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