Patients In Primary Care Setting Research Articles

Views of family physicians in southwestern Ontario on preventive care services and performance incentives

Although the Canadian Task Force on Preventive Health Care recommends that several preventive care services be routinely provided to eligible patients in primary care settings, the delivery rate for these services continues to be suboptimal. A recent metaanalysis found evidence to support the use of several strategies to improve preventive care delivery rates, yet many practitioners still rely primarily on an opportunistic approach for delivering preventive care services. Primary care networks (PCN) and family health networks (FHN) are two new models of primary health care delivery in Ontario, characterized by patient rostering and a capitation payment structure with added incentives. One such incentive is the preventive care management program, offering annual preventive care performance bonuses that are calculated from the delivery rate of biennial Papanicolaou smear screening (age 35–69 years) and mammography screening (age 50– 69 years), annual influenza vaccination (age 65 years or over), and a series of five childhood immunizations by 2 years of age. The annual bonus payments increase incrementally to a maximum of $CAN 2200 for delivery rates ranging from 75% for mammography screening to 95% for childhood immunizations. Each physician is also eligible to claim a management fee of $CAN 6.86 per service for each overdue patient contacted by reminder letter and telephone call. The ‘Provider and Patient Reminders in Ontario: Multi-strategy Prevention Tools’ (P-PROMPT) demonstration project is currently implementing a reminder and recall strategy in participating PCN and FHN practices across southwestern Ontario to increase the delivery of the four targeted preventive care services. The purpose of the current report was to explore the views of family physicians enrolled in the P-PROMPT project on preventive care in general and of the preventive care management program in particular, and to gather information on their current preventive care delivery strategies.

Outcomes of Minor and Subsyndromal Depression among Elderly Patients in Primary Care Settings

Although depressive conditions in later life are a major public health problem, the outcomes of minor and subsyndromal depression are largely unknown. To compare outcomes among patients with minor and subsyndromal depression, major depression, and no depression, and to examine putative outcome predictors. Cohort study. Patients from primary care practices in greater New York City, and Philadelphia and Pittsburgh, Pennsylvania. 622 patients who were at least 60 years of age and presented for treatment in primary care practices that provided usual care in a randomized, controlled trial of suicide prevention. Of the 441 (70.9%) patients who completed 1 year of follow-up, 122 had major depression, 205 had minor or subsyndromal depression, and 114 did not have depression at baseline. One year after a baseline evaluation, data were collected by using the following tools: Hamilton Depression Rating Scale, the depressive disorders section of the Structured Clinical Interview for DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition), Charlson Comorbidity Index, Multilevel Assessment Instrument for measuring instrumental activities of daily living, Physical Component Summary of the Medical Outcomes Study Short Form-36, and Duke Social Support Index. Patients with minor or subsyndromal depression had intermediate depressive and functional outcomes. Mean adjusted 1-year Hamilton depression score was 10.9 (95% CI, 9.6 to 12.2) for those with initial major depression, 7.0 (CI, 5.9 to 8.1) for those with minor or subsyndromal depression, and 2.9 (CI, 1.6 to 4.2) for those without depression (P < 0.001 for each paired comparison). Compared with patients who were not depressed, those who had minor or subsyndromal depression had a 5.5-fold risk (CI, 3.1-fold to 10.0-fold) for major depression at 1 year after controlling for demographic characteristics (P < 0.001). Cerebrovascular risk factors were not associated with a diagnosis of depression at 1 year after controlling for overall medical burden. Initial medical burden, self-rated health, and subjective social support were significant independent predictors of depression outcome. Participants received care at practices that had personnel who had been given enhanced education about depression treatment; 29.1% of participants withdrew from the study before completing 1 year of follow-up. The intermediate outcomes of minor and subsyndromal depression demonstrate the clinical significance of these conditions and suggest that they are part of a spectrum of depressive illness. Greater medical burden, poor subjective health status, and poorer subjective social support confer a higher risk for poor outcome.

The Feasibility of Connecting Physician Offices to a State-Level Tobacco Quit Line

Telephone counseling for tobacco cessation is an effective and evidence-based approach to address tobacco use. The wide dissemination of region- and state-level quit lines has been a major goal for public health agencies. However, connecting patients in primary care settings to state-level quit lines has not been evaluated. Observational study describing two methods (fax referral and providing a brochure) to connect private physician offices with a state-level quit line in Oregon. This study describes the resources required to create a clinical pathway for the 5A's in primary care (ask, advise, assess, assist, and arrange) using a state-level telephone quit line as an intervention for cessation in primary care clinics sharing a common electronic medical record system, focusing on the costs and generalizability of this approach. Of the 15,662 smokers identified in 19 primary care clinics, 745 patients were referred to the Oregon Tobacco Quit Line during the study period. The program cost in the first year was $15 to $22 per patient connected with the quit line; in subsequent years, the cost decreased to $4 to $6 per quit-line connection. Connecting private physician offices to a state-level quit line is feasible, can be accomplished at low cost with minimal use of resources, and may be cost effective. Regional, state, and local tobacco quit lines should consider a physician office "quit-line connection" as a practical approach to increase utilization.

Beyond Efficacy: The STAR*D Trial

Beyond Efficacy: The STAR*D Trial

A qualitative and quantitative review of behavioral activation treatment of major depressive disorder.

In the treatment of Major Depressive Disorder (MDD), Behavioral Activation Therapy (BA) has emerged in recent years as an efficacious intervention. Derived from a component analysis of CBT, it offered at once a parsimonious explanation for the active ingredient of CBT, while demonstrating clinical efficacy as a separate Since the original investigation by Jacobson and colleagues in 1996, several well-controlled studies have been conducted, all of which converge to suggest strong support for BA as a stand-alone therapy for MDD. In this paper we review, evaluate and classify the evidence pertinent to this intervention and provide recommendations concerning its standing as a front line We conclude that the evidence is strong, the quality of research is generally very good and the effects sizes are compelling. Through both a qualitative and meta-analytic review of this evidence we also suggest the types of future studies that will establish greater confidence in BA as a front line treatment of choice therapy for Major Depressive Disorder. Key Terms: Behavioral Activation, Major Depressive Disorder, Cognitive Behavior Therapy, Efficacious Treatment ********** Major Depressive Disorder (MDD) affects approximately 121 million people worldwide (World Health Organization, 2006). In the United States, MDD has a lifetime prevalence of 10% to 25% for women and 5% to 12% for men and a point prevalence of 5% to 9% for women and 2% to 3% for men (American Psychiatric Association, 2000). It has been determined to be the leading cause of disability and the 4th leading contributor to the global burden of disease (World Health Organization, 2006). Despite both the high prevalence and serious costs of depression, up to 90% of depressed patients in primary care settings fail to receive adequate treatment, in the form of empirically supported medication regimens or in the form of empirically supported psychotherapies for depression (Center for the Advancement of Health, 2000). Of the available psychological therapies for treating MDD. Cognitive-Behavior Therapy (CBT) has emerged as the frontline treatment of choice, based on empirical findings demonstrating its efficacy and effectiveness. Dobson (1989) conducted a meta-analysis of the literature investigating Beck's Cognitive Therapy (CT) for depression (which is classified as Cognitive-Behavioral Therapy) and found that CT is more effective than general psychotherapy, Behavior Therapy, and pharmacotherapy in the treatment of MDD. Based in part on Dobson's conclusions, Chambless and colleagues (1998) labeled Cognitive Therapy (CT) for depression as a well-established treatment. Recently, a component of CBT called Behavioral Activation (BA) has received a great deal of attention. First, because as a result of a component analysis it appeared to offer a conceptually parsimonious accounting of the measured effects of CBT. Secondly it offered potential as a more efficient and thus, cost-effective treatment for MDD. Both of these observations resulted from the work of Jacobson and colleagues (1996). For this reason the National Institute of Mental Health called for greater research attention to this technique (NIMH vision statement, 2005). Although BA has a strong theoretical foundation (Lewinsohn, Sullivan, & Grosscup, 1980) and the packaged therapy from which it is derived (CBT) has strong empirical support, the studies devoted to the efficacy and effectiveness of BA as a stand-alone therapy, although encouraging, are somewhat limited. An extensive review of the PsychInfo database yielded eleven treatment relevant studies devoted to behavioral activation, two of which were case studies (Hopko, Lejuez, & Hopko, 2004; Mulick & Naugle, 2004). One of the remaining investigations constituted a follow-up examination for an earlier treatment outcome study (Gortner, Gollan, Dobson, & Jacobson, 1998). The present paper provides a critical review of the controlled studies, and provides a meta-analytic summary of their collective findings. …

Does pulmonary rehabilitation give additional benefit over tiotropium therapy in primary care management of chronic obstructive pulmonary disease? Randomized controlled clinical trial in Hong Kong Chinese

To evaluate whether multidisciplinary pulmonary rehabilitation programme (PRP) provides additional benefit over tiotropium therapy in managing chronic obstructive pulmonary disease (COPD) in primary care. A randomized controlled trial to analyse the difference in outcomes of COPD patients receiving tiotropium plus PRP vs. tiotropium treatment alone. Two primary care teaching clinics affiliated with a university which serves a population of 600,000. Fifty primary care COPD patients. Fifty subjects underwent spirometry and their status of COPD was confirmed by using the Vitalograph Gold Standard. They were then assessed by the 6-min walking distance (6MWD), Peak Visual Analogue Scale (Peak VAS) and Chronic Respiratory Disease Questionnaire (CRQ). All subjects were given tiotropium to optimize their treatment. After a 6-week period, half were randomized to the intervention group (i.e. receiving PRP), whereas the rest were randomized to control group which received only medication. Spirometry, 6MWD, Peak VAS and CRQ were performed in both groups at 6 weeks, 12 weeks and 3 months. Spirometry, 6MWD, Peak VAS and CRQ. Significant improvement (P < 0.05) was seen in 6MWD, symptoms of dyspnoea measured by Peak VAS and CRQ. The improvement was sustained at 3-month follow-up. However, no additional significant improvement was seen in the intervention group when compared with control. Tiotropium therapy has improved health outcomes in COPD patients in primary care settings. A 6 weekly PRP did not give any additional benefits in patients already given tiotropium.

The prognosis of depression in late life versus mid-life: implications for the treatment of older adults

Depression in late life is extremely common. Of those aged 65 years or older, 2–5% have syndromal depression, but up to 20% of elderly people have depressive symptoms (Horwath et al., 2002). Both syndromal and subsyndromal depression carry a high risk of long-term complications and both are associated with elevated risks of morbidity and mortality (Penninx et al., 1999). Despite repeated alerts, depression is consistently under-recognized in acute medical settings, in nursing homes and in primary care (Volkers et al., 2004). For reasons that are inadequately understood, late-life depression seems to be under-treated to an even greater extent than depression in mid-life (Mackenzie et al., 1999). This issue is particularly important, given that effective and safe treatments for depression are available (Bartels et al., 2003), even though the evidence regarding maintenance therapies in older people is inconsistent (Geddes et al., 2003; Wilson et al., 2003). Recent evidence suggests that a package of care can improve the care of older depressed patients in primary care settings (Bruce et al., 2004) and in nursing homes (Ciechanowski et al., 2004). This has led to the development of several clinical guidelines specifically for late-life depression (Baldwin et al., 2003; Charney et al., 2003; Lebowitzet al., 1997). Yet, in the recent National Institute of Clinical Excellence (NICE) guidelines for the management of depression in primary and secondary care, no distinction was made between early, middle and late-life depression (Malone and Mitchell, 2005).

New Medicare Benefit Could Have Unexpected Treatment Consequences

New Medicare Benefit Could Have Unexpected Treatment Consequences

Clinical Management for Hospital-Treated Deliberate Self-Poisoning: Comparisons between Patients with Major Depression and Borderline Personality Disorder

To compare the initial clinical management of hospital-treated deliberate self-poisoning patients with major depressive disorder (MDD) or borderline personality disorder (BPD) after controlling for demographic factors and level of suicide ideation. This study compared sequential hospital treated deliberate self-poisoning patients (n = 570) with either MDD or BPD (but no major comorbid psychopathology) on four outcomes modelled using logistic regression: (i) length of stay in the general hospital; (ii) discharge to a psychiatric hospital; (iii) psychiatric follow-up; and (iv) general practitioner (GP) follow-up. BPD and MDD patients were discharged to psychiatric inpatient care at very similar rates (33%-35%) and almost all subjects with high levels of suicidal ideation were discharged to psychiatric hospital. However, for mild to moderate levels of suicidal ideation BPD patients were more likely to be discharged to psychiatric hospital than MDD patients. After controlling for demographics and suicidal ideation, BPD patients were more likely to be referred for psychiatric hospitalization on discharge (adjusted OR = 1.79, 95% CI = 1.01-3.18) and less likely to be referred to GPs if discharged to home (adjusted OR = 0.44, 95% CI = 0.24-0.81). There were no differences in general hospital length of stay or arrangements made for psychiatric follow-up for those discharged to home. This suggests that for mild to moderate suicidal ideation levels clinicians are more likely to choose to send BPD patients, after deliberate self-poisoning, to inpatient psychiatric care than MDD patients. Clinicians are also apparently more likely to choose to manage MDD patients in primary care settings, for those patients discharged to home. This has implications for service planning and clinical guidelines.

Anxiety Disorders in Older Puerto Rican Primary Care Patients

Authors examined the frequency and comorbidity of anxiety disorders among aging Puerto Ricans seen in primary care. A group of 303 middle-aged and older low-socioeconomic-status Puerto Ricans attending primary-care clinics were surveyed, using a Spanish-language diagnostic interview. Twenty-four percent of participants met probable DSM criteria for at least one anxiety disorder in the previous year, especially generalized anxiety disorder, specific phobia, and panic attacks. Psychiatric comorbidity was common; the occurrence of most anxiety disorders increased the conditional risk of a comorbid disorder from 5- to 30-fold. The present results suggest a need to screen at-risk patients in primary care settings serving this population.

Anxiety Disorders in Older Puerto Rican Primary Care Patients

Authors examined the frequency and comorbidity of anxiety disorders among aging Puerto Ricans seen in primary care.A group of 303 middle-aged and older low-socioeconomic-status Puerto Ricans attending primary-care clinics were surveyed, using a Spanish-language diagnostic interview.Twenty-four percent of participants met probable DSM criteria for at least one anxiety disorder in the previous year, especially generalized anxiety disorder, specific phobia, and panic attacks. Psychiatric comorbidity was common; the occurrence of most anxiety disorders increased the conditional risk of a comorbid disorder from 5- to 30-fold.The present results suggest a need to screen at-risk patients in primary care settings serving this population.

Pharmacist Involvement in Primary Care Improves Hypertensive Patient Clinical Outcomes

The practice of pharmaceutical care in primary care settings in Thailand is currently not generally accepted. To evaluate the effect of pharmacist involvement in treatment with hypertensive patients in primary care settings. The treatment objective was to stabilize the blood pressure (BP) of hypertensive patients in accordance with the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure guidelines. Patients were randomly assigned to a pharmacist-involved group (treatment) or a group with no pharmacist involvement (control). Pre- and post-test BPs, tablet counts, lifestyle modifications, and pharmacists' recommendations were recorded. The 6-month study was carried out in Mahasarakham University pharmacy and 2 primary care units. Patients were monitored monthly by reviewing their medications and supported by providing pharmaceutical care and counseling. From a total of 235 patients, the treatment group (n = 118) had a significant reduction in both systolic (S) and diastolic (D) BP compared with the 117 patients of the control group (p = 0.037, 0.027, respectively). The 158 patients (76 treatment, 82 control) with BPs >or=140/90 mm Hg at the beginning of the study showed significant BP reductions (p = 0.002 SBP, 0.008 DBP). The proportion of 158 patients whose BP became stabilized was higher in the treatment group (p = 0.017). The treatment group showed significantly better adherence (p = 0.014) and exercise control (p = 0.012) at the end of the study. Physicians accepted 42.72% of medication modifications and 5.34% of the suggestions for additional investigations. Hypertensive patients who received pharmacist input achieved a significantly greater benefit in BP reduction, BP control, and improvement in adherence rate and lifestyle modification.

Musculoskeletal Medicine in Practice

Objectives To provide a rapid access treatment facility in the primary care setting for patients with acute low back pain. To implement the recommendations of the Clinical Standards Advisory Group for back pain (CSAG).Design A pilot scheme was initially run with a treatment centre in each of Plymouth’s three locality care groups (LCGs). 12 months funding was obtained from each locality’s development funds. All GPs in the area were invited to refer patients according to an agreed protocol and targets for waiting times were set. Each centre was run by a practitioner with special skills and experience in the management of back pain.Setting Consulting rooms in three general practice surgeries with facilities for carrying out examinations, spinal manipulations, acupuncture and caudal epidurals.Participants The protocol for referral included patients between 18 and 60 with symptoms of six weeks duration or less who were not making progress and who would otherwise have been referred to secondary care.Results In the pilot year, 651 patients were referred and 92% were seen within two weeks of the request. 50% were off work at the time of referral. At discharge, 72% were more than 70% improved and only four percent required further referral, in the majority of cases for a neurosurgical opinion. The average cost per patient treated was £91, considerably less than hospital outpatient treatment.Conclusion A rapid response service for patients with acute back pain has been adopted by Plymouth’s PCT. This service has shown itself to be both effective and economical. A multidisciplinary sub-acute service was added after 12 months. The acute and the sub acute clinics together with the existing hospital pain clinic, provide a seamless service for patients with back pain that satisfies the principal recommendations in the CSAG (HMSO 1994) report.

Improving glycaemic control in patients with Type 2 diabetes mellitus without insulin therapy.

In general practice at least 30% of those with Type 2 diabetes do not achieve good glycaemic control. We studied the effect of improving oral glucose-lowering medication in a primary care setting in patients treated with oral hypoglycaemic agents without satisfactory glycaemic control. We provided flowcharts to general practitioners and outreach visits by trained facilitators, who checked adherence to the protocol. Fifty-two Dutch general practices with 2140 Type 2 diabetes mellitus (DM) patients recruited 288 patients < or = 75 years old inadequately controlled (HbA1c >7%) by diet or oral medication. Outcome measures were decrease of HbA1c, number of patients with HbA1c < or = 7%, and non-compliance rate. After a mean of 3.3 consultations over 14 weeks, 209 patients were following the protocol fully with a reduction in HbA1c from 8.7% to 6.7% (P<0.001). One hundred and fifty-eight patients (55%) achieved HbA1c < or =7%, and 51 (18%) persisted with HbA1c >7% unless fasting blood glucose < or =7 mmol/l (n=18) or a maximum of medication (n=33). Seventy-nine patients (27%) did not adhere to the protocol, mostly due to loss of motivation and non-attendance. A simple flowchart and relatively little support by trained facilitators results in improved glycaemic control.

How well are we managing and monitoring high blood pressure?

We will summarize the latest available data on hypertension control levels in different populations throughout the world, and review the factors that appear to contribute to the widespread lack of blood pressure control in identified hypertensive patients. Population surveys throughout the world indicate that the proportion of hypertensive patients with blood pressure controlled to below 140/90 mmHg ranges from 5% in Taiwan to 25% in the United States. Studies in the US have shown that the majority of hypertensive patients classified as uncontrolled have diastolic pressure below 90 mmHg with mild systolic elevation in the 140-160 mmHg range, and that these blood pressure levels rarely elicit a treatment intensification action by the physician. The results of the Antihypertensive and Lipid Lowering to Prevent Heart Attack Trial indicate that it is feasible to maintain average blood pressures on treatment to levels well below 140/90 mmHg in elderly hypertensive patients in primary care settings. Although the literature on automated blood pressure measurement and comparisons between office blood pressure and home blood pressure continues to grow, there has been little attention paid to practicing physicians' attitudes and beliefs about different blood pressure measurement methods, or to the feasibility of standardizing blood pressure measurement in typical practice settings. The experience in the US indicates that widely publicized treatment guidelines recommending blood pressure control targets and choice of first-line agents may have little influence on practicing physicians, even when based on solid evidence from clinical trials. Controversies in the literature regarding treatment targets, appropriate drug choices, and blood pressure monitoring methods are likely to delay improvements in overall population control.

Practical Geriatrics: Clinically Significant Nonmajor Geriatric Depression

Practical Geriatrics: Clinically Significant Nonmajor Geriatric Depression

Emergency treatment of hyperglycaemia in adult type-2 diabetic patients in primary care settings

Hyperglycaemic crises are common in adult type 2 diabetic patients in the Middle East and other developing countries.These need treatment under certain conditions, as part of the overall goal of striving for good glycaemic control in thesepatients, in order to delay or prevent diabetic complications. As oral hypoglycaemic agents (OHAs) are inefficient in thesecircumstances, we have devised a simple easily applied method for rapid control of these episodes. Intravenous saline rehydration,is given with intramuscular soluble insulin in a dose chosen, according to patient’s weight, age and level ofhyperglycaemia. Blood glucose concentration is checked 3 hours after insulin injection. This regime reduces hyperglycaemiaby an average of 40-60% in 3 hours, which is a more reliable level of reduction than that experienced with OHAs. Whereinsulin is readily available, its flexible use in this way can help greatly in achieving good glycaemic control in type 2 diabeticpatients.

Síndrome de mononucleosis infecciosa en pacientes adolescentes y adultos

Infectious mononucleosis syndrome, characterized in typical cases by fever, sore throat, tonsillar exudates, cervical adenopathies and atypical lymphocytosis is associated in most cases to Epstein-Barr virus (EBV) infection. Other potential causes for this syndrome are acute cytomegalovirus (CMV), Human Immunodeficiency Virus, Toxoplasma gondii or Human Herpes virus 6 infection. These alternative etiologies evolve with a modified clinical picture that includes sometimes leukopenia or rash. Diagnosis of EBV is easily accomplished by atypical lymphocytosis (> 10%), positive heterophil antibodies and IgM antibodies directed against the EB viral capsid antigen (VCA). The latter is needed for cases without positive heterophil antibodies. Acute CMV infection is the second most important cause and can be diagnosed by CMV antigen detection, PCR or shell vial culture of blood samples, although experience with these tests among immunocompetent patients in primary care settings is sparse. Acute primary HIV infection is an important cause for this syndrome and should not be neglected when other causes are discarded. Third or fourth generation HIV ELISA tests, p24 antigen or HIV-PCR detection in blood samples allow recognition of this agent from the second or third week of inoculation. T. gondii and human herpes virus 6 infection can be diagnosed by serological methods. Evolution of EBV or CMV infection is favorable with infrequent complications

Counseling to promote a healthy diet in adults: A summary of the evidence for the U.S. Preventive Services Task Force

Objective The purpose of this study was to examine the effectiveness of counseling to promote a healthy diet among patients in primary care settings. Design and data sources We conducted a MEDLINE search from 1966 to December 2001. Study selection We included randomized controlled trials of at least 3 months’ duration with measures of dietary behavior that were conducted in patient populations similar to those found in primary care practices. We excluded studies that reported only biochemical or anthropomorphic endpoints, had dropout rates greater than 50%, or enrolled patients based on the presence of a chronic disease. Data extraction One author extracted relevant data from each included article into evidence tables. Using definitions developed by the research team, two authors independently rated each study in terms of its effect size, the intensity of its intervention, the patient risk level, and the use of well-proven counseling techniques. Data synthesis We identified 21 trials for use in this review. Dietary counseling produces modest changes in self-reported consumption of saturated fat, fruits and vegetables, and possibly dietary fiber. More-intensive interventions were more likely to produce important changes than brief interventions, but they may be more difficult to apply to typical primary care patients. Interventions using interactive health communications, including computer-generated telephone or mail messages, can also produce moderate dietary changes. Conclusions Moderate- or high-intensity counseling interventions, including use of interactive health communication tools, can reduce consumption of saturated fat and increase intake of fruit and vegetable. Brief counseling of unselected patients by primary care providers appears to produce small changes in dietary behavior, but its effect on health outcomes is unclear.

Does Counseling by Clinicians Improve Physical Activity? A Summary of the Evidence for the U.S. Preventive Services Task Force

To determine whether counseling adults in primary care settings improves and maintains physical activity levels. The Cochrane Database of Systematic Reviews and Registry of Controlled Trials and the MEDLINE, HealthStar, and Best Evidence databases were searched for papers published from 1994 to March 2002. Controlled trials, case-control studies, and observational studies that examined counseling interventions aimed at increasing physical activity in general primary care populations were reviewed. The researchers included trials in which 1) a patient's primary care clinician performed some of the counseling intervention; 2) behavioral outcomes (physical activity) were reported; and 3) the study was of "good" or "fair" quality, according to criteria developed by the U.S. Preventive Services Task Force. Data were abstracted on design and execution, quality, providers, patients, setting, counseling intervention, and self-reported physical activity at follow-up. Eight trials involving 9054 adults met the inclusion criteria. Among six controlled trials with a usual care control group, the effects of counseling on physical activity were mixed. Because most studies had at least one methodologic limitation, it was difficult to rigorously assess the efficacy of the interventions. More research is needed to clarify the effect, benefits, and potential harms of counseling patients in primary care settings to increase physical activity. Evidence is inconclusive that counseling adults in the primary care setting to increase physical activity is effective.