A Communication Intervention to Promote Physical Activity in Underserved Communities

Jennifer Carroll, MD, MPH

Associate ProfessorDepartment 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 <laughter> that’s

true for most of us. Patient: <Laughter> Physician: Is that <laughter> is that something that

you can start to get into? Patient: <sigh> I’m going to try to do better. 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: Okay, now are you exercising regularly? Patient: Okay, no. Physician: Oh I guess it’s kind of hard with four kids. Patient: If chasing four kids count, then yes. But I know that

probably is not on the list. Physician: 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.

Patient: Yeah. I probably need to do… I know. I don’t. I be so exhausted by the end of the day.

Physician: I know.

Example of physician advice

Patient: I go to work. I do only work part-time, but once I go to work, I have to pick them right up.

Physician: Right. Patient: But then it’s like, that’s my day. Physician: Yeah. You should take walks all together. Patient: Yeah. Physician: You know, with your younger kids. Patient: Yeah. Physician: 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

Intervention design-key concepts

SDT 5As Patient-centered communication

Promotingautonomysupportive skills forclinicians whencounseling patientsabout physicalactivity

Use of 5As forphysical activitycounseling

Understanding patients’ social context

Increasing clinicianperceivedcompetence tocounsel

Offering support

Encouraging patient participation

Intervention development-general principles

SDT 5As Patient centered communication

Interactivediscussion onstrategies to increaseboth patientmotivation forphysical activity andclinician motivationto raise the topic

Introduction, repetition, andreinforcement of the 5As via didactic presentation, role play, and standardized patient feedback

Role play and group discussion to develop and reinforce supportivelistening & open-ended questions about physical activity

Offering a choice ofcommunityresources for referral

Use of standardized patients to give feedbackto clinicians on PCCskills

Offering a choice ofoptional electronichealth records toolsand eliciting ongoingfeedback

Intervention training

Assessment/measurement

Clinicians Patients Blinded coders

Surveys (clinicians’ perception of supportive environment to counsel; clinician perceived competence to counsel

Surveys (patient ratings ofautonomy support ofclinicians, perceivedcompetence

Coding of autonomysupportiveness(global rating and foreach A)

Interviews (open-ended questions on how intervention facilitated autonomy support, competence

Interviews (open-ended questions on barriers and sources of support, motivation)

Coding of supportive statements, exploration of patient’s social context related to physical activity,encouraging questions, verifying understanding and agreement

Ongoing process evaluation (feedback during trainings)

Coding of contentand quality ratingsfor the 5A’s

Assessment/measurement

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 Inclusion Criteria Exclusion Criteria

Patient

• 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

Have a life-threatening acute medical problem which precludes participation

Unable to read and understand English

Clinician • Practicing clinicians (physicians, physician assistants, or nurse practitioners) at Westside Health Services

• 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 presentationChallenge Strategy

Needed to move up timeline to start 3-6 months ahead of schedule

Study site had participated in prior pilot work

Study site “went live” with electronic health records adoption shortly before intervention began

-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 collectionChallenge Strategy

Clinician schedules very variable -Adjust data collection pace and schedule to work around clinician-Seek continuous feedback from clinician re: burden of participation

Nurse/staff factors -Incentives, reminders-Kudos to champions at staff meetings-Relationship-building, consistency of study staff

Patient factors, e.g., language, medical, time constraints (either very limited or the opposite)

-Ask staff about space constraints, availability of overflow space ahead of time

Interest among non-study clinicians -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 Patient2. Explore use of eCW tools to support 5As discussion

Specific Tasks:3. Generate guided patient plan for physical activity4. Make referral to Healthy Living Program5. Practice using physical activity template and Order

Sets for (1) and (2)

Challenges to intervention (clinician training) delivery

Challenge Strategy

Unpredictable delays and freezes in the electronic health record system due to server problems

Organizational advocacy with vendor to improve overall systems functioning

Uncertainty about how to link the tools to diagnosis for charting, coding purposes

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

Some tools “clunky”, awkward to use 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

Baseline Post 6 Month Post

3.68

3.94

4.06

Mean mHCCQ Scores

*p=.0096

Patient perceptions of clinician autonomy supportiveness

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).

Baseline Post

6.8

8.4PAEI score

*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

Patient report of clinician problem solving skills

Clinicians report limited knowledge of community resources

Clinicians report low confidence about negotiating a physical activity action planNeg

otiate an

exerc

ise plan

Turn se

t-back

s into le

arning

Help co

pe with

barrier

s (to ex

ercise

)

Integrat

e counsel

ing into vis

it0

0.51

1.52

2.53

3.54

4.5

PrePost

Mean Scores (scale 1-5) 5=very confident

*All were significant

2.8 3.1 2.82.2 2.4

2 2.1

3.23.8

4.3 43.4

4.13.5 3.5

4

PHYSICAL ACTIVITY COUNSELINGMEAN CLINICIAN CONFIDENCE RATINGS

PRE POST

Clinician reported changes in PA counseling, cont.

2.72.4 2.4

1.82.2

22.2

2.82.83.2

32.6 2.7

3.1 3.23.4

PHYSICAL ACTIVITY COUNSELINGMEAN CLINICIAN FREQUENCY RATINGS

PRE POST

1=never, 5= always

Exploratory aimFeasibility 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 Strategy

Attrition in HLP groups Phone calls/outreach, problem-solving, buddy system, transportation assistance, changing location

Imbalance between supply (program spots available) and demand (number of referrals)

Strategic planning, reconfiguration of team roles, improved tracking and clear referral procedures

Financial sustainability 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 jennifer_carroll@urmc.rochester.edu

Thank you for your time and interest!

Questions and comments are welcome!

Thank you for your time and interest!