Download - Slides for Kutob, Hekler, Thomson
The Only Prescription with Unlimited Refills
Every Patient, Every Visit, Every Treatment Plan
Saturday, March 10, 20127:00 AM - 4:30 PM
DoubleTree by Hilton Hotels
The Only Prescription with Unlimited Refills
Every Patient, Every Visit, Every Treatment Plan
Made possible by funding from the Centers for Disease Control and Prevention and the Pima County Health Department. The
trademark Exercise is Medicine is used by permission from the
American College of Sports Medicine.
Promoting Healthy Lifestyles in Real World Clinical Settings: Moving Beyond the Barriers.
Randa M. Kutob, MD, MPHExercise is Medicine ConferenceMarch 10, 2012Department of Family and Community MedicineUniversity of Arizona, College of [email protected]
Disclosures
• I have no financial or other conflicts of interest to disclose.
What Are We Here For?
• Review data on obesity, physical activity, and diabetes in the U.S.
• Explore provider barriers to lifestyle counseling
• Examine the evidence for what works• Share ways to put more lifestyle change
into our practices
What I Hope You Will Get Out of It
Just one idea to implement in your practice to promote physical activity and lifestyle change.
Do You Know How Food Portions Have Changed in 20 Years?
National Heart, Lung, and Blood Institute
Obesity Education Initiative
COFFEE 20 Years Ago
Coffee(with whole milk and sugar)
Today
Mocha Coffee(with steamed whole milk and
mocha syrup)
45 calories 8 ounces
How many calories are in today's coffee?
COFFEE 20 Years Ago
Coffee(with whole milk and sugar)
Today
Mocha Coffee(with steamed whole milk and
mocha syrup)
45 calories 8 ounces
350 calories16 ounces
Calorie Difference: 305 calories
How long will you have to walk in order to burn those extra 305
calories?*
*Based on 130-pound person
Maintaining a Healthy Weight is a Balancing ActCalories In = Calories Out
If you walk 1 hour and 20 minutes, you will burn approximately 305 calories.*
*Based on 130-pound person
Calories In = Calories Out
320 calories How many calories are in today’s turkey sandwich?
TURKEY SANDWICH20 Years Ago Today
Calorie Difference: 500 calories
820 calories 320 calories
TURKEY SANDWICH20 Years Ago Today
How long will you have to ride a bike in order
to burn those extra calories?*
*Based on 160-pound person
Maintaining a Healthy Weight is a Balancing ActCalories In = Calories Out
*Based on 160-pound person
If you ride a bike for 1 hour and 25 minutes,you will burn approximately 500 calories.*
Calories In = Calories Out
Scope of the Problem
Obesity Trends* Among U.S. Adults, BRFSS, 1990, 2000, 2010
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
Centers for Disease Control and Prevention: National Diabetes Surveillance System. http://apps.nccd.cdc.gov/DDTSTRS/default.aspx
.
Obesity Trends* Among U.S. AdultsBRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1986
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1987
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1988
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1989
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1990
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. AdultsBRFSS, 1991
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1992
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1993
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1994
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1995
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1996
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19%
Obesity Trends* Among U.S. AdultsBRFSS, 1997
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsBRFSS, 1998
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsBRFSS, 1999
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsBRFSS, 2000
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. AdultsBRFSS, 2001
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
Obesity Trends* Among U.S. AdultsBRFSS, 2002
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Obesity Trends* Among U.S. AdultsBRFSS, 2003
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Obesity Trends* Among U.S. AdultsBRFSS, 2004
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Obesity Trends* Among U.S. AdultsBRFSS, 2005
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 0%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. AdultsBRFSS, 2006
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. AdultsBRFSS, 2007
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. AdultsBRFSS, 2008
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. AdultsBRFSS, 2009
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. AdultsBRFSS, 2010
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
www.cdc.gov/diabetes
County-level Estimates of Diagnosed Diabetes among Adults aged ≥ 20 years: United States 2008
Age-adjusted ranks based on age-adjusted percent of diabetesAbove median rank
Below median rank
Not above median rank or below median rank
www.cdc.gov/diabetes
County-level Estimates of Leisure-time Physical Inactivity among Adults aged ≥ 20 years: United States 2008
Age-adjusted percentQuartiles
0 - 23.2
23.3 - 26.2
26.3 - 29.1
> 29.2
FRENCH FRIES 20 Years Ago Today
210 Calories
2.4 ounces How many calories are intoday’s portion of fries?
610 Calories6.9 ounces
Calorie Difference: 400 Calories
FRENCH FRIES 20 Years Ago Today
210 Calories
2.4 ounces
How long will you have to walk leisurely in order to burn those extra 400 calories?*
*Based on 160-pound person
Maintaining a Healthy Weight is a Balancing ActCalories In = Calories Out
*Based on 160-pound person
If you walk leisurely for 1 hour and 10 minutes you will burn approximately 400 calories.*
Calories In = Calories Out
Walking in the U.S.
• U.S. Men-5,340 steps• U.S. Women-4,912 steps (Bassett, 2010)
• Amish men-18,425 steps• Amish women-14,196 steps (Bassett, 2004)
Obesity, Diabetes, and Physical Inactivity in the U.S., Arizona, and Pima County
United States
Arizona Pima County
Obesity 33.8 % (2008)
24.3 % (2010)
23.8 % (2010)
Diabetes 8.3 % (2011)
8.1 % (2010)
7.0 % (2008)
Physical Inactivity
25.0 % (2008)
22.9 % (2010)
19.7 % (2008)
Centers for Disease Control and Prevention: National Diabetes Surveillance System. http://apps.nccd.cdc.gov/DDTSTRS/default.aspx
.
Scope of the Problem
Diabetes and Prediabetes 18.8 million with diabetes 7.0 million undiagnosed +79.0 million w/prediabetes______________________= 104.8 million!!!!
Centers for Disease Control and Prevention. National Diabetes Fact Sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011.
Diagnosed DiabetesUndiagnosed Di-abetesPrediabetesThose Unaffected
BUT…
Only 1/3 of those with prediabetes received provider advise about it in the past year! (Geiss, 2010)
What are Practicing Docs/Providers Doing? A Survey of Our Practice
(n=62)
Gordon JS, Thomson C, Kutob R, Burns KD, Byron D, Marquis A, & Cunningham J. Practices, attitudes, self-efficacy, and perceived barriers for preventing and treating obesity in the primary care clinic. Poster presented at the Research Frontiers in Nutritional Sciences Conference, February 29 – March 1, 2012, Tucson, AZ.
What Does the Literature Say?
• Time• Lack of materials• Lack of resources• Lack of confidence in counseling skills• Reimbursement• Concerns about effectiveness
(Kushner 1995, Kolasa 2010)
So What Can We Do?
If primary care physicians did all the preventive services recommended by the USPSTF, we would spend 7.4 hours out of an 8-hour day doing them! (Yarnall 2003)
Exercise Matching Game
Activity• Walking• Yoga/stretching• Bicycling• Jumping Rope• Yard Work• Weight Training• Swimming • Basketball• Jogging
Calories Burned in 30 minutes
• a. 140 calories• b. 220 calories• c. 295 calories• d. 145 calories• e. 165 calories• f. 90 calories• g. 110 calories• h. 255 calories• i. 325 calories
Table 2. From the Surgeon General’s Vision for a Healthy and Fit Nation52.
Kolasa K M , Rickett K Nutr Clin Pract 2010;25:502-509
Copyright © by The American Society for Parenteral and Enteral Nutrition
Training, Effectiveness, and Confidence: Know What Works
• High intensity (face to face at least once a month for 3 months)
• Frequent contact• Self-monitoring (keeping food diaries and
activity records)• Nutrition education and meal planning (portion
size and not skipping meals)• Control of the stimuli that activate eating• Goal setting• Social support• Increasing physical activity
More Is Better
At 2 years:
• Usual Care: minus 1.7 kg• Brief Lifestyle Counseling: minus 2.9
kg• Brief Lifestyle Counseling plus Meal
Replacement: minus 4.6 kg (Wadden, 2011)
Think About How to Deliver the Message: Eliciting Explanatory
Models• “How do you feel about your weight?”• “How do you feel your weight affects your
health?”• Think about Stages of Change• Use Motivational Interviewing techniques• Help your patient set realistic, specific goals• Ask about barriers• Telling patients to exercise without a
specific intervention does not work!
Time and Teams: Don’t Do It All Yourself
• Registered Dieticians• Medical Assistants• Nurses• Promotoras• Referrals to community programs
The UA Health Network’s Clinical Weight Loss Program
Community Resources
• YMCA’s: up to 100% financial assistance available• Diabetes Prevention: YMCA and United Healthcare• Community Centers:
– E.g., Kino, Drexel Heights, Catalina, JCC, Ellie Townes Flowing Wells, John Valenzuela Youth Center, Littletown, Robles Ranch
• Parks and Recreation• City Pools
(Byron, UA Family Medicine Residency Program, 2011)
Reimbursement
• If you can, collect data to show key stake holders the value of what you do
• Or share with the data that already exists
24.7 Billion Dollars!!!! (Ormand, 2011)
Don’t Do It In the Same Way:Families United:Familias Unidas
Group Office Visits for Diabetes Prevention• Twelve, 2-hour sessions • Adults, ages 18-70, with any diabetes risk factor (e.g., hypertension, hypertriglyceridemia, etc.) were eligible
• Participants identified one support person, age 14-70, to accompany them
Have Fun Doing It !Have Fun Doing It!
The Only Prescription with Unlimited RefillsSPECIAL THANKS TO:
Advisory Board:
Carondelet Health Network - Donna Zazworsky, RN, CCM, FAAN, VP Community Health Continuum
Taz Greiner, Obesity Prevention Program Manager. Carondelet Diabetes Education Institute
Maureen MacDonald, MEd, MSW, LMSW, Carondelet Diabetes Education Coordinator.
Carondelet Medical Group - Michael Connolly, DO, Internal Medicine.
Children’s Medical Center of Tucson - Jessica Schultz, M.D., Pediatrician.
Pima Heart - Charles Katzenberg, M.D., FACC Cardiologist.
Pima County Medical Society - Steve Nash, JD, Executive Director.
University of Arizona Section of Endocrinology, Diabetes and Hypertension- Craig Stump, M.D., PhD, Professor.
University of Arizona Center For Physical Activity and Nutrition - Scott Going, PhD, Professor.
University of Arizona Mel & Enid Zuckerman College of Public Health - Canyon Ranch Center for Prevention and Health Promotion - Cynthia Thomson, PhD, RD, Professor.
Creative Team:
Centrum Medical Communications: Medical Education & Marketing - Laurel Rokowski, RN.
M2Design: Graphic Design - Michael Drabousky.
Dupont Videography: Video Recording & Editing - John Dupont.
Sonora Communications: Computing, Networking, Internet Services Gene Cooper.
The Only Prescription with Unlimited Refills
Every Patient, Every Visit, Every Treatment Plan
Saturday, March 10, 20127:00 AM - 4:30 PM
DoubleTree by Hilton Hotels
The Only Prescription with Unlimited Refills
Every Patient, Every Visit, Every Treatment Plan
Made possible by funding from the Centers for Disease Control and Prevention and the Pima County Health Department. The
trademark Exercise is Medicine is used by permission from the
American College of Sports Medicine.
TECHNOLOGY PRACTICE APPLICATIONS
Eric Hekler, Ph.D.Assistant Professor
School of Nutrition and Health Promotion
Arizona State University
Outline
My background
State of technology
State of the science
Promising commercial technologies
Coming soon…
My background Clinical Health Psychologist, Rutgers
Postdoc – Stanford University
Focus: The use of technologies for health behavior change
ACSM Committees:SHI-Behavioral Health CommitteeEIM Family Website developmentEIM Committee member for identifying evidence-based
practices
Technology-focused projects
Mobile Interventions for Lifestyle Eating and Exercise at Stanford (MILES) study
Exploring the influence of intentions when playing Exergames
The CHAT Trial - Focused on promoting physical activity by telephone delivered either by a human or automated counselor
The Stanford Healthy Neighborhood Discovery Tool
CHART-2: Intervention to increase physical activity using PDAs
Disclaimer
I will be discussing many different technologies. I am in no way affiliated with any of the corporations mentioned and I am NOT endorsing them in any way. I use them more as illustrative examples.
Outline
My background
State of technology
State of the science
Promising commercial technologies
Coming soon…
What has changed?
Technology offers opportunities for behavior change that were near impossible10 years ago
Key playersWidespread use of cell phones (and smartphones)“Cloud” computingCheap wireless sensors with APIsAlgorithmsInformation development modelsSocial Networking
http://thenextweb.com/mobile/2011/02/02/the-shocking-numbers-behind-cellphone-usage-infographic/
What is the cloud?
Algorithms
Powerful data analytic techniquesMachine learning, data mining, system
identification Used in a variety of contexts
Focused Search (i.e., Google)Activity classification“Recommender” systemsPersuasion ProfilesMood classification via voice, writing style, etc.
“2024”“2014”
Development Models
Expert-sourcedContent generated by
“experts”
Information evaluated by experts
Rigorous but slow
www.britannica.com
Crowd-sourcedContent generated by
“crowd”
Information evaluated by crowd
Fast but inaccurate?
www.wikipedia.org
Wired, July 2009, Quantified Self
Outline
My background
State of technology
State of the science
Promising commercial technologies
Coming soon…
Technology delivery channels
Exergames Text messaging (SMS) Web pages Interactive voice response systems Wearable sensors Smartphones Social media
Norman, Kolodziejczyk, Hekler, & Ramirez, under review; Brassington, Hekler, et al. in press
Exergames
ExergamesCan promote light to moderate intensity PA
Much less work on sustained use
Some research exploring best practices
Barnett, Cerin, Baranowski, 2011; Chen, Hekler, King, under review
Text messaging
Some efficacy for general health promotion Less work on PA in particular, but promising
Most used SMS as just one component
Work best if appropriately timed
Fjeldsoe, B. et al. 2009; Franklin, et al. 2006; Norman, Kolodziejczyk, Hekler, & Ramirez, under review
Web pages
“Small but statistically significant effects”
Efficacious interventions tended to:Compared to wait-list controlFocused on shorter-timeline
Key problemSustained adherence
Cugelman, Thelwall, & Dawes, 2011; Webb, Joseph, Yardley, & Michie, 2010; Norman, Kolodziejczyk, Hekler, & Ramirez, under review; Neve, Collins, et al. 2010
Interactive voice response Very few studies, but very promising results
Comparable to human intervention
Even for promoting 18m maintenance
Norman, Kolodziejczyk, Hekler, & Ramirez, under review; AC King, et al. 2007; King, Hekler, et al. under review
Wearable sensors
Lots of devices out there, with some evidence starting to be collected
Pedometers (particularly accelerometer-based such as Omron’s devices)
BodyMedia best evidence for weight loss Others just starting to be researched
Fitbit, Phillips Direct Life
Norman, Kolodziejczyk, Hekler, & Ramirez, under review; Brassington, Hekler, et al. in press
Smartphones
Very limited evidence but popular topic
Will be reporting some preliminary efficacy
Norman, Kolodziejczyk, Hekler, & Ramirez, under review; Brassington, Hekler, et al. in press
Social media
Very limited evidence, very popular topic Research finds health advice given One study, StepMatron, used Facebook
app and pedometer to motivate PAResults found increased check-ins on steps
when using Facebook compared to not Much more work is needed
Norman, Kolodziejczyk, Hekler, & Ramirez, under review; J. A. Greene, Choudhry, Kilabuk, & Shrank, 2011; Foster, Linehan, Kirman, Lawson, & James, 2010
Outline My background
State of technology
State of the science
Promising commercial technologies
Coming soon…
Happtique
Healthcare-APP-bouTIQUE
Focused on categorizing health apps
Exploring ways to build evidence into apps practice
Popular Smartphone apps RunKeeper iMapMyFitness Nike+GPS Hundred PushUps All in Yoga HD Monumental
Lots of new devices
Nike Fuelband
Striiv
Jawbone UP
Outline
My background
State of technology
State of the science
Promising commercial technologies
Coming soon…
Lots of new stuff being tested
Many health researchersUCSD- Smart Trial
Human Computer InteractionsCHI ConferencePersonalinformatics.org
Introduction Mobile Interventions for Lifestyle Exercise and Eating at
Stanford (MILES)
NHLBI-funded Challenge Grant (10/09 – 08/12) PI- King, 1RC1HL099340-01
Status: Ran preliminary pilot with 36 older adults; iterated on design and now running second trial
Collaborators: Abby King, Tom Robinson, Matt Buman, Lauren Grieco, Frank Chen, Jesse Cirimele, Beth Mezias, Banny Banerjee, Martin Alonso
Purpose
Develop theoretically meaningful smartphone apps for midlife & older adults
Physical activity & sedentary behavior
Passively assess PA & SB
Provide just-in-time feedback for behavior change
Activity Algorithm Validation
Hekler et al, 2010, November
N=15, Men & Women, Mean Age=55 12 laboratory-based activities 3-4 min each Hip- and pocket-worn Android phones Compared to Actigraph & Zephyr Bioharness
Results
Hekler et al, 2010, November
0 2000 4000 6000 8000 10000 120000
200
400
600
800
1000
f(x) = 0.0896939917730109 x + 55.075461392382R² = 0.825752545985109
Comparison of Phone to Actigraph "Counts"
Minute-level "counts" Linear (Minute-level "counts")
Actigraph "counts"
Ph
on
e A
UC
m/s
3
The “Apps”
mTrack mSmiles mConnect
King, Hekler, et al. April, 2012, Hekler et al. 2011
Control: Calorific
Very Preliminary Results
King, Hekler, et al. April, 2012
mSmiles mConnect mTrack0
10
20
30
40
50
60
70
80
90
Difference in LMPA across the intervention compared to control
min
/day
of
Lig
ht/
Mo
der
ate
Ph
ys-
ical
Act
ivit
y D
iffe
ren
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com
-p
ared
to
Co
ntr
ol
**
**
ns
EIM initiatives in the works EIM Family-focused website
EIM evidence-based practices
Thank you for inviting me!
Eric Hekler
Designing Health Lab @ASU
Twitter: @ehekler
References Barnett, A., Cerin, E., & Baranowski, T. (2011). Active video games for youth: a
systematic review. Journal of Physical Activity & Health, 8(5), 724-737. Retrieved from http://www-ncbi-nlm-nih-gov.ezproxy1.lib.asu.edu/pubmed/21734319
Brassington, G., Hekler, E. B., Cohen, Z., & King, A. C. (2011). Health Enhancing Physical Activity. Handbook of Health Psychology. Mahwah, New Jersey: Lawrence Erlbaum Associates Publishers.
Chen, F. X., Hekler, E. B., & King, A. C. (2012). Designing Health Messages: Framing Exergames for Exercise Improves Duration of Use. submitted for publication2.
Cugelman, B., Thelwall, M., & Dawes, P. (2011). Online Interventions for Social Marketing Health Behavior Change Campaigns: A Meta-Analysis of Psychological Architectures and Adherence Factors. Journal of Medical Internet Research, 13(1), 84-107. doi:e17 10.2196/jmir.1367
Fjeldsoe, B. S., Marshall, A. L., & Miller, Y. D. (2009). Behavior change interventions delivered by mobile telephone short-message service. American journal of preventive medicine, 36(2), 165-73. American Journal of Preventive Medicine. doi:10.1016/j.amepre.2008.09.040
Foster, D., Linehan, C., & Kirman, B. (2010). Motivating physical activity at work: using persuasive social media for competitive step counting. Proceedings of the 14th …. Retrieved from http://dl.acm.org.ezproxy1.lib.asu.edu/citation.cfm?id=1930510
References Franklin, V. L., Waller, A., Pagliari, C., & Greene, S. A. (2006). A randomized controlled trial
of Sweet Talk, a text-messaging system to support young people with diabetes. Diabetic Medicine, 23(12), 1332-1338.
Hekler, E B, Buman, M. P., Haskell, W. L., Rosenberger, M., & King, A. C. (n.d.). Validity of Android-Based Mobile Phones as Assessment Devices of Physical Activity. mHealth Summit. Washington, DC.
King, A C, Friedman, R., Marcus, B., Castro, C., Napolitano, M., Alm, D., & Baker, L. (2007). Ongoing physical activity advice by humans versus computers: The community health advice by telephone (CHAT) trial. Health Psychology, 26(6), 718-727. doi:10.1037/0278-6133.26.6.718
Neve, M. J., Collins, C. E., & Morgan, P. J. (2010). Dropout, Nonusage Attrition, and Pretreatment Predictors of Nonusage Attrition in a Commercial Web-Based Weight Loss Program. Journal of Medical Internet Research, 12(4), 81-96. doi:e69 10.2196/jmir.1640
Neve, M., Morgan, P. J., Jones, P. R., & Collins, C. E. (2010). Effectiveness of web-based interventions in achieving weight loss and weight loss maintenance in overweight and obese adults: a systematic review with meta-analysis. Obesity Reviews, 11(4), 306-321. doi:10.1111/j.1467-789X.2009.00646.x
Webb, T. L., Joseph, J., Yardley, L., & Michie, S. (2010). Using the Internet to Promote Health Behavior Change: A Systematic Review and Meta-analysis of the Impact of Theoretical Basis, Use of Behavior Change Techniques, and Mode of Delivery on Efficacy. Journal of Medical Internet Research, 12(1). doi:e4 10.2196/jmir.1376
The Only Prescription with Unlimited RefillsSPECIAL THANKS TO:
Advisory Board:
Carondelet Health Network - Donna Zazworsky, RN, CCM, FAAN, VP Community Health Continuum
Taz Greiner, Obesity Prevention Program Manager. Carondelet Diabetes Education Institute
Maureen MacDonald, MEd, MSW, LMSW, Carondelet Diabetes Education Coordinator.
Carondelet Medical Group - Michael Connolly, DO, Internal Medicine.
Children’s Medical Center of Tucson - Jessica Schultz, M.D., Pediatrician.
Pima Heart - Charles Katzenberg, M.D., FACC Cardiologist.
Pima County Medical Society - Steve Nash, JD, Executive Director.
University of Arizona Section of Endocrinology, Diabetes and Hypertension- Craig Stump, M.D., PhD, Professor.
University of Arizona Center For Physical Activity and Nutrition - Scott Going, PhD, Professor.
University of Arizona Mel & Enid Zuckerman College of Public Health - Canyon Ranch Center for Prevention and Health Promotion - Cynthia Thomson, PhD, RD, Professor.
Creative Team:
Centrum Medical Communications: Medical Education & Marketing - Laurel Rokowski, RN.
M2Design: Graphic Design - Michael Drabousky.
Dupont Videography: Video Recording & Editing - John Dupont.
Sonora Communications: Computing, Networking, Internet Services Gene Cooper.
The Only Prescription with Unlimited Refills
Every Patient, Every Visit, Every Treatment Plan
Saturday, March 10, 20127:00 AM - 4:30 PM
DoubleTree by Hilton Hotels
The Only Prescription with Unlimited Refills
Every Patient, Every Visit, Every Treatment Plan
Made possible by funding from the Centers for Disease Control and Prevention and the Pima County Health Department. The
trademark Exercise is Medicine is used by permission from the
American College of Sports Medicine.
Tool-Kit: Putting Prevention into Action in Your Clinic
Cynthia Thomson, PhD, RDDirector
Canyon Ranch Center for Prevention and Health Promotion
Exercise is Medicine Planning Committee
fittucson.org
1 Great Plate® Magnets
USDA MyPlate Poster
USDA MyPlate Placemat Tablet
Energy In/Energy Out Poster Set
Bodies Built Here Poster
MyHealthy Prescription Pads
Let’s eat for the health of it
EiM A Clinician’s Guide to Exercise Prescription
EiM Health Care Providers’ Action Guide
EiM Exercise Prescription and Referral Form
EiM Physical Activity Clearance Form
EiM Physical Activity Readiness Questionnaire
EiM Starting an Exercise Program
Food and Activity Log
Guide to Group Visits
Starting the ConversationGet Active
Starting the ConversationHealthy Eating
32 local restaurants Minimum 3 menu
items meeting “healthy” criteria
< 700 calories <1000 mg sodium < 15 grams fat
NutritionHub
Smart Choices for Healthy Dining
Healthy Dining Guide Insert
Materials without Implementation = Trash
Post information in a visible location◦ Place strategically:
Shared with key staff in your office◦ Personal wellness◦ Wellness ambassadors
Write scripts for healthy behaviors Follow-up, monitor and reward progress Visit fittucson.org
The Only Prescription with Unlimited RefillsSPECIAL THANKS TO:
Advisory Board:
Carondelet Health Network - Donna Zazworsky, RN, CCM, FAAN, VP Community Health Continuum
Taz Greiner, Obesity Prevention Program Manager. Carondelet Diabetes Education Institute
Maureen MacDonald, MEd, MSW, LMSW, Carondelet Diabetes Education Coordinator.
Carondelet Medical Group - Michael Connolly, DO, Internal Medicine.
Children’s Medical Center of Tucson - Jessica Schultz, M.D., Pediatrician.
Pima Heart - Charles Katzenberg, M.D., FACC Cardiologist.
Pima County Medical Society - Steve Nash, JD, Executive Director.
University of Arizona Section of Endocrinology, Diabetes and Hypertension- Craig Stump, M.D., PhD, Professor.
University of Arizona Center For Physical Activity and Nutrition - Scott Going, PhD, Professor.
University of Arizona Mel & Enid Zuckerman College of Public Health - Canyon Ranch Center for Prevention and Health Promotion - Cynthia Thomson, PhD, RD, Professor.
Creative Team:
Centrum Medical Communications: Medical Education & Marketing - Laurel Rokowski, RN.
M2Design: Graphic Design - Michael Drabousky.
Dupont Videography: Video Recording & Editing - John Dupont.
Sonora Communications: Computing, Networking, Internet Services Gene Cooper.
The Only Prescription with Unlimited Refills
Every Patient, Every Visit, Every Treatment Plan
Saturday, March 10, 20127:00 AM - 4:30 PM
DoubleTree by Hilton Hotels
The Only Prescription with Unlimited Refills
Every Patient, Every Visit, Every Treatment Plan
Made possible by funding from the Centers for Disease Control and Prevention and the Pima County Health Department. The
trademark Exercise is Medicine is used by permission from the
American College of Sports Medicine.
Group Visits forChronic Conditions Affectedby Overweight and Obesity
Tucson, March 10, 2012
Talk Outline1. What are group visits?2. How do you organize and schedule a group visit?3. How do you bill & document a group visit?4. Apply group visit techniques to exercise
What Kinds of Patients Benefit Most from Group Visits?
High Risk Patients, Namely◦ Those patients who have an increased risk for “both” high
resource utilization and poor outcomes◦ Obese patients are certainly at high risk for both
High Risk Groups Diabetes Obesity Tobacco users Asthma Cardiovascular disease (CVD) Dyslipidemia Depression Total joint replacements Frail elderly HIV/AIDS
What Are Group Visits?
Maximize educational time by working with 6-30 patients at a time
Many patients prefer group visits Group visits offer a billable service Any medical provider can offer group visits
◦ Doctors, nurses, PA, pharmacists, mental therapists, dieticians, etc.-- a physician and a dietician can even do a visit together
◦ Attendance drops if the primary physician is not involved
Shared Medical Visits Provide an Effective Way to Manage High Risk Cohorts
Annual visits share information and reach set targets for the group’s diagnosis (Lipids, BP)
A series of 2-4 visits focused upon weight loss or tobacco cessation
Longitudinal group visits can substitute many individual doctor visits (e.g., type 2 diabetes over 6-10 visits)
Group Visits can be Annual, a Series, or Longitudinal
Class provides information to a group Group visit must gather information and
document it in the patient record, label an assessment, and note a plan
Group visit is a billable service, a class usually is NOT a billable service◦ Billing information will follow◦ You must spend a moment of one-on-one time to clarify
the subjective, objective, assessment, and plan for the visit. 60-90 seconds will suffice
Difference Between a Group Visit and a Class
NO “right model,” just the one that works for you and your patients
The model you use is based upon◦The goals for your patients◦Your patients diagnoses◦Your reimbursement needs◦Office space you have available
Many Models Exist for Group Visits
Improve clinical outcomes Increase your productivity by about 15% to 25% Improve both patient and provider satisfaction Lower total health care costs
Premise: The Model You Choose Should
Group visits help many patients succeed in making lifestyle changes:◦Quitting tobacco use◦Food monitoring improves diet
compliance◦Monitoring and promoting activity
encourages exercise
Succeed in Changing Lifestyles with Group Visits
Share more information in less time Improve clinical outcomes Improve patient satisfaction for many patients Save money on the cost of providing care Enhance reimbursement (~20%) Improve provider satisfaction This is a rare Win/Win/Win/Win/Win opportunity
Why Should You Offer Group Visits?
Organizing & Scheduling Group Visits
(This section is addressed in your handout in detail)
“By doing just a little every day, I can gradually let the task completely overwhelm me.”
--Ashleigh Brilliant
Schedule a session 8-12 weeks in advance
Schedule 2-3 MA/LPN level providers for the first 15-30 minutes to collect data
Reserve a room! Prepare material in advance Prepare chart note forms in advance
Plan in Advance for Group Visits
Group Visit Organization
Organization brings order Disorganization produces CHAOS Some chaos will occur
“In science as in love, too much concentration on technique can often lead to impotence.”
--P.L. Berger
Allow 4 hrs total time for a group visit with 20-30 patients/session: 2 hrs group time & 2 hrs prep time (5 pts/hr of your time)
◦1 hour to prepare didactic materials and to coordinate with your staff
◦1 hour for chart reviews prior to the visit◦1/2 hour for 2-3 nurses to collect data and for the
provider to document specific plans◦1 hour to share information with the group ◦1/2 hour for wrap-up
How Much Time Do You Need For a Group Visit? (one tested method)
Choose a group visit size that reflects your style, patient population, and group visit room
You could see 10 patients during a total of 2 hours of physician time for a 1-hour group visit session
◦ Allow 30 min chart review, 30 min to prepare materials, and 1 hour for the session (again at least 5 pts/hour of MD time
Vary the Time with the Size of Your Group
30 minutes to collect patient data, meet individually, and complete medical record notes
15 minutes for the group to address their concerns to me and each other
45 minutes to introduce didactic material and interact
30 minutes to answer questions, plus time to write prescriptions, and meet individual needs
Actual physician time varies; I encourage you to finish on time!
How Do I Organize My Time During the 2-Hour Group Visit Session?
4-6 weeks prior, mail/e-mail a letter to selected patients in your practice advertising dates for you next group visit (See sample letter)
The letter encourages them to call and enroll for the group visit
Have your receptionist call 1 week later to encourage enrollment (See sample phone call script)
Anticipate 40-50% enrollment (if the primary physician invites own patients to attend; 5-15% enrollment if primary writes the letter, and another provider offers the group visit)
How to Recruit Patients for a Group Visit?
Addresses key targets for the specific diagnosis If you have a registry of high risk cohort patients,
this is very easy If your charts lack cohort specific targets, the
first review can be lengthy, but critically important
Once a template is built for the chart review, nurse/MA can add data for physicians review
Chart Review Before the Group Visit (ensures quality)
First visit, during registration forms must be signed (I strongly recommend confidentiality and HIPAA forms), patients should be registered and fees collected
Thereafter, register, collect co-payment or normal appointment fee, and begin data collection
Be prepared for a wave all arriving at once◦ You can’t have them line up like a usual visit
Registration
I agree to meet with a group of patients and my doctor. I have the choice to be seen by my physician in this group, or individually
Like any doctor’s appointment, I agree to be responsible for the bill or co-payment associated with this doctor’s visit
Signature: ___________________
Agreement to Participate
I agree to keep all information regarding other patients at these visits private, and agree not to disclose any information regarding other patients in these group visits
I will respect others’ privacy - ok to discuss what you have learned in these sessions, but don’t mention anyone’s name outside this group!
Signature: _________________
Confidentiality Form
Receptionist should mention this issue when they register for the appointment
Signed HIPAA Disclosure Form Essential ◦ Share with your HIPAA compliance officer (Example)◦ During a Group Visit, it is possible that some of my
personal health information will be disclosed. For example, at a Group Visit for Tobacco Cessation, it might be assumed that everyone attending uses tobacco. Discussions may occur regarding personal health information during a group visit. I have been notified of this potential disclosure and I wish to participate in a group medical visit. I realize that I have the option of being seen individually.
Signature___________________
HIPAA Issues
Arrive on time Register Find a chair and complete subjective aspect of the
SOAP note Then meet with the nurse Next meet with the doctor Return to chair
Patient Role
Maximum 3-4 minutes/ pt (sees 10 pts/30 min) Medical Record (EMR or paper) New progress note completed. MD may have already
made comments from chart review Scale, BP cuff, monofilament for foot exam, peak flow
meter, etc, etc Subjective and objective part of the note completed at
this station Physician will complete the note and sign the progress
note
Nurse Exam Stations (2-3)
Maximum 45-90 seconds one-on-one, face-to-face ◦ Signed HIPAA disclosure essential◦ Clarify assessment with the patient, (You smoke, it
is harmful, & I advise you to stop using tobacco)◦ Get permission to share questions and answers
with the group◦ Might include starting a new medication and the
risks/ benefits with that Rx◦ Put issues to address on the clip board◦ Private issues can be addressed at an individual
follow up visit (a recent headache)
Physician/PA/NP Role
Have a typed, fill in the blank note for your chart reviews (examples to follow)
Fill in targets and recent labs prior with the chart review
Choose targets you want to reach for the note Leave subjective and objective data for a nurse
to collect, let your patients fill out the subjective part of the chart
Your chart note documentation determines your billing level
Prepare Your Chart Note In Advance
Documentation and Billing Examples
Group Visits are Only Intended for Established Patients
New patients should initially be seen individually
Otherwise, the potential patient interactions and billing aspects may become very complicated
Sample CVD Progress Note HPI: Subjective
Any new angina. Any new signs CHF (SOB, edema, wt increase?)
ROS: Recent activity level◦ No activity◦ Moderate 2-3 times / wk◦ Moderate 4-6 times / wk * vigorous <4 times
/wk vigorous 4 or more x/ wk
Recent type fat intake◦ Most common fat intake
Produce serving intake◦ Less than 2 cups daily◦ 2-3 cups daily◦ 4 or more cups daily
Past Med Hx: (See chart)
Meds: (See med chart)
Tobacco Use:
Objective◦ Wt, BP, recent lipid profile,
FBS or HbgA1C Assessment
◦ CAD; At target? Yes/No Plan
◦ Treat and follow lipids◦ ASA daily (or other Rx)◦ Encourage activity and healthy
diet◦ Review med options: risks,
benefits, effects◦ Mange HTN & glycemia◦ >50% of this 90-minute visit in
counseling
99213, with 4 parts to the history, a brief exam, and decision making regarding a complex problem, with a stable patient and no therapy changes for a diagnosis of CAD
99214, with 4 parts to the history, 2 past med parts, and 2 ROS parts, a brief exam, and a CAD patient requiring a change in therapy with documentation of a risk benefit discussion related to that therapy change
Billing for a CVD Group Visit
SAMPLE DIABETES PROGRESS NOTE
HPI: SubjectiveRecent hypoglycemia? (shaky, jittery, light-headed)Fatigue? Freq urination?
ROS: Activity Level◦ No activity◦ Moderate 2-3 times / wk◦ Moderate 4-6 times / wk vigorous <4
times / wk vigorous 4 or more x / wk
Produce servings intake◦ Less than 2 cups daily◦ 2-4 cups daily◦ 5 or more cups daily
Past Med Hx: (See chart)Meds: (Include ASA qd; see flow sheet)Tobacco Use:
Objective (dated)◦ Wt, BP, recent HbgA1C, lipids, urinary
microalbumin, creatinine◦ Foot and eye exams
Assessment◦ Type 2 Diabetes
(controlled/uncontrolled) Plan
◦ HgbA1C Rx reviewed◦ ASA daily◦ Encourage activity◦ Encourage healthy diet◦ Review med options: risks, benefits, side
effects (Including ace-inhib.)◦ Manage lipids, HTN, proteinuria, feet,
retina◦ >50% of this 90-minute visit in counseling
99213, with 4 parts to the history, a brief exam, and decision making regarding a complex problem, with a stable patient and no therapy changes for a diagnosis of TYPE 2 DIABETES
99214, with 4 parts to the history, 2 past med parts, and 2 ROS parts, a brief exam, and a TYPE 2 DIABETIC patient requiring a change in therapy with documentation of a risk benefit discussion related to that therapy change
Billing For A Group Diabetic Visit
SAMPLE OSTEOPOROSIS PROGRESS NOTE Name: ____________________________________________ Date: ____________ID #: ____________________________________________ HPI: Subjective History severe spinal pain? yes noAny fracture during the last year? yes noTroubles tolerating medications for osteoporosis? yes noConstipation with calcium supplements? yes noTaking Vit D and magnesium with their calcium? yes noAny specific issue you want addressed at this session? __________________________________________________ ROS: Current weight bearing activity level: No activity, moderate 2-3 times / wk, moderate 4-6 times / wk, vigorous <4 times / wk, vigorous 4 or more x / wk Strength training sessions per week (circle one)None 1 session/wk 2 sessions/wk 3 sessions/wk >3 sessions/wk
How many mg of calcium intake do you get per day (diet plus supplements) _______(See handout to calculate calcium intake) Past Med Hx: (See chart for details) Meds: (Include; see flow sheet)Current Tobacco Use: yes no
OSTEOPOROSIS PROGRESS NOTE (cont)Objective
– Wt __________ BP __________ BMI ________ Hand Grip Strength ______kg (____
%)
– Last DEXA Completed ______ Lumbar BMD, _____ gm/cm Total Hip BMD ______ gm/cm
AssessmentOsteoporosis, responding to therapy
Osteoporosis, not responding to therapy
Other diagnoses: __________, _____________, ______________, ____________
Plan– Clarify next DEXA date
– Reviewed calcium, magnesium, and Vitamin D therapy recommendations– Encouraged activity, including weight bearing and strength training
– Moderate salt, animal protein, caffeine, and Vitamin A intake– AAFP osteoporosis patient handouts reviewed (3)
(http://search.aafp.org/htdigsearch/htsearch?words=osteoporosis)– > 50% of this 90 minute visit was spent on counseling
Billing: 99213 99214
SAMPLE TOBACCO CESSATION PROGRESS NOTE
Name: _______________________________ Date: ____________ID #: _______________________________ HPI: Subjective (at least 4 questions)Years you have smoked? _____ Average cigarettes per day? _____ How many times have you tried to quit? _____Number tobacco pack years? ____________ Hx recent heartburn? yes noHx smoker’s cough/coughing? yes noHx sinus problems? yes noAny specific issues you want addressed at this visit with the group? ___________________________________________________________________ ROS: (at least 2 questions)– Has your activity level been recently limited by breathing issues?– Any chest pain with exercise?– Any problems with insomnia? Past Med Hx: (See chart for details) Meds: (Include ASA qd; see flow sheet)
TOBACCO USE: PROGRESS NOTE (cont)
Objective: – Wt __________ BP __________ BMI ________ RR ________– Peak flow today ___________
Assessment: (Tobacco abuse, 305.1) Other related diagnoses? _____________________
Plan:– Quit date planned– Behavioral options to quit reviewed– Medication options reviewed. Risks, benefits, and side effects discussed and questions answered– Rx ________________________________________– Additional plan _________________________________
Billing: (circle one) 99213 99214
Tobacco Abuse Visit Billing Options 99213, stable patient with tobacco abuse, evaluation
includes a history with 4 questions and ROS with two questions (may or may not include a brief exam), and decision making regarding a complex problem, receiving education, updated information
99214, Tobacco abuse with other complicated medical problems and in addition to the above, you address a treatment plan that entails some risk and benefit regarding the additional problems ◦ Usually a patient requiring a change in therapy with
documentation of a risk benefit discussion related to that therapy change in addition to tobacco cessation, such as a change in blood pressure therapy during this same visit
You are not limited to taking insurance An example, I offer a Ten Years Younger Group Visit Course
◦4-12 group sessions◦Body composition measures taken pre & post◦Initial nutrition evaluation◦Individual fitness evaluation pre & post◦They have the option of weekly trainer sessions
at a gym and get a 8-12 week gym membership◦Price varies from $500-1200 mostly depending
upon amount of trainer time
CASH GROUP VISITS
Group Visit Details
Do not rely upon time Rely upon the complexity of the diagnosis and
your documentation Spend a few moments of individual time with each
patient, briefly review the data collected, their diagnosis, and ensure their individual questions are addressed with the group
Adding extra diagnoses beyond overweight will help for insurance coverage of this visit
Insurance Billing Issues (Key points)
Call coverage, especially inpatient and obstetrical call
Minimize patient “NO SHOWS” with: ◦ Reminder calls 1-2 days prior “Your MD expects you at
this visit!”◦ Advertise guest speakers or cooking demonstrations◦ If the patient’s physician isn’t going to lead the group
visit a physician letter encouraging the session improves attendance
Pitfalls in Offering Group Visits
Mid afternoon for seniors Early evenings for working adults Tuesday, Wednesday, and Thursdays
appear the most popular days Saturday mornings work for some groups
(about 1/3-1/4 of those willing to participate in group visits)
Choose A Time That Suits Your Audience
Exercise topics Weight loss Tobacco cessation Food choices (Adding foods, increase fiber
intake, changing type fat intake, reducing fat intake)
Medications and supplements Lab testing topics Shopping, dining, and cooking skills Understanding lipid levels and targets Stress management
Get Paid to Address Lifestyle Issues During Group Visits
Space? Managed care environment? Staff support? Inertia?
What Would Keep You From Trying This?
Not all clinics are set-up to provide group visits with a lecture hall room
Try using the waiting room, works for smaller groups
Hospitals, community clinics, and religious centers will often provide space for free to a physician and their group to meet
Space
Horse-shoe shape works well Back corners used for nurse evals
◦ Curtain for privacy optional Put handout materials by the entry/exit
door Have a cart with blood pressure cuffs,
charts, materials, extra pens, etc. Consider table for tea, healthy snacks, or
for cooking demos
Room Set-Up
You need an administrative champion◦ Offer to track your success as a pilot for other
clinicians Every group visit tracked to date has
resulted in better satisfaction, lower cost to provide care, and better outcomes
Many managed care companies encourage and promote group visits
Managed Care
Organize your staff in advance Anticipate several people during the first ~ 30
minutes and one person to stay throughout the visit
Teach your staff to encourage group visits
Staff Support
This is a real factor It takes energy to save energy Are you fed up with the status quo yet? How dissatisfied to you need to become to
be willing to make things better?◦ Why not make this better before things get even worse
???
Inertia
Finally, you can get paid to educate your patients during a group visit and: ◦Improve outcomes◦Improve patient satisfaction◦Reduce health care expenses◦Enhance provider satisfaction and
provider compensation
Group Visits Are Effective
The Only Prescription with Unlimited RefillsSPECIAL THANKS TO:
Advisory Board:
Carondelet Health Network - Donna Zazworsky, RN, CCM, FAAN, VP Community Health Continuum
Taz Greiner, Obesity Prevention Program Manager. Carondelet Diabetes Education Institute
Maureen MacDonald, MEd, MSW, LMSW, Carondelet Diabetes Education Coordinator.
Carondelet Medical Group - Michael Connolly, DO, Internal Medicine.
Children’s Medical Center of Tucson - Jessica Schultz, M.D., Pediatrician.
Pima Heart - Charles Katzenberg, M.D., FACC Cardiologist.
Pima County Medical Society - Steve Nash, JD, Executive Director.
University of Arizona Section of Endocrinology, Diabetes and Hypertension- Craig Stump, M.D., PhD, Professor.
University of Arizona Center For Physical Activity and Nutrition - Scott Going, PhD, Professor.
University of Arizona Mel & Enid Zuckerman College of Public Health - Canyon Ranch Center for Prevention and Health Promotion - Cynthia Thomson, PhD, RD, Professor.
Creative Team:
Centrum Medical Communications: Medical Education & Marketing - Laurel Rokowski, RN.
M2Design: Graphic Design - Michael Drabousky.
Dupont Videography: Video Recording & Editing - John Dupont.
Sonora Communications: Computing, Networking, Internet Services Gene Cooper.