Susan A Flocke

• PhD
• Professor at Oregon Health & Science University

Introduction The COVID-19 pandemic dramatically altered patterns of health care delivery. Smoking remains an important risk factor for multiple chronic conditions and may exacerbate more severe symptoms of COVID-19. Thus, it is important to understand how pandemic-induced changes in primary care practice patterns affected smoking assessment and ces...

UNSTRUCTURED Machine learning approaches can be an innovative and useful tool in implementation science. In this viewpoint, we introduce a roadmap for applying machine learning techniques to address implementation science questions, such as predicting what will work best, for whom, under what circumstances, and with what predicted level of support;...

Machine learning (ML) approaches could expand the usefulness and application of implementation science methods in clinical medicine and public health settings. The aim of this viewpoint is to introduce a roadmap for applying ML techniques to address implementation science questions, such as predicting what will work best, for whom, under what circu...

Few have studied the COVID-19 pandemic's impact on tobacco use status assessment and cessation counseling. Electronic health record data from 217 primary care clinics were examined from January 1, 2019 to July 31, 2021. Data included telehealth and in-person visits for 759,138 adult patients (aged ≥18 years). Monthly rates of tobacco assessment per...

Introduction: Primary care settings that serve lower-income patients are critical for reducing tobacco-related disparities; however, tobacco-related care in these settings remains low. This study examined whether processes for the provision of tobacco cessation care are sustained 18 and 24 months after implementing a health system-level interventi...

Background Even after a physician recommendation, many people remain unscreened for colorectal cancer (CRC). The proliferation of electronic health records (EHRs) and tethered online portals may afford new opportunities to embed patient-facing interventions within clinic workflows and engage patients following a physician recommendation for care. W...

Introduction Current measures of nicotine dependence (ND) were developed and validated for cigarette smokers only, limiting their utility for other combustible tobacco users. This study evaluates the psychometric properties of a pool of new and adapted items to measure ND among cigarillo and multiple tobacco product users. Methods Items were drawn...

Background While prior research has informed how cigarette smokers understand and apply the term addiction, little is known about how this term is used by cigarillo smokers. This is an important area of study given the decline in cigarette use and increase in cigar product consumption. Purpose/Objectives: This paper examines how cigarillo smokers s...

Background Clinical trials are a critical source of evidence for oncology care, yet very few patients participate. Among healthcare providers, nurses spend the most time with cancer patients and are the most highly trusted professionals. We developed and evaluated an educational program for oncology nurses targeting knowledge, attitudes, self-effic...

Introduction Proactive, electronic referral of primary care patients to quitlines has great potential to provide evidence-based tobacco-cessation assistance to tobacco users. However, the quitline contact rates and engagement of individuals beyond 1 counseling call are poor. This study examines the characteristics of electronically referred patient...

Introduction This study examines the uptake of a clinician-focused teachable moment communication process (TMCP) and its impact on patient receipt of tobacco cessation support. The TMCP is a counseling method that uses patient concerns to help clinicians guide behavior change discussions about tobacco. We evaluate the added value of the TMCP traini...

Purpose: Access to a usual source of care is associated with improved health outcomes, but research on how the physician-patient relationship affects a patient's health, particularly long-term, is limited. The aim of this study was to investigate the longitudinal effect of changes in the physician-patient relationship on functional health. Method...

Objectives: In this study, we examine the frequency of 'simultaneous use' (smoking tobacco in close temporal proximity to smoking marijuana) and substitution (smoking a cigarillo in place of a marijuana blunt – a cigar wrapper filled with marijuana) and their association with nicotine dependence (ND) among young cigarillo users. Methods: The sample...

Background: Primary care practice-based research networks (PBRNs) are critical laboratories for generating evidence from real-world settings, including studying natural experiments. Primary care's response to the novel coronavirus-19 (COVID-19) pandemic is arguably the most impactful natural experiment in our lifetime. EVALUATING THE IMPACT OF COV...

Low-socioeconomic status (SES) individuals have higher rates of obesity. Social media platforms are used frequently by low-SES individuals and facilitate important weight loss program components including social support. Very few social media-based weight loss interventions, however, have enrolled or been tailored to low-SES participants. The purpo...

Significance: Guidelines urge primary care practices to routinely provide tobacco cessation care (i.e., assess tobacco use, provide brief cessation advice, and refer to cessation support). This study evaluates the impact of a systems-based strategy to provide tobacco cessation care in eight primary care clinics serving low-income patients. Method...

Background: The use of electronic referrals (eReferrals) to state quitlines (QLs) for tobacco-using patients is a promising approach for addressing smoking cessation on a large scale. However, QL contact, enrollment, and completion rates are low. The purpose of this study was to examine the eReferral to QL process from the patient's perspective in...

Introduction Multiple tobacco product (MTP) use is a growing public health concern, particularly among adolescents and young adults. This study identifies subgroups of MTP use among cigarillo users and examines associations with nicotine dependence (ND). Methods 1,089 youth (ages 14-28) who currently smoke cigarillos completed a web-based survey r...

Background: The use of electronic referrals (eReferrals) to state quitlines (QLs) for tobacco-using patients is a promising approach for addressing smoking cessation on a large scale. However, QL contact, enrollment, and completion rates are low. The purpose of this study was to examine the eReferral to QL process from the patient’s perspective in...

Background: The use of electronic referrals (eReferrals) to state quitlines (QLs) for tobacco-using patients is a promising approach for addressing smoking cessation on a large scale. However, QL contact, enrollment, and completion rates are low. The purpose of this study was to examine the eReferral to QL process from the patient’s perspective in...

Background: The use of electronic referrals (eReferrals) to state quitlines (QLs) for tobacco-using patients is a promising approach for addressing smoking cessation on a large scale. However, QL contact, enrollment, and completion rates are low. The purpose of this study was to examine the eReferral to QL process from the patient’s perspective in...

Background: The use of electronic referrals (eReferrals) to state quitlines (QLs) for tobacco-using patients is a promising approach for addressing smoking cessation on a large scale. However, QL contact, enrollment, and completion rates are low. The purpose of this study was to examine the eReferral to QL process from the patient’s perspective in...

Background: The published literature provides few insights regarding how to develop or consider the effects of knowledge co-production partnerships in the context of delivery system science. Objective: To describe how a healthcare organisation-university-based research partnership was developed and used to design, develop and implement a practic...

Background: While there is a great deal of literature regarding effective recruitment and challenges of recruiting specific patient populations, there is less known about best practices for recruitment of nurses as study subjects. Objectives: The purpose of this paper is to report our experience with recruitment and retention for a randomized tr...

Background: Guidelines urge primary care practices to routinely provide tobacco cessation care, but quality indicators for the provision of advice and assistance to quit smoking lag. This study evaluated the implementation of a systems-based strategy to improve performance of tobacco cessation care in primary care clinics. Methods: Changes to th...

Background: The advancement of primary care research requires reliable and validated measures that capture primary care processes embedded within nationally representative datasets. Objective: The objective of this study was to assess the validity of a newly developed measure of primary care processes [Medical Expenditure Panel Survey (MEPS)-PC]...

We describe the use of an online patient portal to recruit and enroll primary care patients in a randomized trial testing the effectiveness of a colorectal cancer (CRC) screening decision support program. We use multiple logistic regression to identify patient characteristics associated with trial recruitment, enrollment, and engagement. We found t...

Introduction: Many young consumers of non-cigarette tobacco products, such as cigarillos, do not identify as smokers. These "phantom smokers" tend to underestimate risks to health and feel little urgency to quit. This study examines the prevalence and characteristics of phantom smoker status among young cigarillo users. Methods: An online survey...

This study assesses the current practices of Federally Qualified Health Centers (FQHCs) to address tobacco cessation with patients. A national sample of 112 FQHC medical directors completed the web-based survey. Frequently endorsed barriers to providing tobacco cessation services were: patients lacking insurance coverage (35%), limited transportati...

Objective: To develop and assess the reliability of a measure of primary care using items from the Medical Expenditure Panel Survey (MEPS), a US representative survey of community-dwelling persons. Methods: On the basis of the domains from the literature on primary care characteristics, we identified relevant items within the 2013-2014 MEPS fami...

Farmers’ markets have been implemented to improve access to nutritious foods, yet use is low among people receiving Supplemental Nutrition Assistance Program (SNAP) benefits. This study’s objectives were to assess the feasibility of implementing the FreshLink Ambassador intervention to promote use of farmers’ markets located in high SNAP neighborho...

In the United States less than 10% of cancer patients engage in clinical trials. Although most oncology nurses have multiple opportunities to discuss clinical trials with patients, barriers including attitudes and social norms may impede these discussions. Guided by the Theory of Planned Behavior, we developed and evaluated measures for attitudes,...

Introduction: Patient–physician communication about colorectal cancer screening can affect screening use, but discussions often lack information that patients need for informed decision making and seldom address personal preferences or barriers. To address this gap, a series of patient focus groups was conducted to guide the development of an onlin...

Objective Cigarillo use is widespread among young people. Accurate assessment of cigarillo consumption is necessary to inform and evaluate tobacco research, but is complicated by product sharing and irregular use. This study compares a conventional approach with a detailed approach for measuring cigarillo consumption. Methods Data are drawn from a...

Introduction How to provide practice-integrated decision support to patients remains a challenge. We are testing the effectiveness of a practice-integrated programme targeting patients with a physician recommendation for colorectal cancer (CRC) screening. Methods and analysis In partnership with healthcare teams, we developed ‘e-assist: Colon Heal...

While colorectal cancer (CRC) screening rates have been increasing in the general population, rates are considerably lower in Federally Qualified Health Centers (FQHCs), which serve a large proportion of uninsured and medically vulnerable patients. Efforts to screen eligible patients must be accelerated if we are to reach the national screening goa...

Objectives The high prevalence of tobacco use at primary care safety‐net clinics represents an opportunity to offer assistance with cessation. Documentation of smoking status, offering advice and medications, and referral to cessation services are important steps in supporting cessation attempts and are required elements by payors and accrediting a...

BACKGROUND The prevalence of social media (SM) use among youth and young adults suggests SM as an appropriate platform for study recruitment from this population. Previous studies have examined the use of SM for recruitment, but few have compared different SM platforms, and none to our knowledge have attempted to recruit cigarillo users. OBJECTIVE...

Background: The prevalence of social media (SM) use among youth and young adults suggests SM as an appropriate platform for study recruitment from this population. Previous studies have examined the use of SM for recruitment, but few have compared different SM platforms, and none to our knowledge have attempted to recruit cigarillo users. Objecti...

A key gap in existing food environment research is a more complex understanding of the interplay between physical and social contexts, including the influence of social networks on food habits. This mixed methods research examined the nature of social connections at food procurement places among a sample of 30 people receiving Supplemental Nutritio...

Introduction: Cigarettes and little cigars and cigarillos (LCCs) are the most prevalent dual-use tobacco combination; one-third of cigarette smokers use LCCs. Risk factors for multiple tobacco product use have been reported; however, there is little understanding of why some individuals transition to and maintain multiple product use. In this stud...

Study finds factors influencing farmers’ market use among low income. Awareness of farmers’ markets and incentive programming were related to increased market use. Farmers’ market use associated with multiple dimensions of healthy food access among low income. Findings reveal modifiable leverage points to enhance reach of farmers’ markets. Promotin...

Introduction: The purpose of this study is to identify issues faced by Federally Qualified Health Centers (FQHCs) in implementing lung cancer screening in low-resource settings. Methods: Medical directors of 258 FQHCs serving communities with tobacco use prevalence above the median of all 1,202 FQHCs nationally were sampled to participate in a w...

Background: We sought to explore the perspective of older breast cancer survivors (BCS) from diverse racial and socioeconomic backgrounds toward physical activity (PA) to inform the design of a PA program that fosters acceptability. Methods: Participants included sixty women, ≥65years, within two years of treatment completion for stage I-III bre...

Objectives: We systematically evaluated changes in availability, price, and quality of perishable food items from the beginning to the end of the month in lowincome, urban neighborhoods. Methods: The sample included grocery stores or supermarkets in Cleveland, Ohio, within neighborhoods with >30% of population receiving food assistance. We colle...

Objective The 5As framework (ask, advise, assess, assist, arrange) is a recommended strategy for smoking cessation counseling in primary care. This study compares patient report with direct observation to assess the degree of recall bias for each of the 5As. Methods Primary care visits by 107 adult smokers and 16 physicians were audio-recorded. Wi...

Background: The use of cigarillos for smoking as a tobacco product and for making marijuana blunts is increasing among adolescents. Previous research has documented the co-use of these products, however little is known about the contextual features that generate and sustain this practice. Objective: This study aims for a deeper understanding of...

Purpose/Objectives: To describe oncology nurses' experiences discussing clinical trials with their patients, and to assess barriers to these discussions. Research Approach: A qualitative study designed to elicit narratives from oncology nurses. Setting: Community-and academic-based oncology clinics throughout the United States. Participants: 33 onc...

Objective: Access to nutritious foods is key to achieving health promotion goals. While there is evidence that nutritious food access is complex, measures assessing multiple domains of access, including spatial-temporal, economic, social, service delivery and personal, are lacking. The current study evaluates psychometric properties of scales desi...

Rationale, aims, and objectives: This study examines the degree to which a "Hawthorne effect" alters outpatient-visit content. Methods: Trained research nurses directly observed 4454 visits to 138 family physicians. Multiple data sources were used to examine the Hawthorne effect including differences in medical record documentation for observed...

Background: As an organized screening program, the national Breast and Cervical Cancer Early Detection Program (BCCEDP) was launched in the early 1990s to improve breast cancer outcomes among underserved women. To analyze the impact of the BCCEDP on breast cancer outcomes in Ohio, this study compared cancer stages and mortality across BCCEDP parti...

Objective: We evaluate the effectiveness of a swim skill acquisition intervention among Latino youths, ages 3-14, a minority population at increased risk of drowning. Methods: Parents were recruited through community institutions to have their children participate in group swim lessons. Each child's swim ability was assessed at baseline, and the...

We explored tobacco use across federally qualified health centers (FQHCs) and compared data on state-level tobacco use between FQHC patients and the general population. We used data from the Uniform Data System (UDS) and the Behavioral Risk Factor Surveillance System (BRFSS) to generate estimates of 2013 prevalence of tobacco use among adults aged...

Objective: Evaluate farmers' market (FM) use patterns among Supplemental Nutrition Assistance Program (SNAP) recipients. Design: Cross-sectional survey administered June to August, 2015. Setting: Cleveland and East Cleveland, OH. Participants: A total of 304 SNAP recipients with children. Participants lived within 1 mile of 1 of 17 FMs. Most...

Introduction: Cigarillo use is increasing, particularly among young adults. Nicotine dependence (ND) is important for understanding smoking behavior and cessation, but the development of measures of ND has focused almost exclusively on cigarette smokers. We examined smoking patterns, preferences, and beliefs of cigarillo users to better understand...

Introduction A reliable measure capable of detecting progression towards smoking cessation would be valuable for evaluating and optimizing the effectiveness of low to moderate intensity cessation interventions, such as brief advice in the primary care setting. This paper presents the development and evaluation of a brief self-report measure of incr...

National guidelines have been established to support the role of primary care physicians in addressing obesity. Preparing primary care residents to recognize and treat overweight/obesity has been identified as an essential component of postgraduate medical training that is currently lacking. This study aims to identify how primary care residency pr...

Background. Physical activity (PA) counselling is challenging in primary care. It is unknown whether clinician training on the 5As (Ask, Advise, Agree, Assist, Arrange) improves PA counselling skills. Objective. To evaluate the effect of a clinician training intervention on PA counselling for underserved adults using the 5As framework. Methods. P...

Background: Recent evidence indicates a widening gap in fruit and vegetable (F/V) consumption between high- and low-income Americans. This gap is related, in part, to decreased access to food retailers that sell fresh F/V in low-income communities. Farmers' markets are identified as a strategy for improving F/V consumption by increasing access to...

Objectives: Compared to cigarettes, little cigars and cigarillos (LCC) are minimally regulated, affordable, and widely available to young people. Because Twitter is a preferred mode of communication among younger people, product portrayals may be useful for informing both interventions and public health or tobacco policy. Methods: A mixed-methods s...

Objectives: The aims of the study were to examine barriers to cervical cancer screening among women who have experienced intimate partner violence (IPV) and accessed domestic violence shelters, to compare barriers among those up-to-date (UTD) and not UTD on screening, and to evaluate acceptability of human papillomavirus self-sampling. Materials...

African-American (AA) breast cancer (BCa) survivors have higher mortality rates, more comorbidities and are less likely to meet national physical activity guidelines after diagnosis compared to Caucasian BCa survivors. We previously reported that a 20-week resistance exercise intervention coupled with a support group and home walking program, condu...

Objective: Although smoking cessation is a key priority emphasized by professional societies and multidisciplinary consensus guidelines, significant variation exists in the methods and efficacy of smoking cessation treatment practiced by vascular surgeons. We conducted a series of patient, surgeon, and nonpatient stakeholder focus groups to identi...

Background: Context-based evaluation includes evaluation for outcome effect, return on the investment (ROI), social capital effect and stakeholder satisfaction. We employed this methodology to a case study intervention in health promotion aimed at a high-risk population. Drowning is a leading cause of death among children across the world, and in t...

Purpose: To compare outcomes between women enrolling in Medicaid after being diagnosed with breast cancer and those referred to Medicaid through the Ohio Breast and Cervical Cancer Early Detection Program (BCCEDP). Methods: Using linked data from the 2002 to 2008 Ohio Cancer Incidence Surveillance System, Medicaid, the BCCEDP database, and Ohio...

Introduction: The National Breast and Cervical Cancer Early Detection Program (BCCP) in Ohio provides screening and treatment services for uninsured low-income women aged 40 to 64. Because participation in the BCCP might engender greater self-efficacy for cancer screening, we hypothesized that breast cancer and survival outcomes would be better in...

Background: Obesity and being overweight are both significant risk factors for multiple chronic conditions. Primary care physicians are in a position to provide health behavior counseling to the majority of US adults, yet most report insufficient training to deliver effective counseling for obesity. Objective: To assess the degree to which resid...

The impact of patient-physician communication on subsequent patient behavior has rarely been evaluated in the context of colorectal cancer (CRC) screening discussions. We describe physicians' use of persuasive techniques when recommending CRC screening and evaluate its association with patients' subsequent adherence to screening. Audio recordings o...

To describe the impact of the cancer experience on the health behaviors of survivors' family members and to determine factors associated with family members' intentions for health behavior change. Descriptive, cross-sectional, correlational. A National Cancer Institute-designated comprehensive cancer center in the midwestern United States. 39 famil...

Purpose: To define the concept of "health care insecurity,” validate a new self-report measure, and examine the impact of beginning care at a free clinic on uninsured patients' health care insecurity. Methods: Consecutive new patients presenting at a free clinic completed 15 items assessing domains of health care insecurity (HCI) at their first...

Objective: To implement and evaluate the impact of a Teachable Moment Communication Process (TMCP) training intervention on clinicians' smoking cessation counseling behaviors in practice. Method: Using a group randomized trial, 31 community-based, primary care clinicians in Northeast Ohio received either TMCP training or an attention control (20...

Purpose ▶ We undertook this study to explore the factors associated with differences between patients' stated main reasons for outpatient visits and physicians' main concerns at those same visits. Methods ▶ This cross-sectional, mixed-methods study examined 192 outpatient visits with 4 physicians at 4 diverse primary care practices. During each vis...

Objective Teachable moments (TM) are opportunities created through physician-patient interaction and used to encourage patients to change unhealthy behaviors. We examine the effectiveness of TMs to increase patients’ recall of advice, motivation to modify behavior, and behavior change. Method A mixed-method observational study of 811 patient visit...

Background and objectives: Strengthening the contribution of reflective practice and new knowledge generation to the learning relationships forged during graduate and undergraduate medical training offers a possibility to create a climate more conducive to the recruitment and retention of family physicians. The Culture of Inquiry (CI) fellowship,...

Objectives The aims of the study were to examine barriers to cervical cancer screening among women who have experienced intimate partner violence (IPV) and accessed domestic violence shelters, to compare barriers among those up-to-date (UTD) and not UTD on screening, and to evaluate acceptability of human papillomavirus self-sampling. Materials and...

Consuming a diet that is rich in fruits and vegetables is critical for preventing cancer and cancer-related disparities. Food systems approaches that increase spatial-temporal, economic, and social access to fruits and vegetables may ultimately result in improved consumption patterns among Americans. Engaging the triad of Cooperative Extension Serv...

Primary care physicians provide care to a disproportionate number of overweight and obese patients and are uniquely positioned to help patients manage their weight in the context of a continuity relationship. The US National Heart, Lung and Blood Institute (NHLBI) developed evidence-based guidelines for the effective and efficient care of overweigh...

The US Preventive Services Task Force recommends using the 5As (i.e., Assess, Advise, Agree, Assist and Arrange) when discussing preventive services. We evaluate the association of the 5As discussion during primary care office visits with patients' subsequent colorectal cancer (CRC) screening use. Audio-recordings of n=443 periodic health exams amo...

Background: An infectious etiology for chronic breast pain in breastfeeding women continues to be debated. Although recent data suggest that Staphylococcus aureus and coagulase-negative Staphylococcus (CNS) may cause chronic breast pain, no studies have used quantitative cultures to address this question. In this study we compared bacterial specie...

Objectives: This study examined the degree of similarity between motivational interviewing (MI) methods and smoking cessation techniques that are routinely used by primary care physicians. Its purpose was to inform the development of more effective MI-based health behavior change training programs for primary care physicians. Methods: Visits to...

7 Background: We evaluate the association of the 5A steps as recommended by the US Preventive Services Task Force (i.e., assess, advise, agree, assist and arrange) with adherence to physician-recommended colorectal cancer (CRC) screening. Methods: Audio-recordings of periodic health exams (PHEs) were joined with electronic medical record data and p...

Success of a surgical intervention is often measured by hard clinical outcomes. In ventral hernia repair (VHR) these include wound morbidity and hernia recurrence. These outcomes fail to account for a surgical intervention's effect on a patient's quality of life (QofL). Our objective was to design a hernia-specific QofL instrument with a focus on a...

Insurance plans periodically change their formularies to enhance medical efficacy and cost savings. Patients face challenges when formulary changes affect their treatment. This study assessed the impact of insurance-driven medication changes on primary care patients and examined implications for patient care. We mailed questionnaires to a cross-sec...

Background Effective clinician-patient communication about health behavior change is one of the most important and most overlooked strategies to promote health and prevent disease. Existing guidelines for specific health behavior counseling have been created and promulgated, but not successfully adopted in primary care practice. Building on work fo...

To evaluate the patient, physician, and visit-related factors associated with patient ratings of positive physician relational communication. Pre- and post-visit surveys were conducted with 485 patients attending a routine periodic health exam with one of 64 participating physicians. The audio-recorded visits were coded for elements of patient-phys...

To determine the psychometric properties of the Components of Primary Care Instrument (CPCI) in a patient population aged 65 or older. 795 participants in the OKLAHOMA Studies, a longitudinal population-based study of predominantly Caucasian, elderly patients, completed the CPCI. Reliability analysis and confirmatory factor analysis were done to pr...

Background: Few valid and reliable measures exist for health care professionals interested in determining their levels of cultural and linguistic competence. Objective: To evaluate the measurement properties of the Cultural Competence Health Practitioner Assessment (CCHPA-129). Methods: The CCHPA-129 is a 129-item web-based instrument, develop...

The U.S. Preventive Services Task Force advocates use of a 5A's framework (assess, advise, agree, assist, and arrange) for preventive health recommendations. To describe 5A content of patient-physician colorectal cancer (CRC) screening discussions and physician-recommended screening modality and to test if these vary by whether patient previously r...

Background/Aims Limited time and competing demands force primary care physicians and patients to prioritize among evidence-based preventive health services during periodic health examinations (PHE). We examined the rate of discussion of and recommendation for 19 USPSTF-endorsed preventive services during PHEs. Methods Claims data, a pre-visit surve...

Purpose: Many approaches used by physicians during the medical encounter have the potential to affect patient adherence to recommendations for preventive health services. Persuasion is one approach defined as a principal method of inducing compliance (Chayes et al. 1995). However, more recent findings suggest that the use of persuasion may be detri...

The 5As (ask, advise, assess, assist, arrange) are recommended as a strategy for brief physical activity counseling in primary care. There is no reference standard for measurement, however, and patient participation is not well understood. This study's objectives were to (1) develop a coding scheme to measure the 5As using audio-recordings of prima...

Physician recommendation is one of the most important determinants of obtaining colorectal cancer (CRC) screening; however, little is known about the degree to which CRC screening discussions include information that patients report as important to guide screening decisions. This study examines and compares both patient rated importance and physici...