INVITED COMMENTARY
Exercise Prescription: Who Is the Pharm D? Elizabeth A. Joy, MD, MPH
When I prescribe a statin for a patient with hyperlipidemia, most likely, he or she will fill the prescription at a local pharmacy and the medication will be dispensed with instructions from a Doctor of Pharmacy (Pharm D) V this is for a pill that takes seconds to take, either during the day or night, with or without food. Yet when a patient leaves the office with an exercise prescription, where will she fill it? Likewise when we prescribe a new medication, we counsel the patient on potential side effects, risk factors, interactions, and perhaps even cost. Think back to your last exercise prescription V did you spend as much time outlining potential risks and benefits as you do when prescribing a medication to treat hyperlipidemia, hypertension, or depression? This brings me back to the question raised in the title V for the exercise prescription, who is the Pharm D? Until recently, there was very little (if any) coverage from thirdparty payers for care related to the exercise prescription. Some patients may get an exercise prescription from a physical therapist, some may get them as part of a cardiac rehabilitation program, and others may have received exercise counseling from a dietitian or diabetic educator as part of nutrition education. The Affordable Care Act now mandates expanded coverage for medical nutrition therapy for those with commercial insurance and intensive lifestyle intervention in primary care for Medicare patients with obesity. However even with these changes, when the patient leaves the office, where will he or she ‘‘fill the prescription’’? The medication analogy can be taken only so far. Exercise is a much more complex behavior. That said, despite the relative ease of taking a pill, only 50% of patients still are taking their statin 6 months later (2). Going back to exercise, would not it be great if our patients could fill their prescription at a local gymnasium or recreation center or if they could meet with a personal trainer or clinical exercise physiologist? Is it even possible? Yes, it isI in New Zealand! The Kiwi are leaders in the development of the ‘‘Green Prescription (GRx),’’ which is a health professional’s Clinical Outcomes Research, Intermountain Healthcare, Salt Lake City, UT Address for correspondence: Elizabeth A. Joy, MD, MPH, Clinical Outcomes Research, Intermountain Healthcare, 36 S. State St., Salt Lake City, UT 84111; E-mail: [email protected]. 1537-890X/1304/207Y208 Current Sports Medicine Reports Copyright * 2014 by the American College of Sports Medicine www.acsm-csmr.org
written advice to a patient to be physically active. Most referrals for a GRx are for patients with chronic disease and long-term conditions such as cardiovascular disease and diabetes. The GRx encourages patients to manage their own conditions by increasing physical activity and improving nutrition. From the New Zealand Ministry of Health Web site, the following outlines the various steps in the GRx (6):
1. The health professional (primary care provider) issues their patient a GRx, provided that the patient’s medical condition is stable. 2. The script either is written or is issued electronically. If the patient wants ongoing support, the script is forwarded through to the nearest GRx patient support person. 3. The patient support person encourages the patient to become more active through the following:
& monthly telephone calls for 3 to 4 months, & face-to-face meetings for 3 to 4 months, or & group support in a community setting for
3 to
6 months.
4. The patient’s progress on their path to an active lifestyle is reported back to the referring health professional. 5. If the patient feels that they would benefit from ongoing support, they are encouraged to ask their health professional for another GRx (6). In this model, the patient support person is someone with a background in health, fitness, and/or nutrition. A recent survey of New Zealanders who received a GRx found that 80% of patients say their support person motivated them to become or stay physically active (5). The GRx has been available for adults since 1998 and to families since 2004. The GRx has been found to be effective in helping patients achieve 150 minIwkj1 of moderate-intensity exercise (9). So what will it take for us (U.S. health care) to implement something like the GRx? A number of initiatives by both professional organizations (Exercise is MedicineA (EIMA) (4)) and health care organizations (Kaiser Permanente (3) and Intermountain Healthcare (7)) are a good start. Kaiser’s Exercise Vital Sign and Intermountain’s Physical Activity Vital Sign have been integrated into the electronic health record as a tool to help primary care providers and their care teams systematically assess physical activity levels at medical office visits. EIMA has taken it one step further, Current Sports Medicine Reports
Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
207
developing an entire ‘‘solution’’ for the patient who is inactive or insufficiently active. It allows the primary care provider to refer the patient to an EIMA-certified health and fitness professional. In this setting, the referral and subsequent care by the fitness professional may or may not be covered by third-party reimbursement. Different payment approaches are currently in development and testing by EIMA and appear promising. Given the concerns regarding the unsustainable increase in health care costs in the United States, health care systems are loath to adding additional expense to the system. Efforts aimed at encouraging everyone to ‘‘work at the top of their license’’ as an ‘‘interdisciplinary health care team’’ are rampant, along with efforts to leverage existing resources. Examples of this include expansion of the role of physical therapists and dietitians in physical activity counseling. The EIMA Registered Dietitian Toolkit (8) is a fantastic resource aimed at providing dietitians with information and tools to promote exercise effectively among their patients. Nurses are an often-overlooked provider in this effort to promote physical activity. When one considers that nurses constitute the largest work force in health care, it seems like a missed opportunity to not engage them actively in efforts to promote physical activity (1). To engage this group of professionals, changes in their educational curriculum and continuing education would have to take place. Until we have insurance coverage for health and fitness professionals, providers and patients will need to up their own game when it comes to prescribing exercise to patients. A physical activity vital sign followed by, at a minimum, a walking prescription is a great start. Knowing the regulations and expanded coverage for lifestyle and preventive care in the Affordable Care Act (10) and how these services are available within your community are also important.
208
Volume 13 & Number 4 & July/August 2014
So in this scenario, we ALL are the Pharm D. We need to remind our patients that exercise is medicine, that sitting is the new smoking, walking (not the dog!) is man’s best friend, and the risk of doing nothing far exceeds any risk from a brisk walk. The author declares no conflicts of interest and does not have any financial disclosures.
References 1. American Association of Colleges of Nursing. Nursing Fact Sheet. Available from: https://www.aacn.nche.edu/media-relations/fact-sheets/nursing-fact-sheet. Accessed 7 February 2014. 2. Brown MT, Bussell JK. Medication adherence: WHO cares? Mayo Clin. Proc. 2011; 86:304Y14. 3. Coleman KJ, Ngor E, Reynolds K, et al. Initial validation of an exercise ‘‘vital sign’’ in electronic medical records. Med. Sci. Sports Exerc. 2012; 44:2071Y6. 4. Exercise is MedicineA. Available from: http://www.exerciseismedicine.org. Accessed 3 February 2014 5. Green Prescription Patient Survey 2013 Report. Research New Zealand. July 2013. Available from http://www.health.govt.nz/system/files/documents/ pages/green-prescription-patient-survey.pdf. Accessed 3 February 2014. 6. How the Green Prescription Works. Available from: http://www.health. govt.nz/our-work/preventative-health-wellness/physical-activity/greenprescriptions/how-green-prescription-works. Accessed 3 February 2014. 7. Joy E. Time for a new ‘vital sign’. Providers should monitor patients’ physical activity in battle against obesity. Mod. Healthc. 2013; 43:29. 8. Schwartz J, Carpenter RA, Manore MM, Kruskall L. A physical activity toolkit for registered dietitians: utilizing resources of Exercise is MedicineA. Available from http://www.eatright.org/HealthProfessionals/content.aspx?id= 6442478841. Accessed 3 February 2014. 9. Swinburn BA, Walter LG, Arroll B, et al. The green prescription study: a randomized controlled trial of written exercise advice provided by general practitioners. Am. J. Public Health. 1998; 88:288Y91. 10. What are my preventive care benefits? Available from: https://www.healthcare.gov/ what-are-my-preventive-care-benefits/. Accessed 7 February 2014.
Invited Commentary
Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Exercise Prescription: Who Is the Pharm D? Elizabeth A. Joy, MD, MPH
When I prescribe a statin for a patient with hyperlipidemia, most likely, he or she will fill the prescription at a local pharmacy and the medication will be dispensed with instructions from a Doctor of Pharmacy (Pharm D) V this is for a pill that takes seconds to take, either during the day or night, with or without food. Yet when a patient leaves the office with an exercise prescription, where will she fill it? Likewise when we prescribe a new medication, we counsel the patient on potential side effects, risk factors, interactions, and perhaps even cost. Think back to your last exercise prescription V did you spend as much time outlining potential risks and benefits as you do when prescribing a medication to treat hyperlipidemia, hypertension, or depression? This brings me back to the question raised in the title V for the exercise prescription, who is the Pharm D? Until recently, there was very little (if any) coverage from thirdparty payers for care related to the exercise prescription. Some patients may get an exercise prescription from a physical therapist, some may get them as part of a cardiac rehabilitation program, and others may have received exercise counseling from a dietitian or diabetic educator as part of nutrition education. The Affordable Care Act now mandates expanded coverage for medical nutrition therapy for those with commercial insurance and intensive lifestyle intervention in primary care for Medicare patients with obesity. However even with these changes, when the patient leaves the office, where will he or she ‘‘fill the prescription’’? The medication analogy can be taken only so far. Exercise is a much more complex behavior. That said, despite the relative ease of taking a pill, only 50% of patients still are taking their statin 6 months later (2). Going back to exercise, would not it be great if our patients could fill their prescription at a local gymnasium or recreation center or if they could meet with a personal trainer or clinical exercise physiologist? Is it even possible? Yes, it isI in New Zealand! The Kiwi are leaders in the development of the ‘‘Green Prescription (GRx),’’ which is a health professional’s Clinical Outcomes Research, Intermountain Healthcare, Salt Lake City, UT Address for correspondence: Elizabeth A. Joy, MD, MPH, Clinical Outcomes Research, Intermountain Healthcare, 36 S. State St., Salt Lake City, UT 84111; E-mail: [email protected]. 1537-890X/1304/207Y208 Current Sports Medicine Reports Copyright * 2014 by the American College of Sports Medicine www.acsm-csmr.org
written advice to a patient to be physically active. Most referrals for a GRx are for patients with chronic disease and long-term conditions such as cardiovascular disease and diabetes. The GRx encourages patients to manage their own conditions by increasing physical activity and improving nutrition. From the New Zealand Ministry of Health Web site, the following outlines the various steps in the GRx (6):
1. The health professional (primary care provider) issues their patient a GRx, provided that the patient’s medical condition is stable. 2. The script either is written or is issued electronically. If the patient wants ongoing support, the script is forwarded through to the nearest GRx patient support person. 3. The patient support person encourages the patient to become more active through the following:
& monthly telephone calls for 3 to 4 months, & face-to-face meetings for 3 to 4 months, or & group support in a community setting for
3 to
6 months.
4. The patient’s progress on their path to an active lifestyle is reported back to the referring health professional. 5. If the patient feels that they would benefit from ongoing support, they are encouraged to ask their health professional for another GRx (6). In this model, the patient support person is someone with a background in health, fitness, and/or nutrition. A recent survey of New Zealanders who received a GRx found that 80% of patients say their support person motivated them to become or stay physically active (5). The GRx has been available for adults since 1998 and to families since 2004. The GRx has been found to be effective in helping patients achieve 150 minIwkj1 of moderate-intensity exercise (9). So what will it take for us (U.S. health care) to implement something like the GRx? A number of initiatives by both professional organizations (Exercise is MedicineA (EIMA) (4)) and health care organizations (Kaiser Permanente (3) and Intermountain Healthcare (7)) are a good start. Kaiser’s Exercise Vital Sign and Intermountain’s Physical Activity Vital Sign have been integrated into the electronic health record as a tool to help primary care providers and their care teams systematically assess physical activity levels at medical office visits. EIMA has taken it one step further, Current Sports Medicine Reports
Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
207
developing an entire ‘‘solution’’ for the patient who is inactive or insufficiently active. It allows the primary care provider to refer the patient to an EIMA-certified health and fitness professional. In this setting, the referral and subsequent care by the fitness professional may or may not be covered by third-party reimbursement. Different payment approaches are currently in development and testing by EIMA and appear promising. Given the concerns regarding the unsustainable increase in health care costs in the United States, health care systems are loath to adding additional expense to the system. Efforts aimed at encouraging everyone to ‘‘work at the top of their license’’ as an ‘‘interdisciplinary health care team’’ are rampant, along with efforts to leverage existing resources. Examples of this include expansion of the role of physical therapists and dietitians in physical activity counseling. The EIMA Registered Dietitian Toolkit (8) is a fantastic resource aimed at providing dietitians with information and tools to promote exercise effectively among their patients. Nurses are an often-overlooked provider in this effort to promote physical activity. When one considers that nurses constitute the largest work force in health care, it seems like a missed opportunity to not engage them actively in efforts to promote physical activity (1). To engage this group of professionals, changes in their educational curriculum and continuing education would have to take place. Until we have insurance coverage for health and fitness professionals, providers and patients will need to up their own game when it comes to prescribing exercise to patients. A physical activity vital sign followed by, at a minimum, a walking prescription is a great start. Knowing the regulations and expanded coverage for lifestyle and preventive care in the Affordable Care Act (10) and how these services are available within your community are also important.
208
Volume 13 & Number 4 & July/August 2014
So in this scenario, we ALL are the Pharm D. We need to remind our patients that exercise is medicine, that sitting is the new smoking, walking (not the dog!) is man’s best friend, and the risk of doing nothing far exceeds any risk from a brisk walk. The author declares no conflicts of interest and does not have any financial disclosures.
References 1. American Association of Colleges of Nursing. Nursing Fact Sheet. Available from: https://www.aacn.nche.edu/media-relations/fact-sheets/nursing-fact-sheet. Accessed 7 February 2014. 2. Brown MT, Bussell JK. Medication adherence: WHO cares? Mayo Clin. Proc. 2011; 86:304Y14. 3. Coleman KJ, Ngor E, Reynolds K, et al. Initial validation of an exercise ‘‘vital sign’’ in electronic medical records. Med. Sci. Sports Exerc. 2012; 44:2071Y6. 4. Exercise is MedicineA. Available from: http://www.exerciseismedicine.org. Accessed 3 February 2014 5. Green Prescription Patient Survey 2013 Report. Research New Zealand. July 2013. Available from http://www.health.govt.nz/system/files/documents/ pages/green-prescription-patient-survey.pdf. Accessed 3 February 2014. 6. How the Green Prescription Works. Available from: http://www.health. govt.nz/our-work/preventative-health-wellness/physical-activity/greenprescriptions/how-green-prescription-works. Accessed 3 February 2014. 7. Joy E. Time for a new ‘vital sign’. Providers should monitor patients’ physical activity in battle against obesity. Mod. Healthc. 2013; 43:29. 8. Schwartz J, Carpenter RA, Manore MM, Kruskall L. A physical activity toolkit for registered dietitians: utilizing resources of Exercise is MedicineA. Available from http://www.eatright.org/HealthProfessionals/content.aspx?id= 6442478841. Accessed 3 February 2014. 9. Swinburn BA, Walter LG, Arroll B, et al. The green prescription study: a randomized controlled trial of written exercise advice provided by general practitioners. Am. J. Public Health. 1998; 88:288Y91. 10. What are my preventive care benefits? Available from: https://www.healthcare.gov/ what-are-my-preventive-care-benefits/. Accessed 7 February 2014.
Invited Commentary
Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
