title: Improving Patient-Clinician Conversations During Annual Wellness Visits.
abstract: BACKGROUND
  Health risk assessments (HRAs) have been implemented and studied for decades in various settings, but little is known about the effect of introducing HRAs on the dynamics and content of patient-clinician conversations during Medicare Annual Wellness Visits (AWVs) and whether the effective use of HRAs requires additional training and resources.
  
  
  METHODS
  We used Conversation Analysis techniques to analyze 40 AWVs conducted in an academic family medicine residency practice. After a 3-month baseline period, a low-intensity intervention was implemented to explore improvements in the dynamics and content of conversations. Short exit interviews with patients and clinicians were evaluated by standard content analytic techniques.
  
  
  RESULTS
  Six overarching themes emerged that described the dynamics of AWV conversations. Patients and clinicians sub-optimally utilized the HRA report and missed many opportunities for promoting behavior change. However, a low-intensity, multi-component intervention significantly decreased the proportion of clinician talk time per visit by 9% (P< .001), while it increased the proportion of patient talk time by 7% (P< .001), robustly increased the number and duration of "change talk" by 639% (P= .0007), increased the number of patient cut-ins by 237% (P= .04) and tended to increase the number and duration of clinician "advice talk" (P= .065). Patients felt more informed, empowered, and motivated by the HRA-enhanced wellness visit. Clinicians found that the process helped them construct a more effective visit agenda and it facilitated the convergence of patient goals with evidence-based recommendations.
  
  
  CONCLUSIONS
  Our study suggests that HRAs introduced without proper framing, education, and additional resources may not allow patients and clinicians to leverage AWVs for effective health planning and improvement. A targeted, low-intensity intervention may help patients and clinicians improve the quality of HRA-guided health conversations during AWVs.
authors.affiliation: From the Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City. znagykal@ouhsc.edu.
authors.forename: Zsolt J
authors.initials: ZJ
authors.lastname: Nagykaldi
authors.affiliation: From the Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City.
authors.forename: Ami
authors.initials: A
authors.lastname: Dave
authors.affiliation: From the Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City.
authors.forename: Connor J
authors.initials: CJ
authors.lastname: Kristof
authors.affiliation: From the Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City.
authors.forename: Tanya N
authors.initials: TN
authors.lastname: Watts
authors.affiliation: From the Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City.
authors.forename: Sravanthi
authors.initials: S
authors.lastname: Utpala
authors.affiliation: From the Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Wickersham
mesh_terms: D000328:Adult; D000368:Aged; D018672:Community Health Planning / Q000458:organization & administration; D005194:Family Practice / Q000458:organization & administration* / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D006278:Medicare; D008875:Middle Aged; D009825:Oklahoma; D010817:Physician-Patient Relations; D010821:Physicians, Family / Q000523:psychology*; D010865:Pilot Projects; D058996:Quality Improvement; D018570:Risk Assessment; D014481:United States
keywords: Annual Wellness Visit; Conversation Analysis; Health Risk Appraisal; Patient Goals; Primary Health Care