Increasing Screening and Interventions for Four Unhealthy Behaviors Jim Mold, M.D., M.P.H. Dept. of Family and Preventive Medicine OUHSC, OKC Research Team Jim Mold Mike Aaron Cheryl Aspy Sharad Swami Zsolt Nagykaldi Tamara Hartsell Millisa Ellefson Heather Tipsword Eileen Merchen Ingrid Jackson Cara Vaught Suben Naidu Katy Smith Zack Bechtol Rene Russell Shawn Anderson Funding Source The Robert Wood Johnson Foundation Project Period 7/1/2005 – 9/30/2007 Challenge More than 50% of premature deaths in the U.S. are the result of one or more of the four unhealthy behaviors: unhealthy diet, inadequate exercise, use of tobacco, abuse of alcohol Effective screening methods exist for all four and effective brief counseling strategies are available for tobacco and alcohol and possibly exercise Primary care clinicians are not consistently screening for these behaviors or intervening when they are discovered. Research Question Primary Research Question Will a multi-component translational strategy result in the consistent and sustainable delivery of effective screening, very brief interventions, and counseling for improving diet, increasing exercise, and reducing cigarette and alcohol use among patients 14 years old and older being seen in primary care practices. Research Aims 1. Offer and provide the translational strategies - training, practice facilitation, quality circles, and peer support - to geographically clustered primary care practices, and determine rates of adoption, implementation, reach, and sustainability; 2. Estimate the cost of the translational intervention and the cost to the practices of implementation; and 3. In conjunction with other RWJF funded teams, estimate the effectiveness of systematic screening and behavioral interventions delivered in primary care settings. Practice Interventions Screening: Addition of evidence-based screening questions to the vital signs process Very Brief Interventions: Referral to a community-based resource or provision of written educational material Brief Counseling: 5 - 15 minute evidence- based counseling provided by the clinician Translational Strategies Chart Audit and Feedback: Chart audits Q1month to document proportion of patients screened and proportion receiving interventions Training Modules: Three evidence-based training sessions (five modules) for clinicians and staff Practice Facilitation: Coordination of QI activities and assistance with obstacles (e.g. form/template redesign; identification of community resources, etc.) by PEA Translational Strategies Quality Circles: Q2month lunch meetings during which geographical clusters of practices met to review progress, address problems, and share successes PI Visits: Q6month visits by PI during patient care activities to observe and ask questions about the processes, answer questions, and make suggestions. Training Modules Stages of change and motivational interviewing Healthy eating and weight control Exercise Smoking cessation Alcohol use reduction Training Modules 1. Pretest 2. General Information 3. Evidence regarding effectiveness of screening and brief interventions 4. Role play scenarios 5. Post-test Training time was reimbursed and evidence- based (double) CME was awarded. QI Process: PDSA Cycles PLAN: Small change proposed DO: Trial in a small number of patient encounters STUDY: Documentation of what happened ACT: Decision regarding what to do next (expand, abandon, modify) Practice Facilitation (cont) Identification of community resources – Weight loss programs – Alcohol counselor Development of materials – Adolescent high-risk behaviors Flow sheets and templates – Vital signs flow sheets – EHR templates – Wall charts Design Interventions were introduced in 6-month cycles, each group of practices adding different interventions each cycle. Group 11/01/05 – 4/30/06 05/01/06 – 11/01/06 – 10/31/06 04/30/07 Diet and Exercise & Stages Reduced Smoking A of Change Alcohol Use Cessation Smoking Cessation & Diet and Reduced B Stages of Change Exercise Alcohol Use Reduced Alcohol Use & Smoking Diet and C Stages of Change Cessation Exercise Data Collection • Practice Information Form (by practice facilitators) • Practice Assessment Template (by research assistant) • Knowledge Tests pre- and post-training (by clinicians and MA/nurse) Data Collection Chart audits: 75 randomly-selected records; screening, VBI, BC at that visit Patient surveys (pre-office visit and 1-month later via mail): patients recruited/enrolled by practice facilitator in practices’ waiting rooms; f/u surveys mailed by project manager Data Collection Practice facilitator diaries Field notes from quality circle meetings PI and Co-PI notes 0 PIF/PAT 1 2 3 4 5 6 Field Notes Patient Surveys PI Training QC QC Visit Plan-Do-Study-Act Cycles Baseline Audit Audit PEA Audit PEA Audit PEA Audit PEA Audit PEA Audit Participating Practices 1. W. Oklahoma (Clinton/Weatherford) a. Mike Aaron, M.D. b. Sharad Swami, M.D. c. Tamara Hartsell, NP 2. Central Oklahoma (OKC) a. Heather Tipsword, D.O. b. Ingrid Jackson, M.D. c. Suben Naidu, M.D. 3. E. Oklahoma (Grove) a. Zack Bechtol, M.D. b. Rene Russell, M.D. c. Shawn Anderson, M.D. Overall Results: Screening Rates/Encounter 0.9 0.8 0.7 0.6 0.5 Diet 0.4 Tobacco Alcohol 0.3 0.2 0.1 0 Baseline 6-mo 12-mo 18-mo Overall Results: Brief Counseling Rates/ Encounter 0.25 0.2 0.15 Diet Tobacco 0.1 Alcohol 0.05 0 Baseline 6-mo 12-mo 18-mo Overall Results: Very Brief Intervention Rates/Encounter 0.25 0.2 0.15 Diet Tobacco 0.1 Exercise 0.05 0 Baseline 6-mo 12-mo 18-mo Maintenance: Screening Rates/Encounter 1 0.9 0.8 0.7 0.6 Diet 0.5 Tobacco 0.4 Alcohol 0.3 0.2 0.1 0 Baseline 6-m0 12-mo 18-mo Maintenance: Brief Counseling/Encounter 0.3 0.25 0.2 Diet 0.15 Tobacco Alcohol 0.1 0.05 0 Baseline 6-mo 12-mo 18-mo Maintenance: Very Brief Interventions/Encounter 0.8 0.7 0.6 0.5 Diet 0.4 Tobacco 0.3 Alcohol 0.2 0.1 0 Baseline 6-mo 12-mo 18-mo OKC Diet 100 90 80 70 60 50 Screened + Screen 40 30 20 10 0 Pre Audit1- Audit2- Audit3- Audit4- Audit5- Audit6- Audit1- Audit2- Audit3- Audit4- Audit5- Audit6- Audit1- Audit2- Audit3- Audit4- Audit5- Audit6- 1 1 1 1 1 1 2 2 2 2 2 2 3 3 3 3 3 3 Baseline Diet/Exercise Alcohol Smoking Weatherford Smoking 100 90 80 70 60 50 Screened + Screen 40 30 20 10 0 Pre Audit1- Audit2- Audit3- Audit4- Audit5- Audit6- Audit1- Audit2- Audit3- Audit4- Audit5- Audit6- Audit1- Audit2- Audit3- Audit4- Audit5- Audit6- 1 1 1 1 1 1 2 2 2 2 2 2 3 3 3 3 3 3 Baseline Alcohol Smoking Diet/Exercise Cumulative Results: Final 6 months 0.9 0.8 0.7 0.6 0.5 Screened Screen + 0.4 Intervention 0.3 0.2 0.1 0 Diet Exercise Tobacco Alcohol Cost of the Intervention (Per 1000 patient encounters estimate) Screening (1000): $200 Very brief interventions (400): $ 80 Brief counseling (50): $830 TOTAL: $1,110 Cost of Implementation (Per Cluster Estimate) Project management: $2,080 Training and CME: Trainers: $ 450 Trainees: $15,120 Practice facilitation: $6,750 Quality circles: $ 900 PI visits: $2,700 Travel and food: $8,000 TOTAL: $36,000 Challenges and Caveats Alcohol screening – How to comfortably and effectively ask – Who should do it – How often (every encounter?) Alcohol treatment resources – Availability – Issues of confidentiality in small towns Overweight and obesity – Lack of effective approaches – Insurance coverage of surgery EHR limitations Challenges and Caveats Inadequate instruction and monitoring of exercise screening and interventions Documentation issues in the practices Comments from Participants?