sue flocke, phd - prchn for prc... · 2014-07-22 · sue flocke, phd eileen l. seeholzer, md ms...

Sue Flocke, PhDEileen L. Seeholzer, MD MSHeidi Gullett, MD MPH

Brigid Jackson, MASamantha Smith, MAElizabeth Antognoli, PhDSue Krejci, MBAPeter J. Lawson, MA MPH MBA

Practice-based Research Network Core staff Funding by a Cooperative Agreement from the CDC

• Background and context• Obesity prevalence

• Primary care context

• Current practice

• Findings from part 1 of study: resident survey

• Findings from part 2: curriculum audit

• Preliminary findings from part 3: testing associations

• Discussion

• Overweight/obesity • High prevalence in US and many other developed countries

• Risk factor for many chronic conditions, including several cancers

• Overweight/obesity • Risk factor for many chronic conditions

Coronary heart disease, stroke, and high blood pressure.

Type 2 diabetes.

Cancers, such as endometrial, breast, and colon cancer.

Liver and gallbladder disease.

Sleep apnea and respiratory problems.

Osteoarthritis.

Reproductive health complications such as infertility.

• Overweight/obesity prevalence• US - 34.9% of adults with BMI ≥30†;

- 35% are overweight BMI 25-30

• Ohio - 30.%*

• Cuyahoga County 26.3%^

• Cleveland 34.4%^

† NHANES data 2011,

• Overweight/obesity prevalence• Primary care practices: ~70-90% of adults obese or overweight with a

chronic condition.

• Opportunity in primary care context• Potential to reach a large portion of the population

• US Preventive Services Task Force recommendations

• National Heart Lung & Blood Institute guidelines for clinicians• Assessment

• Treatment

• Weight-related counseling is: • Not systematic

• Not aligned with recommended methods shown to support behavior change.

• Barriers include:• Physicians feel inadequately trained

• Report low confidence (self-efficacy)

• Report lack of time

1. Assess residents’ knowledge, attitudes, and self-efficacy to provide obesity, nutrition, and physical activity (ONPA) counseling.

2. Identify the scope and modalities of training for preparing primary care residents to provide ONPA counseling.

3. Examine resident characteristics and features of primary care programs including discipline, program settings, and modes of training associated with variation of resident knowledge, attitudes and self-efficacy for ONPA counseling.

• Cross sectional study design

• Survey

• Interview and document review

• Analyses• Descriptive statistics

• Structured coding of interview data

• Bi-variate associations – t-test, chi square, anova, regression

Primary Care Resident Training Programs in Ohio

Specialty Total N Study Sample

Family Medicine 21 9

Internal Medicine 22 10

Obstetrics/Gynocology 11 6

Total 54 25

Target sample (24)

Senior residents –Third year residents for Family Medicine and Internal Medicine.

Third and fourth year residents for OB/GYN

Survey conducted in person at scheduled conference session.Attendance was noted.

Other strategies for follow up were pursued.

A presentation about obesity management was offered.

Example items:

“I’m confident in my ability to assist patients in

developing a plan for physical activity”

“Counseling patients to lose weight is not an

efficient use of my time”

In-person survey= 145

Online survey = 65

Online survey with raffle = 10

Mailed surveys = 5

Table 1. Resident Characteristics

n=220Demographic characteristics %

Female 59

Age, mean (SD) 30 (3)

Race

White 57

Black/African American 5

Asian 29

Other 10

US citizen 70

US medical school 69

Chief resident 27

Training characteristics %

Specialty

Family Medicine 22

Internal Medicine 55

OB/GYN 23

Half day outpatient clinic

sessions/week, mean (SD)

Elective rotation in ONPA 16

2 (1)

Table 2.

Summary scores on 100 point scale

ONPA domain Mean SD Min Max

Counseling knowledge 54.41 12.87 22 83

Cancer risk knowledge 70.94 8.56 39 87

Attitude 54.86 13.97 21 92

Self-efficacy 51.66 16.90 0 100

B SE P

Demographic characteristics

Female 0.92 2.03 0.65

Age -0.02 0.30 0.94

Race

White

Black/African American -6.41 4.96 0.20

Asian -6.61 2.25 0.004

Other -6.22 3.33 0.06

US citizen 6.26 2.12 0.004

US medical school 5.11 2.16 0.02

Chief resident -4.04 2.20 0.07

Training characteristics

Specialty

Family Medicine

Internal Medicine -4.35 2.43 0.08

OB/GYN -3.86 2.85 0.18

Half day outpatient clinic

sessions/week

Elective rotation in ONPA 5.17 2.66 0.05

reference

0.00 0.72 1.00

Counseling knowledge score

reference

Table 3a. Associations between residents’ ONPA counseling knowledge

and demographic and training characteristics

Table 3b. Associations between residents’ cancer risk knowledge

and demographic and training characteristics

B SE P

Demographic characteristics

Female -0.12 1.45 0.93

Age -0.05 0.21 0.82

Race

White

Black/African American 2.19 3.67 0.55

Asian 0.29 1.62 0.86

Other -1.43 2.50 0.57

US citizen 0.24 1.61 0.88

US medical school 0.59 1.60 0.71

Chief resident 3.39 1.58 0.03

Training characteristics

Specialty

Family Medicine

Internal Medicine -1.88 1.69 0.27

OB/GYN 3.43 1.95 0.08

Half day outpatient clinic

sessions/week

Elective rotation in ONPA -2.63 1.81 0.15

reference

0.40 0.51 0.44

Cancer risk knowledge score

reference

Table 3c. Associations between residents’ attitudes

and demographic and training characteristics

B SE P

Demographic characteristics

Female -2.34 2.14 0.28

Age 0.49 0.33 0.13

Race

White

Black/African American 3.52 4.85 0.47

Asian 5.52 2.31 0.02

Other 11.49 3.47 0.001

US citizen -9.12 2.23 <0.001

US medical school -11.17 2.20 <0.001

Chief resident -1.50 2.42 0.54

Training characteristics

Specialty

Family Medicine

Internal Medicine 0.02 2.53 0.99

OB/GYN -5.97 2.97 0.05

Half day outpatient clinic

sessions/week

Elective rotation in ONPA 13.99 2.75 <0.001

-0.67 0.75 0.37

reference

Attitude score

reference

Table 3d. Associations between residents’ self-efficacy

and demographic and training characteristics

B SE P

Demographic characteristics

Female -5.69 2.63 0.03

Age 0.71 0.41 0.08

Race

White

Black/African American 1.11 6.32 0.86

Asian 1.76 3.03 0.56

Other 8.24 4.52 0.07

US citizen -4.08 2.83 0.15

US medical school -9.17 2.82 0.001

Chief resident -4.23 2.97 0.16

Training characteristics

Specialty

Family Medicine

Internal Medicine -8.52 2.96 0.004

OB/GYN -16.98 3.46 <0.001

Half day outpatient clinic

sessions/week

Elective rotation in ONPA 17.79 3.32 <0.001

2.21 0.93 0.02

reference

Self-efficacy score

reference

Table 3e. Associations between residents’ professional norms

and demographic and training characteristics

B SE P

Demographic characteristics

Female -2.62 1.92 0.17

Age 0.24 0.30 0.43

Hispanic/Latino 1.60 4.28 0.71

Race

White

Black/African American 7.16 4.29 0.10

Asian 5.72 2.09 0.01

Other 2.57 3.58 0.47

US citizen -7.86 2.05 <0.001

US medical school -7.89 2.12 <0.001

Chief resident -5.17 2.20 0.02

Training characteristics

Specialty

Family Medicine

Internal Medicine -1.74 2.34 0.46

OB/GYN -11.31 2.78 <0.001

Half day outpatient clinic

sessions/week

Elective rotation in ONPA 13.95 2.62 <0.001

Professional norms

reference

reference

0.01 0.72 0.99

• United States Medical Licensing Exam (USMLE) Step 1 after first two years of medical school

• USMLE Step 2CK (clinical knowledge) and 2CS (clinical skills)

• Eligible to take USMLE Step 3 – when all 3 parts passed, may obtain unlimited medical license

Table 4a. Program characteristics (n=25)

n %

Location

North Coast 9 36

Northeast 7 28

Northwest 3 12

Central/Southwest 6 24

Context

University-based hospital 6 24

Community-based, university

affiliated hospital

Community-based hospital 2 8

Setting

Urban 22 88

Suburban 3 12

Semirural/Rural 0 0

mean % SD

Payor mix

Commercial 22.3 18.4

Medicaid 39.2 20.0

Medicare 23.9 14.8

Self-pay/Uninsured 13.5 12.3

Other 1.1 2.2

mean SD

First year positions available annually 13 12.3

Total current residents 41 36.6

Current foreign medical graduates 11 13.2

Year program established 1970 13.7

Core faculty 11 6.2

Total

n=25

17 68

Table 4b. Program characteristics (n=25)

Formal opportunities for ONPA training n (%) mean (SD)

Hours of didactics per year 254.7 (96.0)

Hours of ONPA related didactics per year 2.7 (4.9)

ONPA guidelines taught:

Formally 4 (17)

Informally 3 (13)

Not taught 17 (71)

Health behavior change counseling techniques taught 10 (42)

HB change counseling techniques applied to ONPA 1 (10)

Offers ONPA related track(s) 0 (0)

Offers ONPA related fellowship(s) 6 (24)

Blocks designated for electives 5.1 (3.6)

Offers ONPA related elective(s)* 6 (86)

Type of electives offered

From list or create your own 6 (24)

From list only 8 (32)

Create your own only 10 (40)

Not offered 1 (4)

*Only includes programs that provided an electives list (n=7)

Table 4c. Program characteristics (n=25)

Informal opportunities for ONPA training n (%) mean (SD)

Half-days per week in continuity clinic 1.7 (0.9)

Clinical care blocks 39.2 (4.4)

Hospital (inpatient) 18.8 (4.6)

Specialty rotations** 10.4 (4.3)

Ambulatory (outpatient) 7.5 (3.7)

Emergency Department 1.2 (1.0)

Allied health professional engagement

Type

Dietitian / Nutritionist 18 (78)

Diabetes educator 11 (48)

Nurse educator 7 (30)

Nurse practitioner / Nurse-midwife 7 (30)

Role

Available for referrals 19 (83)

Provides didactics 9 (39)

Available for questions/consults 8 (35)

Part of outpatient group visit/team approach 6 (26)

Patient care only 6 (26)

Part of inpatient rounding 4 (17)

** Includes elective blocks

Table 5. Program characteristics (n=25)Mean SD P-value

Counseling knowledge

ONPA related didacticsN 50.8 13.8

0.03Y 55.3 11.4

HB change counseling techniques taughtN 53.0 12.2

0.07Y 56.7 13.7

ONPA related fellowship(s)N 54.2 13.2

0.88Y 54.5 14.5

Allied health professional provides didacticsN 54.4 11.4

0.88Y 54.1 14.6

Attitudes

ONPA related didacticsN 61.6 13.2

<0.001Y 51.3 12.1

HB change counseling techniques taughtN 55.0 14.4

0.55Y 53.8 12.9

ONPA related fellowship(s)N 54.4 13.6

0.79Y 54.9 14.4

Allied health professional provides didacticsN 52.8 12.4

0.05Y 56.8 15.4

Self-efficacy

ONPA related didacticsN 54.0 19.2

0.23Y 50.7 15.5

HB change counseling techniques taughtN 49.8 16.8

0.03Y 55.3 17.0

ONPA related fellowship(s)N 50.4 18.3

0.22Y 53.5 15.1

Allied health professional provides didacticsN 50.6 16.6

0.38Y 52.8 17.7

ProgramID Residual ICC %

Attitude 38.10 158.51 0.1938 19.38

Self-efficacy 45.67 246.86 0.1561 15.61

Counseling knowledge 15.11 152.63 0.0901 9.01

Cancer risk knowledge 2.70 70.89 0.0367 3.67

Table 6. ICCs

• High level of variability in primary care residents’ preparedness to counsel for obesity.

• There is significant room for improvement in knowledge of recommended methods of obesity assessment and treatment and self-efficacy for behavior change counseling.

• We did not expect or find significant associations between resident demographic characteristics and outcomes.

• Participation in an elective on an ONPA topic was strongly associated with increased self-efficacy

Our assessment of the program curriculum • relatively few hours of formal curriculum devoted to ONPA topics

• informal opportunities through precepting and engagement of allied health professionals were more common.

• However, the degree of exposure to informal opportunities is difficult to assess.

Study limitations• Modest response rate, despite multiple strategies to maximize

participation

• Ohio-centric sample of programs

• Imprecise measurement of some program features; curriculum cycles.

Study strengths• Relatively large sample of programs; multiple specialties represented

• Resident survey and program features assessed

• Strong survey measures with good variability

• Evaluate the association of program features with resident knowledge, attitudes and self-efficacy.

• Multi-level analysis

For primary care clinicians to effectively play a part in addressing the obesity epidemic,

1) Clinicians need to be better equipped with knowledge and counseling skills to be effective team players.

2) Better systems for documenting and tracking,

3) Better alignment of incentives for training and practice

We wish to thank the residency programs and resident physicians that participated in this study.

This project was funded by a grant to Susan A. Flocke, U48-Supplement 3U48DP001930-04S3 to

Four Components of Successful Weight Loss

Low calorie diet

Set a weight goal

Monitor

weight loss

Regular physical

activity

Key Knowledge about obesity that change treatment approach

Key Knowledge about obesity that changes treatment approach