Increasing Screening and Interventions for Four Unhealthy Behaviors

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					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?

				
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