# Presentation: 815518

## A Comprehensive Practice-Friendly Model for Promoting Healthy Behaviors: Impact on Diet, Exercise, and Smoking	

- Alex Krist, MD				Steven Woolf, MD, MPH
- Charles Frazier, MD			Robert Johnson, PhD
- Stephen Rothemich, MD, MS		Amy Burgett, RN
- Sharon Flores, MS			Kelly Devers, PhD
- Diane B. Wilson, EdD, MS, RD 		Resa Jones, PhD

**For more information contact – ahkrist@vcu.edu**

## Frequency of Unhealthy Behaviors 

- 30% of adults are obese and 16% of adolescents are at risk
- 24% of adults and 35% of adolescents are current smokers

## Major Contributor to Health Care Costs

- Tobacco use costs $157 billion per year ($3,856 per smoker) in direct medical expenses and lost productivity
- Obesity accounted for 27% of the rise in per capita health care spending between 1987 and 2001
- Obesity will increase future Medicare beneficiary spending by 34%

## Background

- Intensive counseling can help patients improve physical inactivity, unhealthy diet, and smoking cessation
- The “5As” is an effective framework for delivering health behavior counseling (endorsed by AHRQ)
- Ask (A1), Advise (A2), Agree (A3), Assist (A4), and Arrange (A5)
- Many primary care practices are effective at delivering A1-3, but may lack resources for A4-A5
- Existing community (local and national) programs may effectively provide support for more intensive counseling, motivation, and follow-up

## The Prompt

## Beyond the Prompt – the Form

## Methods

- Pre-post design
- 9 practices in Tidewater Virginia area (Riverside Physician Associates)
- 1 to 33 providers per practice (residency)
- Utilize a common EMR (Centricity Physician Office – Logician)
- Prompts appear for adults with an elevated BMI, who smoke, or who drink excessively

## Main Outcome

- Outcomes assessed by survey, tracking systems within the EMR, counselor databases, and semi-structured interviews
- Main outcome - health behavior change measured by Common Measure survey mailed to random sample of 2400 patients before and after the intervention (4 months and 9 months)

## Health Behaviors as Recorded in the EMR (n=5679)

**12%**

**29%**

**58%**

**<1%**

**29%**

**5%**

**16%**

**25%**

**35%**

- U.B. = Unhealthy Behavior

## EMR Prompt System Use

- Form was loaded for _***22%***_ of patients with an unhealthy behavior
- Form was used for _***14%***_ of patients with an unhealthy behavior
- * Excludes usual care

## Health Behavior Change: % Smokers

- Random Sample of Practice

- Counselees: Patients Referred

## Health Behavior Change: Weight

- Random Sample of Practice

- Counselees: Patients Referred

## Health Behavior Change: Diet(Random sample of entire practice)

|  | Pre-Interv.
(N=1532) | 4 Mo. Post
(N=1392) | P value |
| --- | --- | --- | --- |
| Total diet score (0=worst, 10=best) | 6.90 | 6.89 | p=0.48 |
| % eating 5 fruits / vegetables per day            3-4 fruits / vegetables per day            ≤ 2 fruits / vegetables per day | 9%45%46% | 11%47%42%
  | 
(p=0.045) |
| % eating desserts or sweets 0-1 times per week                                              2-3 times per week                                               >4 times per week | 29% 46% 24% | 33%43%24% | 
(p=0.042)
 |
| % eating fatty foods: very little
                                  some
                                  a lot | 43%49%8% | 47%46%6% | 
(p=0.039) |

## Health Behavior Change: Exercise(Random sample of entire practice)

|  | Pre-Interv.
(N=1532) | 4 Mo. Post
(N=1392) | P value |
| --- | --- | --- | --- |
| Mets of activity per week | 3365 | 3969
 | (p<0.001) |
| Vigorous activity: average days / week

Average minutes / day | 2.1

104 | 2.3

1113 | (p=0.09)

(p=0.003)
 |
| Moderate activity: average days / week

Average minutes / day | 3.2

105 | 3.5 

112 | (p=0.015)

(p=0.009) |
| Walking: average days / week

Average minutes / day | 4.5

86.4 | 4.6

91.2 | (p=0.29)

(p=0.06) |

## Conclusions

- 10% of patients seen in primary care practices were referred for nine months of intensive counseling. Referred patients:
- Lost weight – averaging 5-8 pounds
- Quit smoking – 50-75%
- EMR prompt-referral system could easily be generalized
- Can be modified to local and existing resources
- Can be extended to additional preventive services

## Thank You for Listening!