Practical Strategies for Assessing Patient Physical Activity Levels in Primary Care

Physical inactivity in the United States is a highly prevalent and pressing public health concern that is associated with increased risk of mortality, a broad range of chronic diseases, and substantial economic burden. Given the growing levels of physical inactivity seen in our society, its impact on adverse health outcomes, and its economic and societal cost, it is important that evidence-based approaches be implemented to increase physical activity (PA) among the US population. One such strategy may be to promote the adoption of large-scale routine PA assessment as a first step toward more comprehensive PA counseling during the primary care visit. Physical inactivity is an important public health problem that accounts for nearly 334,000 deaths annually in the United States.1Lee I. Shiroma E.J. Lobelo F. Puska P. Blair S.N. Katzmarzyk P.T. 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Inadequate physical activity and health care expenditures in the United States.Prog Cardiovasc Dis. 2015; 57: 315-323Crossref PubMed Scopus (251) Google Scholar Extensive evidence indicates that increased levels of cardiorespiratory fitness, achieved through consistent exercise, significantly reduce risk for overall mortality10Ross R. Blair S.N. Arena R. et al.American Heart Association Physical Activity Committee of the Council on Lifestyle and Cardiometabolic Health; Council on Clinical Cardiology; Council on Epidemiology and Prevention; Council on Cardiovascular and Stroke Nursing; Council on Functional Genomics and Translational Biology; and Stroke CouncilImportance of assessing cardiorespiratory fitness in clinical practice: a case for fitness as a clinical vital sign: a scientific statement from the American Heart Association.Circulation. 2016; 134: e653-e699Crossref PubMed Scopus (1112) Google Scholar and that fitness-associated biological age prognosticates risk beyond chronological age.11Blaha M.J. Hung R.K. Dardari Z. et al.Age-dependent prognostic value of exercise capacity and derivation of fitness-associated biologic age.Heart. 2016; 102: 431-437Crossref PubMed Scopus (27) Google Scholar In light of this abundance of information, PA should be considered a critical addition to the traditional vital signs used to determine patient risk.12Sallis R.E. Baggish A.L. Franklin B.A. Whitehead J.R. The call for a physical activity vital sign in clinical practice.Am J Med. 2016; 129: 903-905Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Given these adverse health outcomes and economic and societal costs, implementation of user-friendly, evidence-based approaches to increase PA at the population level is important. One strategy is to emphasize PA assessment as part of routine comprehensive counseling. However, feasible, acceptable, and sustainable methods to assess PA in clinical practice are currently not well described. We present pragmatic, validated strategies for assessing PA, based on observational and clinical research, that can be adopted by primary care physicians and their health care teams for use in routine clinical practice. Supporting the growing number of calls to incorporate PA assessment into primary care,13Khan K.M. Weiler R. Blair S.N. Prescribing exercise in primary care.BMJ. 2011; 343: d4141Crossref PubMed Scopus (60) Google Scholar, 14Berra K. Rippe J. Manson J.E. Making physical activity counseling a priority in clinical practice: the time for action is now.JAMA. 2015; 314: 2617-2618Crossref PubMed Scopus (99) Google Scholar, 15Kraus W.E. Bittner V. 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National Academies Press, Washington, DC2001Google Scholar The Robert Wood Johnson Foundation Commission to Build a Healthier America recently emphasized that the mindset, mission and incentives for health care institutions must be broadened beyond treating illness to helping people live healthy lives.17Robert Wood Johnson Foundation (RWJF) Commission to Build a Healthier AmericaTime to Act: Investing in the Health of Our Children and Communities. RWJF, Princeton, NJ2014Google Scholar At the core of these changes is the "triple aim" of health care—to improve the individual experience of care, improve the health of populations, and reduce the cost of care.18Berwick D.M. Nolan T.W. Whittington J. The triple aim: care, health, and cost.Health Aff (Millwood). 2008; 27: 759-769Crossref PubMed Scopus (3392) Google Scholar Coordination of care across populations has the potential to enhance disease prevention efforts and advance broader, population-wide health efforts.19Washington A.E. Coye M.J. Boulware L.E. Academic health systems' third curve: population health improvement.JAMA. 2016; 315: 459-460Crossref PubMed Scopus (34) Google Scholar Systematic PA assessment can be a cornerstone of these efforts by being integrated as a standardized tool into electronic medical records (EMRs) across practices, identifying physically inactive individuals as an at-risk population. Table 1 provides an example of how PA assessment may be incorporated within population health management strategies.Table 1An Example of Physical Activity Assessment as Part of a Population Health Management Strategy Within an Accountable Care Organization1. An urban accountable care organization serving a large segment of a city implements the physical activity vital sign assessment to identify at-risk patients (ie, those who are physically inactive)2. The assessment of physical activity levels in the clinical setting leads to increased discussions about maintaining a healthy lifestyle among the patient, physician, and other members of the health care team3. These discussions lead to more patients receiving advice to become physically active and a semicustomized exercise prescription based on their needs and limitations4. The accountable care organization develops a referral network consisting of physical activity or lifestyle modification programs, which are supported and certified by the local health department and/or health foundation to ensure quality control5. After receiving their semicustomized exercise prescription, patients receive a referral to these programs before leaving the physician's office Open table in a new tab The movement toward incorporating PA counseling as a population health management tool in primary care was first realized in 2005 when the Healthcare Effectiveness Data and Information Set (HEDIS) adopted 2 measures of PA assessment to be used with Medicare beneficiaries.20NCQA adds four new measures to HEDIS 2005.Qual Lett Healthc Lead. 2004; 16: 12-13Google Scholar Per HEDIS objectives, health care professionals were assessed on whether they (1) spoke to their patients about their level of exercise or PA and (2) provided advice on starting or maintaining their exercise programs. However, since its inception in 2004,20NCQA adds four new measures to HEDIS 2005.Qual Lett Healthc Lead. 2004; 16: 12-13Google Scholar national adherence to these 2 measures has hovered around 50%.21National Committee for Quality AssurancePhysical activity in older adults.http://www.ncqa.org/report-cards/health-plans/state-of-health-care-quality/2016-table-of-contents/physical-activity-in-older-adultsGoogle Scholar Pay-for-performance models may work as a similar strategy by providing financial incentives to health care systems and teams for widespread use of PA assessment.22Robert Wood Johnson FoundationHealth Policy Brief: Pay-for-performance.Health Aff. October 11, 2012; (http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_78.pdf. Accessed May 23, 2017.)Google Scholar Per the Quality Bonus Payment Demonstration initiative, data are collected on 48 performance measures, and a quality rating score is given to Medicare Advantage Organizations that determines whether they receive bonus payments and/or rebates for their enrollees.23American Action Forum. Primer: the Medicare advantage star rating system. https://www.americanactionforum.org/research/primer-the-medicare-advantage-star-rating-system/. Published June 2, 2015. Accessed April 15, 2017.Google Scholar One of these measures is delivery of preventive health care involving "monitoring of physical activity."24Jung D.H. Palta M. Smith M. Oliver T.R. DuGoff E.H. Differences in receipt of three preventive health care services by race/ethnicity in Medicare advantage plans: tracking the impact of pay for performance, 2010 and 2013.Prev Chronic Dis. 2016; 13: E125Crossref PubMed Scopus (2) Google Scholar In all these cases, systematic PA assessment increases the number of conversations between patients and health care professionals that include PA and leads to greater adherence to HEDIS objectives and related measures. The broadening of health care toward a patient-centered, population health perspective has been further accelerated by the recent transformation to alternative payment models, such as bundled payment systems and accountable care organizations (ACOs).25Kocher R. Chigurupati A. The coming battle over shared savings—primary care physicians versus specialists.N Engl J Med. 2016; 375: 104-106Crossref PubMed Scopus (13) Google Scholar The ACOs, which increasingly are promoting population-level approaches to care, have moved toward a value-based payment structure, often within a global or capitated model with fixed payments on a per-patient basis for a defined population of individuals. This approach has led to an emphasis on new strategies to reduce the total cost of care, improve quality, and increase population health management. The greatest source of savings often comes from medical conditions for which costs can be modified through behavior change, such as type 2 diabetes and cardiovascular disease.25Kocher R. Chigurupati A. The coming battle over shared savings—primary care physicians versus specialists.N Engl J Med. 2016; 375: 104-106Crossref PubMed Scopus (13) Google Scholar Thus, assessing PA levels will provide ACOs with valuable data for identifying an at-risk population (ie, physically inactive individuals). Then, as a recognized health indicator, PA level can be monitored and tracked, and population health measures can be implemented.26Hacker K. Walker D.K. Achieving population health in accountable care organizations.Am J Public Health. 2013; 103: 1163-1167Crossref PubMed Scopus (85) Google Scholar Primary care physicians and their teams are commonly being incentivized to reduce the total cost of care for these populations, reflecting yet another opportunity for PA assessment to be emphasized as a vital sign, catalyzing further PA counseling, and enhancing the broader preventive role of primary care physicians. At Intermountain Healthcare in Utah, the proportion of adult patient visits at which PA levels are assessed and PA advice is provided more than doubles in clinics where physicians receive incentive payment for improving clinical quality (in this case for PA assessment and promotion) under a value recognition program (personal communication, Liz Joy, MD, Medical Director, December 2016). A recent article by Olmstead27Olmstead J. Counseling adults on physical activity: how to capture your work?.J Nurse Practition. 2017; 13: 79-81Abstract Full Text Full Text PDF Google Scholar provides further guidance on how PA assessment and counseling can be included under the current International Classification of Diseases, Tenth Revision billing codes. Another US health care delivery model that has become more ubiquitous is the patient-centered medical home (PCMH), which emphasizes a team-based approach to improving patient access, quality of care, and disease prevention. The PCMH uses a "whole-person" orientation to offer comprehensive primary care, including preventive services.28American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of the patient-centered medical home. http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf. Published March 2007. Accessed January 12, 2017.Google Scholar By accepting financial risk for the health of large populations of patients, PCMHs must seek out new collaborations and innovative strategies for delivering services that can reduce preventable illness.19Washington A.E. Coye M.J. Boulware L.E. Academic health systems' third curve: population health improvement.JAMA. 2016; 315: 459-460Crossref PubMed Scopus (34) Google Scholar New models of diabetes care,29McGinley E.L. Gabbay R.A. The impact of new payment models on quality of diabetes care and outcomes.Curr Diab Rep. 2016; 16: 51Crossref PubMed Scopus (9) Google Scholar of breast, cervical, and colorectal cancer screening,30Markovitz A.R. Alexander J.A. Lantz P.M. Paustian M.L. Patient-centered medical home implementation and use of preventive services: the role of practice socioeconomic context.JAMA Intern Med. 2015; 175: 598-606Crossref PubMed Scopus (36) Google Scholar, 31Green B.B. Anderson M.L. Chubak J. et al.Colorectal cancer screening rates increased after exposure to the patient-centered medical home (PCMH).J Am Board Fam Med. 2016; 29: 191-200Crossref PubMed Scopus (18) Google Scholar and of youth/adolescent preventive services32Garcia-Huidobro D. Shippee N. Joseph-DiCaprio J. O'Brien J.M. Svetaz M.V. Effect of patient-centered medical home on preventive services for adolescents and young adults.Pediatrics. 2016; 137https://doi.org/10.1542/peds.2015-3813Crossref PubMed Scopus (17) Google Scholar have all been successfully tested and incorporated into PCMHs. The systematic integration of routine PA assessment, using validated processes (discussed in the following section), into the health system technology and clinical workflow of a PCMH, accelerates the downstream promotion of PA counseling as part of a comprehensive disease prevention and/or treatment strategy. To further this process, many PCMHs have contracted with in-house wellness professionals to provide PA and nutrition counseling and with patient navigators to engage patients in culturally tailored interventions and monthly counseling sessions. Navigators oversee other PA-related approaches, such as encouraging weekly patient self-monitoring and providing gymnasium memberships. Given the expanding reach of primary care networks in the United States, a window of opportunity is open for regular PA assessment as part of a comprehensive counseling effort that can be systematically integrated into routine primary care practice.33Jacobson D.M. Strohecker L. Compton M.T. Katz D.L. Physical activity counseling in the adult primary care setting: position statement of the American College of Preventive Medicine.Am J Prev Med. 2005; 29: 158-162Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar Primary care physicians are particularly well positioned to address physical inactivity because they have the most frequent patient contact among health care professionals, comprising nearly half of patient ambulatory medical care visits annually.34Ambulatory and Hospital Care Statistics Branch. National ambulatory medical care survey: 2012 state and national summary tables. http://www.cdc.gov/nchs/data/ahcd/namcs_summary/2012_namcs_web_tables.pdf. Accessed July 12, 2016.Google Scholar Further, physicians and other health care professionals have been identified by patients as a preferred source of initial PA counseling.35Patrick K. Pratt M. Sallis R.E. The healthcare sector's role in the U.S. national physical activity plan.J Phys Act Health. 2009; 6: S211-S219Crossref PubMed Scopus (48) Google Scholar, 36Vuori C.J. Blair S.N. Physical activity promotion in the health care 2013; Full Text Full Text PDF PubMed Scopus Google Scholar A substantial proportion of these patients can most from PA counseling, including those with cardiorespiratory fitness S. K. S. et fitness as a of and cardiovascular in healthy men and a 2009; PubMed Scopus Google Scholar and those with a greater M. K. Martin B.W. Health promotion in primary of a systematic and for physical activity 2009; Google Scholar, S. M. An perspective on physical activity by medical Fam 2012; 13: PubMed Scopus Google Scholar, M. 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Physical activity assessment in practice: a methods of use in primary Fam PubMed Scopus Google Scholar to widespread adoption of PA assessment as a to more comprehensive counseling must be and to use with Further, given the time that physicians with patients, the must be in and of using the PA assessment One and assessment currently used in routine practice is the vital as part of the health care system. The was for use and such that a medical or any other may assess PA, their into the as part of routine patient and health care professionals to a need for further counseling or as with traditional vital R. healthcare systems to exercise as the vital J Med. 2011; PubMed Scopus (115) Google Scholar The is by patient to 2 (1) how many engage in to exercise a and (2) how many engage in exercise at this these a the number of of to exercise, which can be national