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Health Care

INTRODUCTION

Promoting physical activity in health care settings is a promising strategy to improve population health. Health care providers are trusted and effective advocates for promoting physical activity as part of their standard practices (Lobelo Garcia de Quevedo, 2016). The average individual in the United States visits a primary care provider 2.8 times per year (CDC/NCHS, 2012). These visits provide valuable opportunities to assess physical activity levels and advise patients to be physically active.

Despite the well-defined health risks of being physically inactive, rates of health care provider assessment and advice for inactivity are low (Blair, 2009). Only 32.4 percent of American adults report having been advised for physical activity by their health care provider in the past year (Barnes and Schoenborn, 2012). Notably, 41 percent of obese American adults report never having been advised for physical activity by their health care provider (Barnes and Schoenborn, 2012).

Challenges to routine physical activity assessment and counseling in primary care medicine include competing demands and time management. Face-to-face time between a physician and patient averages 7.6 minutes per office visit, during which questions, concerns, management of acute and chronic conditions, and preventive care must be addressed (Nathan et al., 2017). Efforts to make it simple for the physician and other members of the health care team to address physical activity are essential. This includes expanded use of a physical activity vital sign (PAVS), assessment of minutes per week of self-reported physical activity, and integration of objectively

measured physical activity through wearable devices into the electronic health record (EHR) and clinical workflow (Lobelo et al., 2018).

Critical gaps remain in our understanding of physical activity promotion in health care settings, including

• What are the key components of a physical activity prescription?
• How do patients implement a physical activity prescription?
• How does prescribed physical activity have an impact on health outcomes?
• What measures are appropriate for performance and quality, and for insurance coverage determinations?

As a health care quality measure, measurement or surveillance of physical activity assessment and counseling by health care providers is ongoing for care provided to children and adolescents, and older adults. However, it remains a measurement gap for care provided to the largest segment of the U.S. population, those aged 18 to 64 years. It is during these years of life that regular physical activity can have a significant impact on risk of chronic disease. Ongoing surveillance of physical activity assessment and counseling by health care providers, and the resultant physical activity performed by patients, provides a lens to better understand the strength of their association, enhancing future efforts in health care.

STRATEGIES AND ACTIONS FOR IMPLEMENTATION OF PHYSICAL ACTIVITY SURVEILLANCE IN HEALTH CARE

Strategy 7

Background

The PAVS is an important prompt for health care providers to discuss physical activity in the context of a patient’s health and health care. The PAVS has been defined as minutes per week of self-reported moderate to vigorous physical activity (MVPA), and has been integrated into commercially available EHRs (Sallis et al., 2016). Additionally, the PAVS has been found to be a valid measure of MVPA (Ball et al., 2016). The PAVS is collected by a clinical assistant and recorded in the EHR, where it can be interpreted by the physician, who can then provide physical activity advice

and a prescription. Similar to other vital signs (e.g., weight, blood pressure), the PAVS is collected at every visit.

The PAVS has been successfully implemented in several health care systems (Golightly et al., 2017). A study of 2.1 million adult patients from Kaiser Permanente in Southern California demonstrated that within the first year of implementation, the health care system was able to capture a PAVS on 85 percent of eligible patients. As a vital sign, physical activity level can be measured and monitored over time, facilitating more comprehensive and personalized counseling initiatives.

Widespread adoption of the PAVS will require multiple stakeholders to come together, including health care organizations, EHR vendors and information technology professionals, and quality assurance organizations (e.g., National Committee for Quality Assurance [NCQA], National Quality Forum [NQF]).

Findings

There is inconsistency in how physical activity is assessed and documented within EHRs, especially in regard to self-reported physical activity intensity. While a matrixed approach assessing minutes of light, moderate, and vigorous activity is likely a more accurate reflection of energy expenditure, it would take more time to administer at the point of care.

The PAVS is a valid measure of adult aerobic physical activity, and has been successfully implemented in a limited number of settings. There are a lack of standards for documentation of the PAVS in EHRs, and there are no standards for assessment and documentation of muscle-strengthening exercise/activities. Broad implementation will require partnership among key stakeholders.

Supporting Actions for Implementation

The committee recommends the following actions to support this strategy:

Strategy 8

Background

The rapidly increasing prevalence of obesity among children is one of the most challenging dilemmas facing pediatricians. Diet and physical activity play a critical role in energy balance across the lifespan. As children age, their likelihood of achieving recommended levels of physical activity declines (Troiano et al., 2008). A 2008 study found that 42 percent of children 6 to 11 years of age achieved 60 minutes of physical activity per day, dropping to 8 percent among children 12 to 15 years of age, and 7.6 percent among children 16 to 19 years of age (Troiano et al., 2008).

Children see their primary health care provider on a regular basis until adolescence to receive age-appropriate immunizations and assess growth

and development. Visit frequency tends to taper off considerably as children enter adolescence, when they are at even greater risk for developing unhealthy lifestyle habits (Uddin et al., 2011).

The NCQA quality measure, “Weight assessment and counseling for nutrition and physical activity for children/adolescents,” assesses the percentage of commercial insurance members 3 to 17 years of age who had an outpatient visit with primary care practitioner (PCP) or obstetrician/gynecologist and who had evidence of body mass index (BMI) percentile documentation, counseling for nutrition, and counseling for physical activity during the measurement year (NCQA, 2018). Performance on this measure reveals that the percentage of children enrolled in commercial health plans who received physical activity counseling (47.8 to 60.6 percent) lags behind counseling for nutrition (52.9 to 67.1 percent), and BMI percentile assessment (56.6 to 72.5 percent) (NCQA, 2018). Furthermore, data from the National Ambulatory Medical Care Survey (NAMCS) indicate that provider education and counseling for lifestyle behaviors in children and adolescents were implemented at a low level (Hammig and Jozkowski, 2015). This likely reflects a variety of factors that include physician training and self-efficacy for physical activity counseling, clinical workflow and tools to aid in physical activity assessment, and the inherent challenge of asking a child how many minutes of MVPA he or she engaged in over a given time frame.

Few clinical assessment and documentation tools for child physical activity have been developed (Berlin et al., 2006; Joy and Lobelo, 2017). Objective measurement of physical activity in youth is promising, although its integration is not yet a standard in health care (Berlin et al., 2006).

Findings

Physical activity counseling for children and adolescents is an important health care quality measure. Documented rates of physical activity counseling lag behind rates of both nutrition counseling and documentation of BMI percentile. There is a lack of tools and clinical workflow in support of physical activity counseling, as well as inconsistency in how children’s physical activity is assessed and documented within EHRs. While a matrixed approach assessing minutes of aerobic, muscle-strengthening, and bone-strengthening activity is likely a more accurate reflection of energy expenditure, it would take considerably more time to administer at the point of care. Additionally, the ability of a child to accurately self-report physical activity remains a significant question.

Supporting Actions for Implementation

The committee recommends the following actions to support this strategy:

Strategy 9

Background

Wearable physical activity devices present health care organizations with an opportunity to engage and monitor an increasing number of patients who would benefit from personalized advice regarding physical activity in the context of their health. This is especially true for patients with chronic health conditions such as diabetes for which physical activity can have a significant impact on health outcomes (USPSTF, 2016). Other at-risk populations (e.g., aging adults, post-operative patients) could also benefit from surveillance of physical activity levels in an effort to improve health and reduce injury and disease; reduction in the higher health care costs associated with these conditions might be realized as well. Studies have demonstrated acceptance of wearable physical activity devices in at-risk populations (e.g., older adults, adults with chronic illness) (Mercer et al., 2016; Lyons et al., 2017), as well as improvement in physical activity levels when combined with counseling (Lyons et al., 2017).

While wearable physical activity devices have been found to be acceptable, valid, and reliable measures of physical activity (especially number of steps taken), notable differences among devices make direct comparisons of data challenging (Case et al., 2015; Kooiman et al., 2015). Integration of wearable physical activity devices into health care, and specifically clinical workflow, is in its infancy. Key to its successful integration is understanding data reduction, analysis, and integration into both the EHR and into clinical workflow.

Additional challenges to integrating data from wearable physical activity devices into health care include device cost and resultant disparities in access to the devices, as well as privacy and security concerns about the data collected and their potential integration into EHRs. Finally, wearable physical activity devices typically do not report physical activity in such a way to assess patient compliance with Physical Activity Guidelines for Americans (i.e., minutes per week of moderate to vigorous physical activity) (Knight et al., 2015).

The U.S. Food and Drug Administration (FDA) considers wearable physical activity devices to be “general wellness product,” and not “regulated medical devices”; as such, these devices are not subject to FDA approval (FDA, 2016).

Findings

Wearable physical activity devices are promising tools to assess patient physical activity levels, and data from these devices have already been integrated into EHRs and health care delivery (Munro, 2014; Pennic, 2015). The benefits of collecting and analyzing data from wearable physical activity devices may be most apparent in populations for which achievement of recommended physical activity has a significant impact on health and cost outcomes, such as patients at risk for cardiovascular disease and patients at risk for falls (USPSTF, 2016). To achieve the potential of these devices to improve both health care delivery and patient health outcomes, it will be important to determine how to integrate actionable wearable data into the EHR, and to develop clinical best practices (e.g., clinical workflow, data management, and reporting) for the use of such data. Integrated wearable devices data must be structured data amenable to clinical decision support tools within the EHR, consistent with public health guidelines (e.g., minutes of physical activity in contrast to number of steps), and broadly understandable and translatable to diverse members of the health care team and to patients themselves.

Supporting Actions for Implementation

The committee recommends the following actions to support this strategy:

Strategy 10

Background

Cardiorespiratory fitness and muscular strength are independent, but additive measures of health and longevity (HHS, 2008). Among older adults, grip strength is a better predictor of premature mortality—independent of age, nutritional status, number of prescribed drugs, number of chronic diseases, and level of physical activity—than blood pressure (Leong et al., 2015; Arvandi et al., 2016). Grip strength has been linked to longevity in several prospective studies (Rantanen et al., 2012; Leong et al., 2015; Syddall et al., 2017). Grip strength is assessed using a handheld dynamometer, taking only minutes to perform; and there are reference values for grip strength for adults of all ages (Perna et al., 2016). Given the small percentage of 18- to 80-year-old adults (~30 percent) and 65- to 74-year-old adults (~24 percent) in the United States who engage in regular strength training, grip strength testing could be a useful “nudge” to encourage older adults to engage in health-promoting muscle strength training (Bennie et al., 2018).

Cardiorespiratory fitness is tested through mechanisms including graded exercise stress tests, step tests, and walking tests (Guazzi et al., 2012; Lobelo et al., 2018; Whitsel et al., 2019). The 6-minute walk test (6MWT) measures the distance that a patient can quickly walk on a flat, hard surface in a period of 6 minutes. The 6MWT has been found to be highly predictive of cardiorespiratory fitness (Sperandio, 2016).

Emerging research has demonstrated that grip strength and the 6MWT combined are highly predictive of frailty, and can be successfully implemented in primary care settings (Lee et al., 2017). Recognition of frailty is important because there is evidence that the degree of frailty can be improved with interventions including high-intensity exercise training (Lee et al., 2017).

Findings

Fitness assessment in older adults is highly predictive of premature mortality. Limited studies have demonstrated the utility of such testing in

ambulatory care settings. The growth in the population older than age 65, combined with higher rates of obesity and lower rates of physical activity, make fitness assessment an even higher priority in the pursuit to lower chronic disease prevalence, high-cost health care utilization, and associated costs.

Supporting Actions for Implementation

The committee recommends the following actions to support this strategy:

Strategy 11

Background

National health care delivery surveys provide data on the proportion of patients or patient visits where counseling for exercise is provided. The NAMCS is designed to provide objective, reliable information about ambulatory medical care services in the United States, and it is administered annually to a national sample of outpatient providers who are asked to provide information regarding patients seen over a 1-week reporting period (CDC/NCHS, 2012). The survey does not ask about patient self-reported physical activity levels, but it does ask if the physician provided health education or counseling for exercise (CDC, 2018). The Medicare Health Outcomes Survey (HOS) is administered to a random sample of Medicare Advantage members and asks if members were asked about their physical activity level, and if so, were they counseled to start, increase, or maintain their physical activity level (CMS, 2018). Finally, the National Health Interview Survey (NHIS) has been used by the National Center for Health Statistics (NCHS) to assess trends in adults and children receiving advice from a health care provider regarding physical activity (Barnes and Schoenborn, 2012). However, the redesigned NHIS for 2019 does not include specific questions addressing physician assessment, advice, or prescription of physical activity or exercise.

Findings

Surveys such as the NAMCS and the Medicare HOS can provide valuable information regarding counseling for physical activity/exercise in health care settings, which in turn can be used to identify gaps in care and opportunities for health care improvement. Current data collected by the NAMCS on health education/counseling for exercise is both insufficient and inconsistent with the Physical Activity Guidelines for Americans. Changes to the NHIS have eliminated specific questions regarding physician assessment, advice, and counseling for physical activity. Understanding health

care delivery practices and trends for the promotion of physical activity in youth and adults could inform interventions and partnerships aimed at improving physical activity counseling in clinical settings.

Supporting Actions for Implementation

The committee recommends the following actions to support this strategy:

Strategy 12

Background

A strong predictor of lifestyle counseling is a health care provider’s personal engagement in health promotion activities. Medical students and practicing physicians who are more physically active are also more likely to counsel their patients regarding physical activity (Oberg and Frank, 2009). Rates of health promotion counseling among physicians can be increased through provider-centered health promotion. In a 4-year controlled trial that addressed lifestyle behaviors over the course of medical school, medical students made improvements in their personal health practices, and their self-reported counseling on those topics improved as well (Oberg and Frank, 2009).

Other health professionals also play an important role in promoting physical activity with patients. A study of physical therapists and physical therapy students found that physical therapy professionals should be role models for healthy lifestyle behaviors such as physical activity (Black et al., 2012). Similar to observations among physicians and medical students, nurses who regularly exercise are more likely to encourage physical activ-

ity as a treatment for patients (McDowell et al., 1997). Given that nurses represent the largest health care workforce, with more than 3 million registered nurses in the United States, further engagement of nurses in regular physical activity, and in turn, physical activity promotion is a key strategy to improving physical activity levels in patients (HHS and HRSA, 2010). Given the trend toward team-based health care delivery, it is important that all members of the health care team engage in health-promoting physical activity and promote physical activity with patients.

Health care professional organizations regularly survey their members to better understand professionals’ experiences and challenges in the current health care environment, and the results are used to inform the development of programs that support providers in professional practice. Likewise, medical education organizations regularly survey learners regarding their educational experiences, and results are used to inform the development of programs that support learners in professional development. However, systematic assessment of U.S. medical students, physicians, nurses, and other health care professionals regarding personal physical activity habits is nonexistent. Research has indicated that physical activity levels decline throughout medical school, and even more so into residency training (Stanford et al., 2014). A study of internal medicine residents found that higher levels of personal physical activity translated into greater physical activity counseling self-efficacy (Rogers et al., 2006).

Physical activity assessment and promotion by health care professionals is also enhanced by educational interventions at all levels of training. A survey of U.S. medical schools found that 78.4 percent reported having physical activity training in their curriculum; however an average of only 8 hours of training over 4 years was offered (Stoutenberg et al., 2015). A systematic review of physical activity counseling in medical school education found evidence that educational programs positively impact students’ attitudes toward physical activity, improve their physical activity counseling knowledge and skills, and their self-efficacy to conduct physical activity counseling (Dacey et al., 2014). An examination of physical activity counseling training programs in family medicine residency training found improvements in knowledge, but inconsistent improvements in self-efficacy to perform physical activity counseling (Wattanapisit et al., 2018).

Findings

Personal physician physical activity behaviors are highly predictive of physician counseling behaviors; and similar findings are observed among nurses, nurse practitioners, and physical therapists. Educational programs likewise are key to advancing knowledge, attitudes, self-efficacy, and physical activity counseling skills. Efforts to improve the personal physical

activity habits of physicians also translate into improved physical activity counseling behaviors. Given the evidence that a physically active workforce is more likely to promote physical activity with patients, both the activity levels of health care providers and the interventions aimed at promoting physical activity among health care providers and their patients should be regularly assessed and reported to ensure ongoing efforts to promote a physically active lifestyle.

Supporting Actions for Implementation

The committee recommends the following actions to support this strategy:

CONCLUSION

Health care settings should be a natural environment for promoting physical activity. As trusted and effective health advocates, health care providers are uniquely positioned to assess and advise patients regarding physical activity behaviors. Furthermore, patients may be particularly motivated to adopt or increase physical activity behaviors to help manage a health condition and/or to prevent adverse health outcomes for which they may be at risk. The 6 strategies and 16 implementation actions recommended in this chapter can help improve the low rates of health care provider physical activity assessment and advice by providing relatively simple solutions that are integrated with existing EHRs and clinical workflows.

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