Faculty Bibliography

BACKGROUND: Physicians frequently report negative attitudes about obesity which is thought to affect patient care. However, little is known about how attitudes toward treating obese patients are formed. We conducted a cross-sectional survey of physicians in order to better characterize their attitudes and explore the relationships among attitudes, perceived competency in obesity care, including report of weight loss in patients, and other key physician, training, and practice characteristics. METHODS: We surveyed all 399 physicians from internal medicine, pediatrics, and psychiatry specialties at one institution regarding obesity care attitudes, competency, including physician report of percent of their patients who lose weight. We performed a factor analysis on the attitude items and used hierarchical regression analysis to explore the degree to which competency, reported weight loss, physician, training and practice characteristics explained the variance in each attitude factor. RESULTS: The overall response rate was 63%. More than 40% of physicians had a negative reaction towards obese patients, 56% felt qualified to treat obesity, and 46% felt successful in this realm. The factor analysis revealed 4 factors-Physician Discomfort/Bias, Physician Success/Self Efficacy, Positive Outcome Expectancy, and Negative Outcome Expectancy. Competency and reported percent of patients who lose weight were most strongly associated with the Physician Success/Self Efficacy attitude factor. Greater skill in patient assessment was associated with less Physician Discomfort/Bias. Training characteristics were associated with outcome expectancies with newer physicians reporting more positive treatment expectancies. Pediatric faculty was more positive and psychiatry faculty less negative in their treatment expectancies than internal medicine faculty. CONCLUSION: Physician attitudes towards obesity are associated with competency, specialty, and years since postgraduate training. Further study is necessary to determine the direction of influence and to explore the impact of these attitudes on patient care

We designed a patient-centered smoking cessation program for women in 2004/2005, incorporating women's preferences and expert opinion. Our four-step process included: (1) concept-development focus groups; (2) an expert panel; (3) concept-testing focus groups, and (4) a pilot study. Data analyses occurred in 2004-2007. The new program offered options: the traditional Veterans Health Administration (VA) male-dominated program was the least selected option in the pilot study. Patients can be effectively involved in program development. The study's implications and limitations are noted. This research (conducted in Los Angeles, California) was funded by the American Legacy Foundation with additional VA support

"¢ Objective: To review recently approved and emerging medications for smoking cessation. "¢ Methods: Studies on newer smoking cessation aids were identified using MEDLINE (1996-2007), the Society for Research on Nicotine and Tobacco abstracts database, and the U.S. Patents and Trademark Office database. All randomized controlled trials evaluating 1 or more medications used in smoking cessation (including vaccines) were included. Phase 1 and animal studies were excluded. "¢ Results: Varenicline has been effective in smoking cessation despite the unquantified risk of serious psychiatric effects. Rimonabant appears to be effective for smoking cessation and possibly relapse prevention and is generally well tolerated. Nicotine vaccines, mecamylamine, topiramate, and selegiline all appear effective for use in smoking cessation in preliminary trials, but additional studies are needed to confirm these findings both in the short and long term. "¢ Conclusion: Currently available first-line treatments for smoking cessation include nicotine replacement (eg, nicotine patch, nicotine gum), bupropion, and varenicline and have proven efficacy in published studies. Several treatments currently under study appear promising.

OBJECTIVE: To evaluate the impact of a locally adapted evidence-based quality improvement (EBQI) approach to implementation of smoking cessation guidelines into routine practice. DATA SOURCES/STUDY SETTING: We used patient questionnaires, practice surveys, and administrative data in Veterans Health Administration (VA) primary care practices across five southwestern states. STUDY DESIGN: In a group-randomized trial of 18 VA facilities, matched on size and academic affiliation, we evaluated intervention practices' abilities to implement evidence-based smoking cessation care following structured evidence review, local priority setting, quality improvement plan development, practice facilitation, expert feedback, and monitoring. Control practices received mailed guidelines and VA audit-feedback reports as usual care. DATA COLLECTION: To represent the population of primary care-based smokers, we randomly sampled and screened 36,445 patients to identify and enroll eligible smokers at baseline (n=1,941) and follow-up at 12 months (n=1,080). We used computer-assisted telephone interviewing to collect smoking behavior, nicotine dependence, readiness to change, health status, and patient sociodemographics. We used practice surveys to measure structure and process changes, and administrative data to assess population utilization patterns. PRINCIPAL FINDINGS: Intervention practices adopted multifaceted EBQI plans, but had difficulty implementing them, ultimately focusing on smoking cessation clinic referral strategies. While attendance rates increased (p<.0001), we found no intervention effect on smoking cessation. CONCLUSIONS: EBQI stimulated practices to increase smoking cessation clinic referrals and try other less evidence-based interventions that did not translate into improved quit rates at a population level.

We used a consumer-driven approach to develop a model smoking-cessation program for women. Four focus groups (N = 23 [5-7/group]), each lasting 2 hours, were led by a professional moderator and audiotaped in 2004. Researchers reviewed transcripts; key themes were identified using scrutiny techniques (Ryan and Bernard, 2003). Necessary elements of a smoking-cessation program for women included support and choice (i.e., control over the program components), suggesting the need for an individualized program. Identifying appropriate components is a critical step in the development of efficacious programs that target substance-abusing populations; focus group methodology is useful in this endeavor. The study's implications and limitations are noted