Transcript HLP Referral - University of Michigan
A Communication Intervention to Promote Physical Activity in Underserved Communities Jennifer Carroll, MD, MPH Associate Professor Department of Family Medicine September 20, 2012
Special thanks
National Cancer Institute career development award K07CA126985 Mentors: Ronald Epstein, Gary Morrow, Kevin Fiscella, Jennifer Griggs Advisors: Geoffrey Williams, Nana Bennett, Toni Yancey, Chris Sciamanna Westside Health Services patients, staff and clinicians Westside Health Services team members Cheryl Rufus, Louise Smyth, Michele Hannagan, Laurie Donohue Department of Family Medicine Research Programs Mechelle Sanders, Paul Winters, Holly Russell, Carol Moulthroup University of Rochester Center for Community Health partners Stacey DeJesus, Candace Lucas YMCA partners Anja Jabs-Devins, Laura Fasano, Theresa Wing
Public health significance
Health care reform emphasizes provisions for community health centers, prevention, primary care workforce development Growing adoption of electronic health records nationally Need to accelerate research into creative partnerships in primary care and community programs to promote physical activity and eliminate disparities in underserved groups Need for both evidence-based and locally tailored interventions
Background
Patients value advice from their primary care physician about physical activity Patients want to discuss it Primary care physicians acknowledge the importance of discussing physical activity YET…
Typical features of physician-patient communication about physical activity
Mean time spent in combined physical activity and dietary discussion in primary care = Vague, nonspecific advice common Patient cues or attempts to participate often not acknowledged Inaccuracies in recall (both for physicians and patients)
Example of physician “advice”
Physician: Are you exercising regularly?
Patient: Not like I should. No.
Physician: No? All right, I suppose
Patient: Patient:
Physician: OK. All I ask is that you try, you know, so and then um a quick question for you. It looks like you’re coming up due for a mammogram.
Example of physician advice
Physician: Patient: Physician: Patient: Physician: Patient: Physician: Okay, now are you exercising regularly?
Okay, no.
Oh I guess it’s kind of hard with four kids.
If chasing four kids count, then yes. But I know that probably is not on the list.
You know, 30 minutes of dedicated exercise – it would be great if you could put them in a stroller and just go for a walk.
Yeah. I probably need to do… I know. I don’t. I be so exhausted by the end of the day.
I know.
Example of physician advice
Patient: Physician: Patient: Physician: Patient: Physician: Patient: Physician: I go to work. I do only work part-time, but once I go to work, I have to pick them right up.
Right.
But then it’s like, that’s my day.
Yeah. You should take walks all together.
Yeah.
You know, with your younger kids.
Yeah.
How about monthly breast exams. Do you check?
Brief physical activity counseling interventions can be effective
STEP trial (Petrella et al, 2003): physician intensive intervention; increased CV fitness at 6 months Physician + Health educator, face-to-face plus telephone (Pinto et al, 2005); increased PA and 3 and 6 months Physician advice + limited assistance (Ackermann et al 2005); increased patient-reported PA
Limited information about interventions for underserved groups
Underserved populations are less likely to engage in sufficient physical activity and thus more likely to suffer a greater burden of disease There is a lack of evidence that promising clinic based interventions are translated into practice
Good evidence exists that clinic-based physical activity interventions can be effective IF Physician involvement is brief Intervention is shared with team, staff, community partners There is a focus on patient involvement and action planning, personalized goal setting, problem-solving There is a shift away from merely Asking and Advising There is a strategy which integrates clinical counseling with community opportunities Adapted from Estabrooks et al 2006; Eakin et al 2000; Glasgow et al
Primary Objective
Test whether a communication training intervention for clinicians to encourage physical activity will result in actual use of these communication skills with underserved patients
Secondary Objectives
Assess whether intervention improves patients’ perceived competence for PA Patient report of autonomy supportiveness of their clinicians Patient recall of 5As discussions clinician barriers to promoting physical activity
Primary Aim
Test whether a communication training intervention for 15 clinicians to encourage physical activity will result in actual use of these communication skills in 325 underserved patients in the post intervention period (immediately post and at 6 months follow-up)
Secondary Aims
Aim 2: Assess whether the communication training intervention will improve patients’ perceived competence to adopt physical activity. Aim 3: Assess whether clinicians and patients believe that the communication intervention is feasible and sustainable and addresses pertinent barriers to promoting physical activity.
Exploratory Aims
Examine potential mediators between the communication training intervention’s primary outcome (use of 5As) and the patient’s perceived competence to adopt physical activity.
Derive effect sizes for the effect of the intervention on patients’ actual physical activity levels (post-intervention compared to baseline) in a subset of participants.
ARRA Supplement (Sept 2009-Aug 2011) Aims
Aim 1. Evaluate whether linkage to a community based lifestyle change program (the Healthy Living Program) enhances the Assist and Arrange steps of the 5As in discussions of physical activity in the intervention group compared to controls.
Aim 2. Evaluate the feasibility and acceptability of an electronic health records template for the intervention materials.
Theoretical and conceptual framework
Self-determination theory (approach/delivery of intervention; measures of motivation, competence, and support) The 5As (the “what” or content of intervention) Patient-centered communication (the “how” or communication style)
What Are The 5As?
Ask Advise Agree Assist Arrange
Study schema
SDT
Promoting autonomy supportive skills for clinicians when counseling patients about physical activity Increasing clinician perceived competence to counsel
5As
Use of 5As for physical activity counseling
Patient-centered communication
Understanding patients’ social context Offering support Encouraging patient participation
SDT
Interactive discussion on strategies to increase both patient motivation for physical activity and clinician motivation to raise the topic Offering a choice of community resources for referral Offering a choice of optional electronic health records tools and eliciting ongoing feedback Intervention training
5As
Introduction, repetition, and reinforcement of the 5As via didactic presentation, role play, and standardized patient feedback
Patient centered communication
Role play and group discussion to develop and reinforce supportive listening & open-ended questions about physical activity Use of standardized patients to give feedback to clinicians on PCC skills
Clinicians
Surveys (clinicians’ perception of supportive environment to counsel; clinician perceived competence to counsel
Patients
Surveys (patient ratings of autonomy support of clinicians, perceived competence Interviews (open-ended questions on how intervention facilitated autonomy support, competence Interviews (open-ended questions on barriers and sources of support, motivation) Ongoing process evaluation (feedback during trainings)
Blinded coders
Coding of autonomy supportiveness (global rating and for each A) Coding of supportive statements, exploration of patient’s social context related to physical activity, encouraging questions, verifying understanding and agreement Coding of content and quality ratings for the 5A’s
Outcome measures
Primary (5As score from audio-recorded patient-clinician office visits) Secondary (patient perceived competence and clinician autonomy supportiveness; clinician feasibility) Exploratory (patient follow-through with 5As; use of electronic health records tools, referral rates to HLP) Process (qualitative and quantitative data from field notes and participation/refusal rates, participation and feedback on intervention, fidelity to intervention)
Inclusion and exclusion criteria
Patient Clinician Inclusion Criteria
• Currently enrolled patients at Westside Health Services • Scheduled for a routine, follow-up, or health maintenance office visit • Scheduled to see a participating clinician • 18 years of age or older • Able to provide written informed consent • Have one or more stable medical conditions for which activity is not contraindicated • Practicing clinicians (physicians, physician assistants, or nurse practitioners) at Westside Health Services •
Exclusion Criteria
Have a life-threatening acute medical problem which precludes participation Unable to read and understand English Extended absence or planning to move to another practice in the study period
Clinician recruitment and enrollment
Prior approval needed from organization’s Board of Directors, and administrative leadership Clinicians recruited via in-person presentation
Challenge
Needed to move up timeline to start 3-6 months ahead of schedule Study site “went live” with electronic health records adoption shortly before intervention began
Strategy
Study site had participated in prior pilot work -Intervention materials revised to incorporate into EHR -PI familiar with clinical environment -new/unanticipated additional funding opportunites available
Baseline assessment
Clinician survey (attitudes and beliefs about physical activity counseling; frequency of 5As use; barriers to counseling; confidence in counseling techniques; knowledge of community resources) Audio-recorded patient-clinician office visits (routine adult visits; chronic/follow-up or health maintenance visits) Post-visit patient survey (socio-demographic information, physical activity level, perceived competence, autonomy supportiveness, other health behaviors, SF-12, trust, satisfaction with care, checklist of co morbidities) Post-visit patient interview (recall of what was discussed in visit, recall of previous communication about physical activity, personal challenges/barriers, sources of strength/support, personal goals for wellness)
Baseline assessment schema
Clinic Staff introduces study to patient Consent Visit, audio recorded Patient completes summary and post visit interview Patient receives $20 for participation
Challenges to data collection
Challenge
Clinician schedules very variable Nurse/staff factors Patient factors, e.g., language, medical, time constraints (either very limited or the opposite) Interest among non-study clinicians
Strategy
-Adjust data collection pace and schedule to work around clinician -Seek continuous feedback from clinician re: burden of participation -Incentives, reminders -Kudos to champions at staff meetings -Relationship-building, consistency of study staff -Ask staff about space constraints, availability of overflow space ahead of time -Offer tools developed for shared use -Invite participation in future projects
Description of intervention
Clinician training intervention, session 1
Review the current guidelines (CDC, ACSM recommendations) for physical activity Review medical contraindications to exercise Discuss how to translate the physical activity guidelines to real-world, challenging clinical situations Motivation Introduction to the 5As
Clinician training intervention, session
2 In-depth discussion of 5As Introduction to low cost community resources and referral options to promote activity Discussion of ecW activity templates and OS pages under construction- walk through, get feedback and ideas from group-needs and suggestions for improvement
Clinician training intervention, session 2 example of resource page
Clinician training intervention, session 3
Goal: Practice 5As using standardized patient Practice using and recommending key community resources for exercise Complete office note using electronic health records tools Peer-peer feedback
Clinician training intervention, session 4
Goal of Session: 1.
Practice 5As discussion with a Standardized Patient 2.
Explore use of eCW tools to support 5As discussion Specific Tasks: 1.
Generate guided patient plan for physical activity 2.
Make referral to Healthy Living Program 3.
Practice using physical activity template and Order Sets for (1) and (2)
Challenges to intervention (clinician training) delivery
Challenge
Unpredictable delays and freezes in the electronic health record system due to server problems
Strategy
Organizational advocacy with vendor to improve overall systems functioning Uncertainty about how to link the tools to diagnosis for charting, coding purposes Some tools “clunky”, awkward to use Revision to tools to improve linking of diagnoses to PA referral in progress Lack of responsiveness of electronic health record vendor to assist with tool development -Ongoing attempts to enlist vendor support -HCNNYS advocacy to leadership Revision of tools to be quicker, easier to use in progress
Results
Clinician recruitment and enrollment
Of the 16 clinicians at Westside, 2 (NP, PA) were ineligible due to planned relocation or absence from the office.
Of the remaining 14 clinicians, 13 enrolled. One declined due to personal illness/health reasons
Clinician socio-demographic information
69 % Family physicians (n=9) 15% Family nurse practitioners (n=2) 15% Family physician assistants (n=2) Average work experience = 15 years (range 2-33) 75% female, 25% male 66% White/Caucasian, 25% Black/African American, 16% Asian/Asian American Mean age=50.6 years (range 31-73 years)
How much time, on average, do you spend discussing exercise if the topic comes up?
For what proportion of your overall visits do you provide exercise counseling?
How often do you ask about patients’ current exercise habits?
How often do you ask about patients’ willingness or motivation to change their activity level?
How often do you discuss the appropriate amount, intensity, and frequency of recommended activity guidelines?
How knowledgeable are you about identifying local, accessible resources for exercise for your patients?
Top three clinician barriers to 5As counseling Too much to do/Not enough time Don’t know how to bill/code for it Don’t know which resources to recommend
CONSORT Diagram (patients)
Patient socio-demographic information, n=325 43 years mean age 75% African American, 10 % Hispanic, and 15% Caucasian 58.2% had public insurance 32.5 average BMI weight-related co-morbidities include diabetes (21%) hypertension (49%) depression (32%) osteoarthritis or chronic pain (50%)
Baseline patient-reported physical activity
65% report some physical activity 4 or less days per week 41% exercise 30 minutes or more each time 56% walk as most common form of physical activity
Patient reported challenges and barriers to physical activity (n=325)
Patient (n=325) sources of support, resources for physical activity
Patient perceptions of clinician autonomy supportiveness
Mean mHCCQ Scores
4,06 3.94
3,68 Baseline Post 6 Month Post *p=.0096
Patient recall of 5As physical activity discussions Using a mixed model controlling for clinician as a random effect, the PAEI score increased from 6.8 to 8.4 (baseline to post-intervention, p=0.01).
PAEI score
8,4 6,8 Baseline Post
*p=0.01
Patients’ perceived competence for physical activity There was no change in patients’ perceived competence for physical activity Mean PCS scores were 3.6 (baseline), 3.7 (post), and 3.8 (six month follow-up) p=0.54
Clinician reported changes in PA counseling
2,8 4,5 4 3,8 3,5 3 2,5 2 1,5 1 0,5 Adapt counseling to patient situation or needs 0 3,1 4,3
PHYSICAL ACTIVITY COUNSELING MEAN CLINICIAN CONFIDENCE RATINGS
PRE POST 2,8 4 4,1 clinician problem solving skills 2,4 2,2 Clinicians report limited knowledge of community resources 2 3,5 Clinicians report low confidence Assess Negotiate Negotiate an history plan about negotiating a physical activity Turn Turn set-backs into learning . Help cope barriers (to exercise) Counsel in Help cope with cost effective way Knowledge Integrate visit needs * Integrate counseling into visit
All were significant
Mean Scores (scale 1-5) 5=very confident
2,1 3,5 3,2 4 Pre Post
Clinician reported changes in PA counseling, cont.
2,7 2,8 2,4 3,2
PHYSICAL ACTIVITY COUNSELING MEAN CLINICIAN FREQUENCY RATINGS
PRE POST 3,1 3 2,7 2,6 2,4 2,2 2 1,8 2,2 3,2 2,8 3,4 Adapt counseling to patient situation or needs Assess exercise history Negotiate an exercise plan Turn setbacks into learning Help cope with barriers Counsel in cost effective way Knowledge of resources that ould meet your patients' needs Integrate counseling into visit
1=never, 5= always
Exploratory aim
Feasibility of referral to Healthy Living Program 506 referrals over 3 years Each class has had the maximum number of enrollees (30) Attrition has been a challenge Among completers, outcomes are promising and satisfaction is high
Challenges
Challenge
Attrition in HLP groups Imbalance between supply (program spots available) and demand (number of referrals) Financial sustainability
Strategy
Phone calls/outreach, problem-solving, buddy system, transportation assistance, changing location Strategic planning, reconfiguration of team roles, improved tracking and clear referral procedures Multi-pronged strategy for future fundraising, grant-writing, capitalizing on community and insurance plan partnerships
Summary
A clinician-directed intervention increased patient recall of discussions of the 5As for physical activity, most notably by increasing Advise, Assist, and Arrange skills The intervention increased patient reports of clinician autonomy supportiveness for physical activity, but not patient perceived competence Demand as evidenced by referral to the community program was high Clinician satisfaction was high
Summary, continued
This project used an innovative, interactive set of clinician training strategies including a referral to a community partner The project focuses exclusively on an underserved population not traditionally well represented in communication research
Limitations
Single geographical site (By design), patients were not followed longitudinally, rather nested within clinician Patient self-report/recall
Next steps
Evaluate audiorecorded data and compare to patient/clinician self-report for the 5As whether the 5As correlate with patient enrollment in community exercise programs and physical activity outcomes Mediational models for SDT constructs and 5As outcomes
Acknowledgements
Special thanks to
▪ the patients and clinicians of who participated in this project ▪ colleagues and staff of the University of Rochester Department of Family Medicine and Family Medicine Research programs This project was supported by a career development award from the National Cancer Institute, K07CA126985 (PI: Jennifer Carroll). For further information, please contact [email protected]
Thank you for your time and interest!
Thank you for your time and interest!
Questions and comments are welcome!