Routine Office Visits Research Articles

Blood-Based Testing for Colorectal Cancer Screening

Colorectal cancer (CRC) is the third most common non-skin cancer diagnosed in men and women in the USA and worldwide. While it has been clearly established that screening for CRC, using a variety of methods, is cost effective and has a significant impact on overall survival, screening rates have proven to be sub-optimal. It has been long conjectured that a simple blood-based test, with a specimen drawn at a routine doctor's office visit, would encourage those individuals who have refused or ignored screening recommendations to undergo screening. This article reviews the currently available blood-based screening tests for CRC, including the ColonSentry™ messenger RNA (mRNA) expression panel and the SEPT9 methylated DNA test, and explores newer biomarkers that are near clinical implementation. Also discussed are additional applications for blood-based CRC testing, such as assessing prognosis, disease surveillance, and expansion of screening tests to high-risk populations, such as the estimated 1.4 million individuals in the USA with inflammatory bowel disease.

Should My Provider Pray with Me? Perspectives of Urban Adolescents with Asthma on Addressing Religious and Spiritual Issues in Hypothetical Clinical Settings

This qualitative study examined the preferences of urban adolescents with asthma for including religious/spiritual (R/S) inquiry in a variety of hypothetical clinical encounters. Twenty-one urban adolescents (M(age) = 15.6 years, 52 % female, 81 % African American) with asthma participated in a semi-structured interview. Interviews were transcribed and underwent a thematic analysis. R/S preferences were contextual rather than personal, driven by: (1) acuity of the hypothetical clinical context; (2) nature of the patient-provider relationship; and (3) level of R/S intervention/inquiry. Most adolescents welcomed prayer if near death, but did not see the relevance of R/S in a routine office visit.

Evaluation of the cost of CA-125 measurement, physical exam, and imaging in the diagnosis of recurrent ovarian cancer

ObjectiveOvarian cancer accounts for 50% of deaths from gynecologic malignancies. We sought to determine the cost of common methods of surveillance of women with ovarian cancer in first clinical remission. The current standard for post treatment surveillance is the National Comprehensive Cancer Network (NCCN) guidelines. MethodsWe retrospectively determined how recurrence was initially detected at our institution and a cost model was created and applied to the United States population to calculate surveillance costs using the Surveillance Epidemiology & End Results (SEER) database. Results57% (n=60) of first recurrences were identified by increasing CA 125 level. Routine office visit identified 27% (n=29) of recurrences, and 15% (n=16) were diagnosed initially with CT scan. In 5% (5/105), CT abnormality was the only finding. 95% (100/105) of patients had either elevated CA 125 or office visit findings at time of recurrence. Of the 22,000 women diagnosed with ovarian cancer yearly, 60% (n=13,266) will have advanced disease and are likely to recur. The surveillance cost for this population for 2years using our model is $32,500,000 using NCCN guidelines and $58,000,000 if one CT scan is obtained. ConclusionsOur data suggests that following NCCN guidelines will detect 95% of recurrences. An additional $26million will be needed to identify the 5% of women with recurrence seen on CT only. Post treatment surveillance of ovarian cancer patients contributes significantly to health care costs. Use of CT scan to follow these patients largely increases cost with only a small increase in recurrence detection.

Private Insurers’ Payments For Routine Physician Office Visits Vary Substantially Across The United States

Anecdotal reports suggest that substantial variation exists in private insurers' payments for physician services, but systematic evidence is lacking. Using a retrospective analysis of insurance claims for routine office visits, consultations, and preventive visits from more than forty million physician claims in 2007, we examined variations in private payments to physicians and the extent to which variation is explained by patients' and physicians' characteristics and by geographic region. We found much variation in payments for these routine evaluation and management services. Physicians at the high end of the payment distribution were generally paid more than twice what physicians at the low end were paid for the same service. Little variation was explained by patients' age or sex, physicians' specialty, place of service, whether the physician was a "network provider," or type of plan, although about one-third of the variation was associated with the geographic area of the practice. Interventions that promote more price-consciousness on the part of patients could help reduce health care spending, but more data on the specific causes of price variation are needed to determine appropriate policy responses.

Growing Up Is Hard

Puberty brings on many biological, mental, and social changes. In this phase of life, the prevalence of serious mental disorders is about 10%. This review is based on a selective search for publications on the prevalence, causes, risk factors, and effects of mental disorders in adolescence. Internalizing mental disorders are more common in girls; these include depression, social anxiety, and eating disorders. Their prevalence ranges from 12% to 23%, depending on the particular diagnostic instruments and criteria that are applied. Disruptive disorders, e.g., disorders of social behavior, are more common in boys, with a worldwide prevalence of approximately 5% to 10%. Marked differences between the sexes appear during puberty. The one-year prevalence of self-injurious behavior is about 14% in boys and 25% in girls. The consumption of legal and illegal drugs is one of the risk-seeking behaviors associated with adolescence. In routine check-ups and medical office visits, particular attention should be paid to the possibility of a mental disorder. Special outpatient clinics for adolescents can help more young people avail themselves of the existing preventive and therapeutic measures. Early diagnosis and treatment may prevent mental disorders in adulthood and foster age-appropriate development.

Unmet Needs in the Assessment and Management of Bipolar I Depression

Bipolar depression remains challenging for clinicians to assess and manage during routine office visits. When patients complete assessments before their office visits, clinicians are able to quickly review the results beforehand and spend more time engaging and assessing the patient. After completing the differential diagnosis, clinicians can focus on discussing treatment goals and expectations with patients, educate them about viable treatment options, and help them select a proven option that will best promote treatment adherence. Collaborating with patients and care partners enables patients to be active participants in the management process. Systematically using assessment tools provides clinicians with measurable data to gauge the effectiveness and tolerability for each treatment and then to guide the next treatment decisions. Patients with bipolar depression value individualized care and rely on the expertise of clinicians to help them achieve remission.

A Multiagency, Multidisciplinary Approach to a Lethal Fetal Diagnosis

<h2>Professional Issues Paper Presentation</h2><h3>Background</h3> A diagnosis of trisomy 18 occurs in approximately one of every 3,000 live births. The devastating news of any diagnosis that is incompatible with life affects the parents, their families, and the healthcare worker. Though uncommon, lethal fetal diagnosis needs to be dealt with proactively. An effective perinatal bereavement program can be used to work with the family to make a plan of care that is realistic and expectant. Once shared, this plan can be an effective way for nursing, physicians, midwives, clergy, and social work to create the best of an imperfect scenario for all involved. <h3>Case</h3> A 39‐year‐old multigravida patient presented to her routine office visit after a diagnosis of fetal trisomy 18. The physician wanted the patient's labor and delivery experience to be well coordinated with the obstetric (OB) nursing department. Once the patient and her husband met with the OB nurse manager, she realized that the family had a knowledge deficit and somewhat unrealistic expectations for the potential outcome. The OB nurse manager arranged for the patient and her husband to meet with the perinatal center's bereavement manager to discuss a plan of care that would meet their needs. The plan was then shared with the obstetrician, the OB staff nurses, the hospital clergy and social service department, and the pediatrician who would be caring for the infant. Despite having a heart rate during labor, the infant delivered in frank breech position with no heart rate. Per the patient's request and plan of care made in advance, no resuscitation was performed. The patient was able to spend several hours with the infant and was discharged home on postpartum day 1. The family was very pleased with all of the planning and care that went into the delivery of the infant, the postmortem care, and the compassion displayed by the healthcare team. <h3>Conclusion</h3> Despite not having a perinatal bereavement program available at a small community hospital, the regional perinatal center's bereavement program was utilized to create a multiagency, multidisciplinary approach to the care of a patient with a lethal fetal diagnosis. Creating a collaborative effort is essential to assist patients in all aspects of care delivery. Communicating the needs of this patient to all departments involved prepared the healthcare providers to meet and exceed the needs of this family.

Live well: a practical and effective low-intensity dietary counseling intervention for use in primary care patients with dyslipidemia - a randomized controlled pilot trial

BackgroundDiet is the first line of treatment for elevated cholesterol. High-intensity dietary counseling (≥360 minutes/year of contact with providers) improves blood lipids, but is expensive and unsustainable in the current healthcare settings. Low-intensity counseling trials (≤ 30 minutes/year) have demonstrated modest diet changes, but no improvement in lipids. This pilot study evaluated the feasibility and the effects on lipids and diet of a low-intensity dietary counseling intervention provided by the primary care physician (PCP), in patients at risk for cardiovascular diseases.MethodsSix month study with a three month randomized-controlled phase (group A received the intervention, group B served as controls) followed by three months of intervention in both groups.Sixty-one adults age 21 to 75 years, with LDL-cholesterol ≥ 3.37 mmol/L, possessing Internet access and active email accounts were enrolled. Diet was evaluated using the Rate-Your-Plate questionnaire. Dietary counseling was provided by the PCP during routine office visits, three months apart, using printed educational materials and a minimally interactive counseling website. Weekly emails were sent reminding participants to use the dietary counseling resources. The outcomes were changes in LDL-cholesterol, other lipid subclasses, and diet quality.ResultsAt month 3, group A (counseling started at month 1) decreased their LDL-cholesterol by −0.23 mmol/L, (−0.04 to −0.42 mmol/L, P = 0.007) and total cholesterol by −0.26 mmol/L, (−0.05 to −0.47 mmol/L, P = 0.001). At month 6, total and LDL-cholesterol in group A remained better than in group B (counseling started at month 3). Diet score in group A improved by 50.3 points (38.4 to 62.2, P < 0.001) at month 3; and increased further by 11.8 (3.5 to 20.0, P = 0.007) at month 6. Group B made the largest improvement in diet at month 6, 55 points (40.0 to 70.1, P < 0.001), after having a small but significant improvement at month 3, 22.3 points (12.9 to 31.7, P < 0.001). No significant changes occurred in HDL-cholesterol in either group.ConclusionsA low-intensity dietary counseling provided by the PCP in patients at risk for cardiovascular diseases produced clinically meaningful improvements in both diet and lipids of magnitude similar to changes reported with high intensity interventions.Trial registrationClinicalTrials.gov: NCT01695837

Impact of a multi-biomarker disease activity test on rheumatoid arthritis treatment decisions and therapy use

Objective:To assess how use of a multi-biomarker disease activity (MBDA) blood test for rheumatoid arthritis (RA) affects treatment decisions made by health care providers (HCPs) in clinical practice.Research design and methods:At routine office visits, 101 patients with RA were assessed by their HCPs (N = 6), and they provided blood samples for MBDA testing. HCPs completed surveys before and after viewing the MBDA test result, recording dosage and frequency for all planned RA medications and physician global assessment of disease activity. Frequency and types of change in treatment plan that resulted from viewing the MBDA test result were determined.Main outcome measure:Percentage of cases in which the HCP changed the planned treatment after viewing the MBDA test result.Results:Prior to HCP review of the MBDA test, disease modifying anti-rheumatic drug (DMARD) use by the 101 patients included methotrexate in 62% of patients; hydroxychloroquine 29%; TNF inhibitor 42%; non-TNF inhibitor biologic agent 19%; and other drugs at lower frequencies. Review of MBDA test results changed HCP treatment decisions in 38 cases (38%), of which 18 involved starting, discontinuing or switching a biologic or non-biologic DMARD. Other changes involved drug dosage, frequency or route of administration. The total frequency of use of the major classes of drug therapy changed by <5%. Treatment plans changed 63% of the time when the MBDA test result was perceived as being not consistent or somewhat consistent with the HCP assessment of disease activity.Study limitations:Limited sample size; lack of control group; no longitudinal follow-up.Conclusions:The addition of the MBDA test to clinical assessment led to meaningful changes in the treatment plans of 38% of RA patients being cared for by HCPs in office practice. Even though treatment was potentially improved, the overall quantity of drug use was minimally affected.

Aid-Assisted Decision Making and Colorectal Cancer Screening: A Randomized Controlled Trial

Shared decision making (SDM) is a widely recommended yet unproven strategy for increasing colorectal cancer (CRC) screening uptake. Previous trials of decision aids to increase SDM and CRC screening uptake have yielded mixed results.To assess the impact of decision aid-assisted SDM on CRC screening uptake.RCT.The study was conducted at an urban, academic safety-net hospital and community health center between 2005 and 2010. Participants were asymptomatic, average-risk patients aged 50-75 years due for CRC screening.Study participants (n=825) were randomized to one of two intervention arms (decision aid plus personalized risk assessment or decision aid alone) or control arm. The interventions took place just prior to a routine office visit with their primary care providers.The primary outcome was completion of a CRC screening test within 12 months of the study visit. Logistic regression was used to identify predictors of test completion and mediators of the intervention effect. Analysis was completed in 2011.Patients in the decision-aid group were more likely to complete a screening test than control patients (43.1% vs 34.8%, p=0.046) within 12 months of the study visit; conversely, test uptake for the decision aid and decision aid plus personalized risk assessment arms was similar (43.1% vs 37.1%, p=0.15). Assignment to the decision-aid arm (AOR=1.48, 95% CI=1.04, 2.10), black race (AOR=1.52, 95% CI=1.12, 2.06) and a preference for a patient-dominant decision-making approach (AOR=1.55, 95% CI=1.02, 2.35) were independent determinants of test completion. Activation of the screening discussion and enhanced screening intentions mediated the intervention effect.Decision aid-assisted SDM has a modest impact on CRC screening uptake. A decision aid plus personalized risk assessment tool is no more effective than a decision aid alone.This study is registered at www.clinicaltrials.govNCT00251862.

Supporting Adolescent Mothers: A Journey Through Policies, Programs, and Research

Several months ago, during a routine office visit, a patient I’ll call Brittany told me she was getting married to her boyfriend of five years. Her adolescent daughter, whose health care I have provided since birth, was to be her maid of honor. Would I come to her wedding, she asked? With satisfaction, I considered how our 17-year journey together began when Brittany was a pregnant 15-year-old girl in our BRIDGES program, funded by an Adolescent Family Life (AFL) Care Demonstration Grant. Back then she was a diffident, troubled adolescent living in a blighted Baltimore, Maryland, neighborhood with her siblings and single mother. We provided Brittany with school-based prenatal care, guided her parenting with a tailored curriculum, encouraged her to delay additional pregnancies until she was older, and supported her to remain in school. Today, she is a confident, productively employed 30- something in a committed healthy relationship and has successfully raised a smart, well-adjusted 17-year-old daughter about to enter college on a scholarship. I thought back to Brittany’s pregnancy and the early years following her daughter’s birth. At that time, there was little published research to help guide the development of support programs for pregnant and parenting adolescents. What role, I wondered, did our AFL program play in her success as a parent and in her own life course?

A design process for using normative models in shared decision making: a case study in the context of prenatal testing

Shared decision making (SDM) encourages the patient to play a more active role in the process of medical consultation and its primary objective is to find the best treatment for a specific patient. Recent findings, however, show that patient preferences cannot be easily or accurately judged on the basis of communicative exchange during routine office visits, even for patients who seek to expand their role in medical decision making (MDM). The objective of this study is to improve the quality of patient-physician communication by developing a novel design process for SDM and then demonstrating, through a case study, the applicability of this process in enabling the use of a normative model for a specific medical situation. Our design process goes through the following stages: definition of medical situation and decision problem, development/identification of normative model, adaptation of normative model, empirical analysis and development of decision support systems (DSS) tools that facilitate the SDM process in the specific medical situation. This study demonstrates the applicability of the process through the implementation of the general normative theory of MDM under uncertainty for the medical-financial dilemma of choosing a physician to perform amniocentesis. The use of normative models in SDM raises several issues, such as the goal of the normative model, the relation between the goals of prediction and recommendation, and the general question of whether it is valid to use a normative model for people who do not behave according to the model's assumptions.

Improving Population Health Through Integration of Primary Care and Public Health: Providing Access to Physical Activity for Community Health Center Patients

Our community health center attempted to meet public health goals for encouraging exercise in adult patients vulnerable to obesity, diabetes, hypertension, and other chronic diseases by partnering with a local YMCA. During routine office visits, providers referred individual patients to the YMCA at no cost to the patient. After 2 years, the YMCA instituted a $10 per month patient copay for new and previously engaged health center patients. The copay policy change led to discontinuation of participation at the YMCA by 80% of patients. Patients who persisted at the YMCA increased their visits by 50%; however, more men than women became frequent users after institution of the copay. New users after the copay were also more likely to be younger men. Thus the copay skewed the population toward a younger group of men who exercised more frequently. Instituting a fee appeared to discourage more tentative users, specifically women and older patients who may be less physically active. Free access to exercise facilities (rather than self-paid memberships) may be a more appropriate approach for clinicians to begin engaging inexperienced or uncertain patients in regular fitness activities to improve health.

A Qualitative Study of Provider Thoughts on Implementing Pre-Exposure Prophylaxis (PrEP) in Clinical Settings to Prevent HIV Infection

BackgroundA recent clinical trial demonstrated that a daily dose tenofovir disoproxil fumarate and emtricitabrine (TDF-FTC) can reduce HIV acquisition among men who have sex with men (MSM) and transgender (TG) women by 44%, and up to 90% if taken daily. We explored how medical and service providers understand research results and plan to develop clinical protocols to prescribe, support and monitor adherence for patients on PrEP in the United States.MethodsUsing referrals from our community collaborators and snowball sampling, we recruited 22 healthcare providers in San Francisco, Oakland, and Los Angeles for in-depth interviews from May-December 2011. The providers included primary care physicians seeing high numbers of MSM and TG women, HIV specialists, community health clinic providers, and public health officials. We analyzed interviews thematically to produce recommendations for setting policy around implementing PrEP. Interview topics included: assessing clinician impressions of PrEP and CDC guidance, considerations of cost, office capacity, dosing schedules, and following patients over time.ResultsLittle or no demand for PrEP from patients was reported at the time of the interviews. Providers did not agree on the most appropriate patients for PrEP and believed that current models of care, which do not involve routine frequent office visits, were not well suited for prescribing PrEP. Providers detailed the need to build capacity and were concerned about monitoring side effects and adherence. PrEP was seen as potentially having impact on the epidemic but providers also noted that community education campaigns needed to be tailored to effectively reach specific vulnerable populations.ConclusionsWhile PrEP may be a novel and clinically compelling prevention intervention for MSM and TG women, it raises a number of important implementation challenges that would need to be addressed. Nonetheless, most providers expressed optimism that they eventually could prescribe and monitor PrEP in their practice.

Smoking cessation for the neurologic patient.

Given the vast health and socioeconomic effects of tobacco use, smoking cessation is no longer a topic reserved for the primary care physician. As a modifiable risk factor that can lead to stroke, dementia, multiple sclerosis, and other neurologic diseases, cigarette smoking should be addressed by all health care providers, including neurologists. Counseling, nicotine replacement therapies, and other medications are the mainstays of treatment. However, even brief advice from a health care professional at the end of a routine office visit can increase a patient's chances of quitting. Armed with a better understanding of smoking's effect on neurologic disease and available resources, such as toll-free quit lines and Web-based interventions, neurologists can help their patients who smoke take the first step to successful cessation.

Neonatal Cholestasis: Opportunities To Increase Early Detection

ObjectiveTo describe primary care management of early and prolonged jaundice in otherwise-healthy term infants to identify opportunities to increase early diagnosis of cholestasis. MethodsCommunity-based pediatricians in St Louis, Missouri completed a mailed, anonymous, 29-item survey to assess practice demographics, timing of routine newborn office visits, and the management of early and prolonged neonatal jaundice. ResultsA total of 108 of 230 (47%) of eligible physicians responded (mean years in practice, 15.3, SD, 9.4). More respondents were very familiar with national guidelines for management of early (49%) than prolonged (16%) neonatal jaundice. Eighty-six percent reported all newborns were checked with transcutaneous bilirubin before hospital discharge. For transcutaneous bilirubin results at 48 hours of 7, 10, 12 and 15 mg/dL, 1%, 26%, 70%, and 74% of respondents, respectively, would order a fractionated bilirubin. Although the first routine visit usually occurred in the first week after discharge, 25% of physicians reported the 2nd visit was routinely scheduled after 4 weeks of age. Ninety-four percent reported they would obtain a fractionated bilirubin for infants jaundiced beyond 4 weeks of age. If cholestasis was identified at 6 weeks of age, 32% would obtain additional testing without referral to a subspecialist. ConclusionsManagement of early and prolonged neonatal jaundice is variable. Current practices appear to miss opportunities for early diagnosis of cholestasis and referral that are unlikely to be addressed without redesigning systems of care.

Multidisciplinary Team Approach to Improved Chronic Care Management for Diabetic Patients in an Urban Safety Net Ambulatory Care Clinic

Since the care of patients with multiple chronic diseases such as diabetes and depression accounts for the majority of health care costs, effective team approaches to managing such complex care in primary care are needed, particularly since psychosocial and physical disorders coexist. Uncontrolled diabetes is a leading health risk for morbidity, disability and premature mortality with between 18-31% of patients also having undiagnosed or undertreated depression. Here we describe a team driven approach that initially focused on patients with poorly controlled diabetes (A1c > 9) that took place at a family medicare office. The team included: resident and faculty physicians, a pharmacist, social worker, nurses, behavioral medicine interns, office scheduler, and an information technologist. The team developed immediate integrative care for diabetic patients during routine office visits.

Towards Universal Screening for Colon Cancer: A Cheap, Reliable, Noninvasive Test Using Gene Expression Analysis of Rectal Swabs

Though colon cancer is the second leading cause of cancer deaths in the US, it is entirely preventable through early screening to detect and remove adenomatous polyps. Colonoscopy has long been regarded as the “gold standard” but is expensive, invasive, and uncomfortable, and only about half those considered at risk for colon cancer currently submit to colonoscopy or to less reliable alternatives such as fecal occult blood test. Here we describe the use of gene expression analysis to detect altered expression of certain genes associated with not only colon cancer but also polyps. The analysis can be performed on rectal swabs, with specimens provided in a routine doctor's office visit. The existence of this cheap and simple test, together with an active program to encourage individuals to submit to screening, could help eradicate colon cancer.

The Oldest Gravidas: A Review of Pregnancy Risks in Women Over 45

As a result of delayed childbearing and increasingly sophisticated assisted reproductive technologies, pregnancy in women aged ≥45 years is becoming more common. Women in this age-group should receive thorough preconception evaluation and counseling about their specific risks in pregnancy. Although many pregnancies in women >45 years old are achieved via assisted reproductive technologies with associated preconception counseling, as many as 45% may be spontaneously conceived. It is therefore important for obstetrician-gynecologists to incorporate education for older women about the risks of pregnancy into routine office visits, and to ask women in this age-group about pregnancy planning. Additionally, many pregnancies in women aged >45 years may be safely managed in a nontertiary care center, avoiding the need for referral and transfer of care to an unfamiliar setting. This review addresses preconception evaluation and counseling, real and perceived risks in older mothers, common pregnancy complications and management of pregnancy in women >45 years old. Obstetricians & Gynecologists, Family Physicians. After completion of this article, the reader should be better able to counsel women about the risks of pregnancy for women aged ≥45, evaluate older women for common risk factors that may further increase risk in pregnancy, assess pregnancy complications that are more common in women aged >45, and manage otherwise uncomplicated pregnancies in women in this age-group.

Assessing Dermatologists ’ Ability to Deliver a Novel Intervention to Improve Patients ’ Use of Sun Protection: The ABC Method of Physician-Patient Communication

Patients are often aware of the benefits of using sun protection, but this does not necessarily translate into positive behavioral outcomes. This disconnect can be a source of frustration for many dermatologists, who often emphasize the importance of proper sun protection to their patients. Research has shown that education alone is not an effective strategy to change behavior, especially among less motivated patients. However, communication that incorporates the principles of motivational interviewing (MI), a patient-centered approach that uses empathic communication, has been successful in improving a variety of health-related behaviors.1 While MI is often effective, most physicians are not familiar with this or similar communication techniques.2 Furthermore, most dermatologists have limited time to interact with patients during an office visit, making it difficult to engage in lengthy conversations about sun protection. Research suggests that training physicians to express empathy to their patients is a promising area for further research with potential to improve patient care.3,4 A recent study found that dermatologists who were shown an example of physician-patient conversations about sun protection that used MI principles felt favorably toward the technique and thought it would be a useful communication tool.5 Based on these findings, we have developed the ABC (addressing behavior change) method as a communication tool for dermatologists to use with their patients to enhance the use of sunscreen. The ABC method is based on the principles of MI and consists of the following components: (1) assess UV risk; (2) assess sunscreen use; (3) assess the obstacles to using sunscreen; (4) facilitate removal of the obstacles to sunscreen use; (5) assess other methods of sun protection; and (6) summarize patients’ motivations and ideas for improved sunscreen use. On average, the ABC method takes 2 to 3 minutes to deliver and was designed for use during a routine office visit that includes a skin examination. The ABC method is delivered in the context of a collaborative conversation with the patient rather than as a direct instruction. The focus of the current study was to teach a sample of dermatologists the ABC method and assess their ability to deliver it with fidelity as well as their sustained use and satisfaction with using it over a 6-month period.