussis (Tdap); and influenza (flu).1 Despite these recommendations, millions of teens remain vulnerable to serious infectious disease.2,3

Family physicians are well equipped to immunize their patients against a host of common infectious diseases and improve public health. However, discussing teen vaccinations during annual appointments may present challenges due to other issues teens and their parents/guardians may be focused on at this age. The American Academy of Family Physicians Foundation (AAFP Foundation) launched Highlight on VACCINATIONS 4 TEENS to help remind family physicians and their care teams to make immunization a priority at these key appointments for teens.

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May Be No Benefit To Statins For Primary Prevention in Older Adults

MedicalResearch.com Interview with:
Benjamin Han, MD, MPH
Assistant professor
Departments of Medicine-Division of Geriatric Medicine and Palliative Care, and Population Health
NYU Langone Medical Center

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: There are an increasing number of older adults being prescribed statins for primary prevention, but the evidence for the benefit for older adults is unclear.

Our study finds that in the ALLHAT-LLT clinical trial, there were no benefits in either all-cause mortality or cardiovascular outcomes for older adults who did not have any evidence of cardiovascular disease at baseline.

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Age-related Macular Degeneration Underdiagnosed in Primary Care

MedicalResearch.com Interview with:

David C Neely, MD The University of Alabama at Birmingham

Dr. Neely

David C Neely, MD
The University of Alabama at Birmingham

MedicalResearch.com: What is the background for this study? What are the main
findings?

Response: This study examined the prevalence of eyes with age-related macular degeneration (AMD) in patients seen in primary eye care clinics who purportedly have normal macular health.

Approximately 25.0% of eyes deemed to be normal based on dilated eye examination by primary eye care providers had macular characteristics that indicated age-related macular degeneration. Continue reading

Hospital Based Primary Care Practices Provide More Low Value Services

MedicalResearch.com Interview with:

John N. Mafi, MD, MPH Assistant Professor of Medicine Division of General Internal Medicine and Health Services Research UCLA David Geffen School of Medicine Los Angeles, CA 90024 Affiliated Natural Scientist in Health Policy RAND Corporation 1776 Main St, Santa Monica, CA 90401

Dr. John Mafi

John N. Mafi, MD, MPH
Assistant Professor of Medicine
Division of General Internal Medicine and Health Services Research
UCLA David Geffen School of Medicine
Los Angeles, CA 90024
Affiliated Natural Scientist in Health Policy
RAND Corporation
1776 Main St, Santa Monica, CA 90401

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Between 10-30% of healthcare costs are due to low value care, or patient care that provides little to no benefit to patients, and can sometimes cause harm (e.g., radiation exposure from diagnostic imaging tests). In this study, we found that hospital-based primary care practice provide more low value care than community-based primary care practices across the United States. Understanding where and why low value care occurs is going to be essential if we want to get serious about eliminating it.

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Why Do So Many Stroke Survivors Give Up On Preventive Medications?

MedicalResearch.com Interview with:
Anna De Simoni

NIHR Academic Clinical Lecturer in Primary Care Research
Centre for Primary Care and Public Health
Barts and The London School of Medicine and Dentistry
London E1 2AB

MedicalResearch.com: What is the background for this study?

Response: Three in 10 stroke survivors will go on to have a further stroke, which causes greater disability or even death. Secondary prevention medications, including antihypertensives, blood thinning and lipid lowering agents, such as statins, can reduce risk of stroke recurrence by up to 75 per cent. However, patients’ persistence with these medications decreases over time because a minority of people experience side effects, which are mild in most cases.

The analysis, involving Queen Mary University of London and the University of Cambridge and published in the journal Family Practice, was performed on the archives from TalkStroke, a UK online forum hosted by the Stroke Association. The forum is used by patients with stroke and their carers, and generated 21,596 posts during 2004-2011. 50 participants were found to discuss GP advice on prevention medications in 43 discussion threads.

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Primary Care Wait Times For Medicaid Patients Increased Modestly Under Affordable Care Act

MedicalResearch.com Interview with:

Molly Candon, PhD Fellow Leonard Davis Institute of Health Economics, The Wharton School Center for Mental Health Policy and Services Research, Perelman School of Medicine University of Pennsylvania

Dr. Molly Candon

Molly Candon, PhD
Fellow
Leonard Davis Institute of Health Economics, The Wharton School
Center for Mental Health Policy and Services Research, Perelman School of Medicine
University of Pennsylvania

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Primary care practices are less likely to schedule appointments with Medicaid patients compared to the privately insured, largely due to lower reimbursement rates for providers. Given the gap in access, concerns have been raised that Medicaid enrollees may struggle to translate their coverage into care. Despite the substantial increase in demand for care resulting from provisions in the Affordable Care Act (ACA), our 10-state audit study recently published in JAMA Internal Medicine finds that primary care appointment availability for new patients with Medicaid increased 5.4 percentage points between 2012 and 2016, while appointment availability for patients with private coverage did not change.

Over the same time period, both Medicaid patients and the privately insured experienced slight increases in wait times.

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Choosing Primary Care Physicians Based On Low Office Visit Price Can Save Money for Patients With High Deductible Plans

MedicalResearch.com Interview with:

Dr. Ateev Mehrotra Associate professor, Department of Health Care Policy Harvard Medical School and a  hospitalist at Beth Israel Deaconess Medical Center Boston, Massachusetts

Dr. Ateev Mehrotra

Dr. Ateev Mehrotra MD
Associate professor, Department of Health Care Policy
Harvard Medical School and a
hospitalist at Beth Israel Deaconess Medical Center
Boston, Massachusetts

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: More people in the US are using price transparency websites to shop for care. Some have wondered whether using the information on these websites to choose a doctor will help them actually save money. A relatively small difference in price for visits on the website translated into hundreds of dollars.

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Short Interventions By Primary Care Physicians Can Help Patients Lose Weight

MedicalResearch.com Interview with:

Paul Aveyard PhD MRCP FRCGP FFPH Professor of Behavioural Medicine Nuffield Department of Primary Care Health Sciences University of Oxford Radcliffe Primary Care Building Radcliffe Observatory Quarter Oxford

Prof. Paul Aveyard

Paul Aveyard PhD MRCP FRCGP FFPH
Professor of Behavioural Medicine
Nuffield Department of Primary Care Health Sciences
University of Oxford
Radcliffe Primary Care Building
Radcliffe Observatory Quarter
Oxford

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: We know that opportunistic brief interventions by physicians can be effective, but there is no evidence that they are so for obesity. Physicians worry that broaching this topic will be offensive, time-consuming, and ineffective. We needed a randomised trial to assess whether physicians’ fears were justified, or in fact brief interventions could be as effective for patients who are overweight as they are for smoking or problem drinking and that’s what we did.

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