Organization of primary care practice for providing energy balance care.

For individual use only. Duplication or distribution prohibited by law.

Preventive Medicine/Behavior Change

Organization of Primary Care Practice for Providing Energy Balance Care Carrie N. Klabunde, PhD; Steven B. Clauser, PhD; Benmei Liu, PhD; Nicolaas P. Pronk, PhD; Rachel Ballard-Barbash, MD, MPH; Terry T.-K. Huang, PhD; Ashley Wilder Smith, PhD

Abstract Purpose. Primary care physicians (PCPs) may not adequately counsel or monitor patients regarding diet, physical activity, and weight control (i.e., provide energy balance care). We assessed the organization of PCPs’ practices for providing this care. Design. The study design was a nationally representative survey conducted in 2008. Setting. The study setting was U.S. primary care practices. Subjects. A total of 1740 PCPs completed two sequential questionnaires (response rate, 55.5%). Measures. The study measured PCPs’ reports of practice resources, and the frequency of body mass index assessment, counseling, referral for further evaluation/management, and monitoring of patients for energy balance care. Analysis. Descriptive statistics and logistic regression modeling were used. Results. More than 80% of PCPs reported having information resources on diet, physical activity, or weight control available in waiting/exam rooms, but fewer billed (45%), used reminder systems (,30%), or received incentive payments (3%) for energy balance care. A total of 26% reported regularly assessing body mass index and always/often providing counseling as well as tracking patients for progress related to energy balance. In multivariate analyses, PCPs in practices with full electronic health records or those that bill for energy balance care provided this care more often and more comprehensively. There were strong specialty differences, with pediatricians more likely (odds ratio, 1.78; 95% confidence interval, 1.26– 2.51) and obstetrician/gynecologists less likely (odds ratio, 0.28; 95% confidence interval, 0.17–0.44) than others to provide energy balance care. Conclusion. PCPs’ practices are not well organized for providing energy balance care. Further research is needed to understand PCP care-related specialty differences. (Am J Health Promot 2014;28[3]:e67– e80.)

Key Words: Primary Care, Physicians, Physician’s Practice Patterns, Primary Health Care–Organization and Administration, Energy Balance, Health Care Surveys, Prevention Research. Manuscript format: research; Research purpose: descriptive, modeling/relationship testing; Study design: nonexperimental; Outcome measure: behavioral; Setting: clinical/health care; Health focus: fitness/ physical activity, nutrition, and weight control; Strategy: policy; Target population age: adults; Target population circumstances: education, geographic location, and race/ethnicity

INTRODUCTION Unhealthy diet, physical inactivity, and obesity are risk factors for type 2 diabetes, cardiovascular disease, many cancers, and other chronic conditions. It has been estimated that more than 300,000 deaths in the United States each year are attributable to poor nutritional choices, sedentary behavior, and obesity.1 Approximately two thirds of U.S. adults and one third of children are overweight or obese, and the prevalence of overweight and obesity has increased dramatically during the past 30 years.2,3 To reduce the burden of chronic illness and promote a healthy population, national public health objectives and clinical practice guidelines prescribe a role for physicians to counsel their patients regarding better nutrition, physical activity, and/or weight control.3–9 This guidance targets energy balance, defined as ‘‘the integrated effects of diet, physical activity, and genetics on growth and body weight over an individual’s lifetime.’’10 Most Americans see a physician at least once a year, and a recommendation from a physician can motivate patients to make healthy

Carrie N. Klabunde, PhD; Steven B. Clauser, PhD; Rachel Ballard-Barbash, MD, MPH; and Ashley Wilder Smith, PhD, are with the Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland. Benmei Liu, PhD, is with the Surveillance Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland. Nicolaas P. Pronk, PhD, is with HealthPartners, Bloomington, Minnesota. Terry T.-K. Huang, PhD, is with the Department of Health Promotion and Social and Behavioral Health, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska. Send reprint requests to Carrie N. Klabunde, PhD, Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Room 3E442, Bethesda, MD 20892-9762; [email protected]. This manuscript was submitted December 19, 2012; revisions were requested May 2, 2013; the manuscript was accepted for publication May 2, 2013. Copyright Ó 2014 by American Journal of Health Promotion, Inc. 0890-1171/14/$5.00 þ 0 DOI: 10.4278/ajhp.121219-QUAN-626

American Journal of Health Promotion

January/February 2014, Vol. 28, No. 3

e67

For individual use only. Duplication or distribution prohibited by law. behavior changes.11–15 Yet studies have shown that only a minority of primary care physicians (PCPs) routinely provide diet and exercise counseling to their patients.16–21 Time constraints, lack of reimbursement, lack of comfort with providing effective counseling, and perceived lack of patient interest are among the barriers cited to physicians’ provision of diet, weight, and physical activity counseling.17,22,23 Specialty differences in physicians’ willingness to take responsibility for helping patients to manage their weight have been documented, with gynecologists less likely than family physicians or internists to assume this role in preventive care.24 Moreover, prior research has shown that the environment in which physicians practice influences counseling on diet and exercise. For example, Honda25 found that patients whose usual care site was a hospital outpatient department were more likely to receive physician advice on diet and exercise than were patients who used other types of settings for their usual health care. Physician practices that are hospital-owned, that are multispecialty, and that use reminders and electronic health records (EHRs) have been shown to more often provide behavioral counseling and referral.26 Nevertheless, documentation of body mass index (BMI)—essential for determining whether patients are overweight or obese—has been found to be low overall27–29 and to vary widely by clinic site, even within integrated delivery networks in which all practices used an EHR system.30,31 Only a few surveys of physicians to ascertain knowledge, attitudes, and practices regarding energy balance care have been fielded; the surveys are dated and did not comprehensively examine U.S. PCPs’ assessment, counseling, and follow-up of patients’ diet, physical activity, and weight control.18–20,23,25 Therefore, in 2008 the National Cancer Institute conducted the National Survey of Energy Balance–Related Care among Primary Care Physicians (EB-PCP). This 2008 survey is particularly useful because it provides baseline information for a period before the passage of the Patient Protection and Affordable Care Act in 2010, which contained provisions for addressing obesity, diet, and physi-

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cian activity in clinical practice, and before the 2009 launch of focused national efforts in obesity prevention. We previously reported on U.S. PCPs’ diet-, physical activity–, and weightrelated care of adult and child patients,28,29 and knowledge of energy balance guidelines.32 These prior investigations focused on physician characteristics associated with counseling, referral, and follow-up practices for energy balance care, and showed that PCPs’ specialty, age, gender, race/ethnicity, and geographic location all were associated with this care. They also demonstrated that PCPs’ knowledge of energy balance guidelines could be improved and was mostly unrelated to clinical care practices. In the present study, we extend this work by assessing the extent to which PCPs’ practices are organized to provide energy balance care. In particular, we examine whether specific characteristics of PCPs’ practice settings and/or use of practice systems, such as electronic medical records, reminders, and reimbursement mechanisms, are associated with more frequent provision of energy balance care.

METHODS Survey Methodology and Study Cohort A nationally representative sample of PCPs was surveyed between March and October 2008. A systematic random sample was drawn from the American Medical Association’s Physician Masterfile, with specialty type used as the sampling strata and after sorting the sample frame database by physicians’ age, gender, and geographic location. Eligible respondents were non-Federal, office-based family physicians, general internists, obstetrician/ gynecologists, and pediatricians ages 75 years or younger who provided patient care as their major activity. PCPs listed in the Masterfile as retired, deceased, or with an address outside the United States, or identified as such in telephone screener calls placed to the offices of PCPs selected into the sample, were excluded. The EB-PCP survey employed three questionnaires: two versions of a physician questionnaire and a questionnaire that focused on the physician’s practice environment. One of the physician questionnaires was tailored

to PCPs who treat adults, the other to PCPs who treat children. Family physicians who only see adult patients were allocated to the sample receiving the adult questionnaire, whereas those who see both children and adults were randomly assigned to receive either the adult or the child questionnaire. The adult questionnaire was mailed to 1908 general internists, obstetrician/gynecologists, and family physicians; the child questionnaire was sent to 1237 pediatricians and family physicians. PCPs received up to four mailings of the questionnaire. A $30 prepaid honorarium was provided. To encourage survey participation, telephone followup calls were placed to the offices of PCPs who were sent second, third, and fourth mailings. The final item on the physician questionnaires asked respondents to provide the name of someone in the practice (e.g., an administrator, office manager, etc.) who could complete a follow-up practice environment questionnaire, or to indicate that the physician preferred to complete this questionnaire himself or herself. The practice environment questionnaire was mailed to the specified respondent after the return of the physician questionnaire (n ¼ 2027); this mailing included an additional $30 honorarium check. Up to three reminder telephone calls were placed to physicians’ offices to encourage completion of the practice environment questionnaire. Because the present study uses data from both the physician and practice environment questionnaires, the study cohort is restricted to the 1740 physicians for whom both were completed. Figure 1 shows how the study cohort was derived. A total of 86% of mailed practice environment questionnaires were completed; when combined with the response rate for the physician questionnaire (64.5%), the response rate for completing both questionnaires was 55.5%. A total of 85% of practice environment questionnaires were completed by sampled physicians. Further details on the survey methodology have been published.28,29 The questionnaires are available at: http://www.outcomes. cancer.gov/surveys/energy/2010. The survey was conducted under contract with Westat, a research organization



Figure 1 National Survey of Energy Balance-Related Care among Primary Care Physicians (EB-PCP) Survey Yields and Study Cohort

cerning behaviors or other measures of progress related to diet, physical activity, or weight (‘‘never,’’ ‘‘rarely,’’ ‘‘sometimes,’’ ‘‘often,’’ ‘‘always’’). A seventh item asked PCPs how often they assess patients’ BMI (‘‘every wellpatient visit,’’ ‘‘every visit,’’ ‘‘annually,’’ ‘‘as clinically indicated,’’ ‘‘never,’’ and ‘‘other interval’’). Practice Environment. Survey items asked about practice type and size, the practice’s geographic location, and the type of medical record system used in the practice. Other items ascertained whether the practice: (1) has a dietician, nutritionist, or health educator on staff; (2) provides information resources about diet, physical activity, or weight control accessible to patients in exam or waiting rooms or through a practice newsletter or Web site; (3) uses reminder systems for patients receiving energy balance care; (4) provides incentive payments to physicians for diet, weight, and/or physical activity counseling; or (5) bills for visits that involve counseling for energy balance care. Other Covariates. The American Medical Association Physician Masterfile provided information on PCPs’ specialty, year of medical school graduation, gender, and Census region of the practice location. PCPs reported their race/ethnicity on the survey.

based in Rockville, Maryland, and approved by its institutional review board as well as by the U.S. Office of Management and Budget. Variables Outcomes. Survey items asking about PCPs’ energy balance care were specific to patients without weight-related chronic disease who have an unhealthy diet, are insufficiently active, or are overweight. Six items inquired about


PCPs’ practices regarding such patients, including the frequency with which they (1) provide general counseling for changing diet, physical activity, or weight; provide specific guidance on (2) diet/nutrition, (3) physical activity, or (4) weight control; (5) refer patients to another health professional or program outside of the practice for further evaluation and/or management; and (6) systematically track/follow patients over time con-

Data Analysis We used descriptive statistics to characterize PCPs’ practice settings and systems to support energy balance care, such as type of medical record used, use of reminder systems and billing practices for energy balance care, and whether the practice has a dietician, nutritionist, or health educator on staff. We hypothesized that PCPs’ energy balance counseling, referral, tracking/monitoring, and BMI assessment practices would vary by practice setting and systems characteristics, independent of demographic characteristics, such as age, specialty, gender, and race/ethnicity.25,33–36 We used contingency tables and v2 tests to examine the bivariate associations of practice and system characteristics with PCPs’ reported frequency of providing seven energy balance care components. We used multiple ordinal logis-


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Table 1 Study Cohort Characteristics, Including Practice and System Supports for Energy Balance Care* By Specialty, % All PCPs (n ¼ 1740) No.

% (95% CI)

Internal Medicine (n ¼ 352)

Family Medicine– Adult (n ¼ 331)

Family Medicine– Child (n ¼ 320)

OB/GYN (n ¼ 351)

Pediatrics (n ¼ 386)

10.0 29.5 33.4 2.70

15.9 32.0 30.5 21.6

15.9 34.5 31.8 17.9

14.1 31.5 27.8 26.7

15.7 30.3 27.2 26.9

0.002

p

Physician characteristics Years since medical school graduation 250 524 531 435

,10 10–19 20–29 30

13.9 31.3 30.5 24.4

(12.5–15.4) (29.7–32.9) (28.8–32.2) (22.7–26.1)

Gender Male Female

1038 702

60.4 (58.5–62.2) 39.6 (37.8–41.5)

68.6 31.4

66.8 33.2

64.6 35.4

53.6 46.4

43.9 56.1

,0.001

1253 82 274 100 31

70.2 5.0 17.1 5.9 1.8

(67.8–72.5) (4.0–6.2) (15.3–19.0) (4.8–7.3) (1.3–2.6)

63.2 5.4 23.9 5.1 2.3

77.0 3.9 10.7 7.1 1.3

77.1 3.5 11.9 5.7 1.7

75.4 7.4 9.4 6.2 1.5

64.3 4.6 23.1 6.2 1.9

,0.001

361 415 587 377

21.2 22.9 33.9 22.0

(19.4–23.1) (21.2–24.6) (31.9–36.0) (20.3–23.8)

24.5 17.9 37.1 20.5

16.2 30.4 30.9 22.5

14.9 28.3 33.4 23.4

23.3 20.9 33.0 22.8

24.9 20.1 33.1 21.9

,0.001

433 490 504 307 6

25.9 27.5 28.8 17.5 0.4

(23.8–28.0) (25.2–29.8) (26.6–31.2) (15.9–19.2) (0.2–0.8)

31.7 26.3 27.1 14.9 0.0

19.2 21.9 31.3 27.7 0.0

19.1 25.0 28.0 26.9 1.0

31.4 28.1 30.4 9.6 0.4

24.8 35.9 28.7 10.0 0.6

,0.001

325 619 499 286 11

19.9 35.1 27.7 16.7 0.7

(18.0–21.8) (32.7–37.6) (25.3–30.1) (15.0–18.7) (0.4–1.2)

29.6 31.0 20.6 18.0 0.8

15.8 39.3 26.3 18.6 0.0

13.7 39.3 29.7 16.7 0.6

21.0 33.5 30.9 14.0 0.6

13.5 35.0 35.3 15.1 1.1

,0.001

928 204 297

53.2 (50.6–55.8) 11.6 (10.1–13.2) 17.1 (15.2–19.1)

59.5 8.5 14.8

49.3 8.2 24.1

42.0 15.5 17.9

61.8 10.7 13.7

50.5 16.5 16.1

,0.001

72 154 85

4.4 (3.4–5.6) 8.6 (7.3–10.1) 5.2 (4.3–6.3)

4.9 5.7 6.6

3.8 11.2 3.4

4.1 13.9 6.6

2.4 8.3 3.1

5.8 6.0 5.0

288

16.5 (14.6–18.5)

17.0

18.8

14.6

14.4

16.7

0.563

1438

82. 9 (81.1–84.6)

82.2

89.4

85.9

73.6

82.9

,0.001

392

22.1 (19.8–24.6)

17.4

24.4

23.3

22.1

26.0

0.027

47

2.7 (2.1–3.5)

2.5

2.8

4.5

1.7

2.1

0.411

435

25.3 (23.3–27.4)

25.4

30.6

28.1

18.3

23.3

,0.001

Race/ethnicity Non-Hispanic white Non-Hispanic black Non-Hispanic Asian Hispanic Other Practice characteristics Census region Northeast Midwest South West Urban/rural location Large city Medium city Small city Rural Other Size Solo (1 clinician) Small group (2–5 clinicians) Medium group (6–20 clinicians) Large group (.20 clinicians) Don’t know Type Physician practice, owner Physician practice, employee Large medical group, health care system, HMO Hospital/clinic, university affiliated Hospital/clinic, not university affiliated Other Has a dietician, nutritionist, and/or health educator on staff Has information resources* on diet, weight control, and/or physical activity available in waiting or exam rooms Practice newsletter or Web site had information about diet/nutrition, physical activity, and/or weight control in the past 12 mo Provides incentive payments to physicians for diet, weight, and/or physical activity counseling System characteristics Type of medical record system Full EHR

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Table 1, Continued By Specialty, % All PCPs (n ¼ 1740) No. In transition from paper to full EHR Partial EHR Paper charts Other

244 134 857 70

% (95% CI) 13.6 7.7 49.3 4.1

(12.0–15.3) (6.6–8.9) (46.9–51.7) (3.3–5.2)

Internal Medicine (n ¼ 352)

Family Medicine– Adult (n ¼ 331)

Family Medicine– Child (n ¼ 320)

OB/GYN (n ¼ 351)

Pediatrics (n ¼ 386)

9.4 7.8 51.8 5.6

17.6 8.4 40.2 3.3

19.4 6.9 41.7 3.9

14.1 9.4 53.6 4.6

10.7 6.1 57.3 2.5

23.8 75.1 1.1

25.1 72.6 2.3

22.7 74.7 2.6

17.3 78.4 4.3

29.9 67.8 2.3

0.011

p

Uses reminder system for patients receiving energy balance counseling within the practice Yes† No‡ Don’t know

415 1280 45

24.0 (21.9–26.3) 73.7 (71.3–76.0) 2.3 (1.7–3.1)

Uses reminder system for patients referred out of the practice for energy balance care Yes† No‡ Don’t know

500 1163 77

28.7 (26.4–31.2) 67.0 (64.4–69.5) 4.3 (3.5–5.3)

25.9 69.6 4.5

31.0 66.1 2.9

28.1 67.6 4.3

26.1 68.3 5.7

33.5 62.3 4.2

0.379

780 331 629

44.7 (42.1–47.1) 19.1 (17.3–21.1) 36.2 (33.9–38.6)

43.5 21.7 34.8

48.3 15.1 36.6

42.3 16.0 41.6

37.4 27.9 34.7

50.6 14.8 34.6

,0.001

Practice bills for energy balance care Yes No Don’t know/NA§

* CI indicates confidence interval; PCP, primary care physician; OB/GYN, obstetrics/gynecology; HMO, health maintenance organization; EHR, electronic health record; and NA, not ascertained. † Includes brochures/pamphlets, flyers for programs/services, books/journal articles, and videos (excludes magazines). ‡ Includes mail, telephone, e-mail, personalized Web page, other reminders. § Includes verbal reminder during office visit. || Includes 562 respondents who skipped out of the billing section because they do not regularly review or work with billing data in the practice.

tic regression modeling to examine the association of practice setting and systems characteristics with each energy balance care component, controlling for physician characteristics. The dependent variable for frequency of BMI assessment was created in two steps: first, responses of ‘‘at every wellpatient visit,’’ ‘‘at every visit,’’ and ‘‘annually’’ were categorized as ‘‘regularly.’’ Then, a value of 2 was assigned to ‘‘regularly,’’ 1 to ‘‘as clinically indicated,’’ and 0 to ‘‘never.’’ For frequency of the six energy balance counseling, referral, and tracking/monitoring practices, dependent variables were created by assigning a numeric score (where 1 ¼ never, 2 ¼ rarely, 3 ¼ sometimes, 4 ¼ often, and 5 ¼ always) to PCPs’ responses to each item. The ordinal logistic regression models were specified to evaluate factors associated with physicians who provide the energy balance care component more frequently. We also assessed the extent to which PCPs comprehensively provide energy balance care. We defined comprehen-


sive care as regularly assessing BMI; always/often providing general counseling and/or specific guidance on diet/nutrition, physical activity, or weight control; and always/often tracking patients over time for progress related to diet, physical activity, or weight. We estimated a binary logistic regression model to examine the association of practice setting and systems characteristics with this measure of comprehensive energy balance care, controlling for physician characteristics. Because of the strong, consistent association of physician specialty with energy balance care in all models, we tested two interaction terms: (1) specialty by type of medical record system used in the practice, and (2) specialty by whether the practice bills for energy balance care. This was done to evaluate whether these system supports vary by provider type. Survey weights adjusting for undercoverage and survey nonresponse were applied in all analyses; the weighted data yield national estimates. Survey Data Analysis (SUDAAN) software ver-

sion 10.0.1 (Research Triangle Institute, Durham, North Carolina) was used in the analyses to account for the complex survey design. Item nonresponse was less than 10% for most survey variables. To minimize loss of data for some subsamples, missing data were imputed for survey items using the AutoImpute macro.37–39

RESULTS Description of PCPs and Practice Organization for Energy Balance Care Of the 1740 PCPs in our study cohort, about 60% were general internists or family physicians, 70% were of non-Hispanic white race/ethnicity, and more than half had graduated from medical school at least 20 years ago (Table 1). A total of 80% of PCPs were in practices of two or more clinicians. More than 80% reported that their practice provided information resources on diet, weight control, and/or physical activity in waiting or exam rooms: 78% provided brochures or pamphlets, 45% flyers for programs or


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Table 2 Physicians’ Self-Reported Frequency of Providing Specific Components of Energy Balance Care, by Specialty and Practice/ System Characteristics (N ¼ 1740 Primary Care Physicians)*

All Physicians

% (95% CI) 53.0 (50.4–55.6)

Provide Guidance on Diet/Nutrition Always/Often

Provide General Counseling Always/Often

Assess BMI Regularly* p

% (95% CI) 82.2 (80.4–83.9)

p

% (95% CI) 80.3 (78.5–82.1)

p

Provide Guidance on Physical Activity Always/Often % (95% CI) 86.8 (85.1–88.3)

p

Physician characteristics Specialty Internal medicine Family medicine Adult questionnaire Child questionnaire OB/GYN Pediatrics

45.87 53.2 53.9 52.5 38.2 75.2

,0.001

82.0 81.7 81.4 81.9 70.7 92.6

,0.001

80.1 76.9 77.6 76.1 71.7 93.7

,0.001

88.6 85.2 87.0 83.4 77.5 93.9

,0.001

56.3 54.4 48.0 56.2

0.030

85.4 82.3 79.1 83.1

0.207

85.4 78.8 78.4 80.0

0.034

90.1 86.9 85.0 86.1

0.149

51.0 57.3 51.4 52.0

0.281

83.3 83.8 82.4 78.2

0.360

84.0 81.5 79.3 75.3

0.051

88.0 86.5 89.1 82.1

0.085

43.6 52.7 56.3 60.3

,0.001

82.8 82.3 81.8 81.3

0.026

84.0 79.7 81.0 78.1

0.634

89.4 86.6 85.6 85.6

0.557

47.7 57.6 63.4

,0.001

82.0 84.8 82.1

0.883

80.8 81.6 78.6

0.042

87.9 87.4 85.5

0.151

Practice characteristics Census region Northeast Midwest South West Urban/rural location Large city Medium city Small city Rural Size Solo (1 clinician) Small group (2–5 clinicians) Medium group (6–20 clinicians) Large group (.20 clinicians) Type Physician (owner) Physician (employee) Large medical group, health care system, HMO Hospital/clinic Other

57.6 52.1

81.5 80.5

76.2 88.9

82.1 89.5

Dietician, nutritionist, and/or health educator on staff Yes No

60.5 51.5

0.004

81.3 82.4

0.699

81.0 80.2

0.744

87.2 86.7

0.831

0.521

80.5 79.4

0.670

87.4 83.7

0.098

Information resources† on diet, weight control, and/or physical activity in waiting or exam rooms Yes No

54.3 46.5

0.015

82.5 80.8

Practice newsletter or Web site had information about diet/nutrition, physical activity, and/or weight control in the past 12 mo Yes No

63.2 50.1

,0.001

82.4 82.2

0.929

83.7 79.4

0.044

86.3 86.9

0.797

76.0 58.8 47.1 41.3 43.7

,0.001

82.8 87.1 83.4 81.2 73.0

0.161

77.7 83.9 81.0 80.5 81.5

0.315

83.9 90.1 85.9 87.1 90.9

0.108

86.4 80.6

0.012

84.0 79.2

0.016

91.5 85.5

,0.001

84.1 81.8

0.216

84.2 79.5

0.012

90.2 85.9

0.005

System characteristics Type of medical record system used Full EHR In transition to full EHR Partial EHR Paper charts Other

Uses reminder system for patients receiving energy balance counseling within the practice Yes‡ No§/don’t know

62.1 49.9

,0.001

Uses reminder system for patients referred out of the practice for energy balance care Yes‡ No§/don’t know

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60.1 49.6

,0.001



Table 2, Extended Refer for Further Evaluation and Management Always/Often

Provide Guidance on Weight Control Always/Often % (95% CI) 66.6 (64.3–68.9)

76.3 63.5 71.3 55.5 57.5 65.1

p

,0.01

% (95% CI) 18.0 (16.2–20.0)

16.8 13.7 13.3 14.1 24.2 22.8

p

,0.01

Systematically Track/Follow Patients Always/Often % (95% CI) 43.8 (41.4–46.2)

55.7 40.2 43.6 36.9 19.2 51.5

p

,0.01

69.5 65.1 66.1 66.3

0.594

22.2 17.5 13.7 21.3

0.002

45.7 45.8 43.0 41.1

0.457

69.1 62.7 70.3 63.6

0.049

21.7 18.3 18.6 11.5

0.007

47.4 40.2 45.4 41.9

0.128

78.0 69.1 58.7 60.8

,0.001

17.4 14.0 22.0 20.7

0.031

54.1 41.6 40.9 40.9

0.002

71.6 59.7 59.6

,0.001

16.2 19.5 18.5

0.252

45.1 47.1 36.4

0.035

58.7 74.0

23.1 18.9

42.4 50.4

63.3 67.3

0.185

25.2 16.6

0.005

45.0 43.6

0.646

68.2 59.2

0.005

18.4 16.2

0.373

45.7 34.3

,0.001

61.3 68.2

0.019

22.4 16.8

0.022

40.9 44.6

0.177

63.6 66.3 62.0 69.2 64.3

0.267

18.1 17.4 24.2 17.2 17.5

0.477

39.4 40.1 41.6 47.8 38.6

0.018

69.7 66.2

0.124

22.6 16.7

0.019

51.6 41.9

,0.001

71.0 65.7

0.008

24.2 15.8

,0.001

48.5 42.7

0.014


services, 18% books or journal articles, and 8% videos. A total of 22% said that their practice provided information about diet/nutrition, physical activity, and/or weight control in the past 12 months in a practice newsletter or on a Web site, and 17% indicated that the practice has a dietician, nutritionist, and/or health educator on staff. Only 3% reported that their practice provides incentive payments to physicians for diet, weight, and/or physical activity counseling. Differences by specialty were statistically significant at p , .05 for the demographic, practice location, practice size and type, and information resources variables. About one quarter of PCPs were in practices using full EHRs, whereas 49% used paper charts. A total of 24% percent reported that their practice uses a reminder system for patients receiving energy balance counseling within the practice, and 29% indicated that their practice uses a reminder system for patients referred out of the practice for this counseling. A total of 45% said that their practice bills for energy balance care. Differences by specialty were statistically significant at p , .05 for reminder and medical record system and practice billing variables. Physicians’ Provision of Energy Balance Care PCPs more often reported always/ often providing specific guidance on physical activity (87%) than they did other components of energy balance care (Table 2). Of the seven care components, PCPs were least likely to always/often refer such patients to a provider outside of the practice for further evaluation and management (18%). Differences of 15 percentage points or greater were noted by specialty type for all care components except referring for further evaluation and management. In contrast, PCPs’ reported provision of energy balance care components did not vary considerably by practice and system characteristics, with a few exceptions. These included assessing BMI regularly, for which there was a 17–percentage point difference between PCPs in solo and those in large group practices (p , .001). PCPs in a large medical group, health maintenance organization


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Table 2, Continued

Assess BMI Regularly† All Physicians

% (95% CI) 53.0 (50.4–55.6)

Provide Guidance on Diet/Nutrition Always/Often

Provide General Counseling Always/Often p

% (95% CI) 82.2 (80.4–83.9)

p

% (95% CI) 80.3 (78.5–82.1)

p

Provide Guidance on Physical Activity Always/Often % (95% CI) 86.8 (85.1–88.3)

p

Practice bills for energy balance care Yes No Don’t know/NA

55.5 45.9 53.8

0.025

83.4 79.2 82.3

0.252

81.8 77.0 80.4

0.190

88.6 85.8 85.0

0.137

* CI indicates confidence interval; BMI, body mass index; OB/GYN, obstetrics/gynecology; HMO, health maintenance organization; EHR, electronic health record; and NA, not ascertained † Every well-patient visit, every visit, and annually. ‡ Includes mail, telephone, e-mail, personalized Web page, other reminders. § Includes verbal reminder during office visit.

(HMO), or health care system setting also more often reported assessing BMI regularly, as did those using reminder systems for energy balance care and those in practices with full EHRs. PCPs in solo and small group practices more often reported always/often providing specific guidance on weight control. A total of 26% of PCPs (95% confidence interval [CI], 23.3%– 27.9%) reported comprehensively providing energy balance care by regularly assessing BMI; providing counseling on diet/nutrition, physical activity, or weight control; and systematically tracking patients over time for progress related to energy balance (data not shown). As shown in Figure 2, the percentages of PCPs who comprehensively provide energy balance care were highest for pediatricians (40.1%; 95% CI, 35.0%–45.5%) and lowest for obstetrician/gynecologists (8.4%; 95% CI, 5.8%–11.8%; p , .0001), and they were higher for PCPs in practices with full EHRs (32.1%; 95% CI, 27.8%–36.8%) than for those in practices using paper charts (23.3%; 95% CI, 20.3%–26.6%; p , .005). Factors Associated With Physicians’ Reported Frequency of Providing Energy Balance Care Physician, practice, and system characteristics were all associated with more frequently providing energy balance care components in adjusted analyses (Table 3). When controlling

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for practice and system characteristics, there were striking specialty differences in provision of energy balance care, as well as differences by PCPs’ age group, gender, and race/ethnicity. With respect to the practice environment, there was variation by Census region, with PCPs located in the South less likely than those in the Northeast to more frequently provide each component of energy balance care except systematic tracking of patients. Likewise, PCPs located in smaller cities or rural areas were less likely than those in large cities to provide each care component except regular assessment of BMI. PCPs in practices with information resources on diet, weight control, or physical activity in waiting or exam rooms were more likely to regularly assess BMI, counsel about physical activity or weight control, or systematically track patients. Practice type; having a dietician, nutritionist, or health educator on staff; or practice newsletter/Web site provision of information about diet, weight control, or physical activity was not associated with PCPs’ more frequent provision of energy balance care. With respect to system characteristics, being in a practice with a full EHR or in transition to a full EHR was associated with PCPs’ regularly assessing BMI. Having reminder systems about patients receiving energy balance counseling within the practice or referred out of the practice was associ-

ated with more frequent counseling about physical activity or weight control, more frequent referral of patients for further evaluation and management, and systematic tracking of patients. PCPs in practices that bill for energy balance care were more likely to provide energy balance counseling and to systematically track patients compared with PCPs in practices that do not bill for this care. Factors Associated With Physicians Who Comprehensively Provide Energy Balance Care Table 4 shows results from the main effects model assessing factors associated with PCPs who comprehensively provide energy balance care. Compared with general internists, pediatricians were more likely and obstetrician/gynecologists were less likely to regularly assess BMI, provide counseling, and systematically track patients over time for progress. Those who comprehensively provide energy balance care were also more likely to be of a racial/ethnic group other than white; an employee of a physicianowned practice; in a practice with a full EHR; or in a practice that bills for this care. A separate model was estimated to evaluate two interaction terms: specialty by type of medical record system, and specialty by billing practice. Neither interaction was statistically significant at p , .05. However,



Table 2, Extended Continued Refer for Further Evaluation and Management Always/Often

Provide Guidance on Weight Control Always/Often % (95% CI) 66.6 (64.3–68.9)

68.0 68.9 63.8

p

0.209

% (95% CI) 18.0 (16.2–20.0)

16.2 18.3 20.2

for conditional effects, we did find that among PCPs in practices with full EHRs, family physicians (odds ratio, 2.43; 95% CI, 1.46–4.05) and pediatricians (odds ratio, 1.74; 95% CI, 1.03–2.91) were statistically significantly more likely than other PCPs to comprehensively provide energy balance care; these specialty differences were not found among PCPs in practices with other types of medical records, however (data not shown).

Discussion The literature on how U.S. PCPs’ practices are organized to provide energy balance care is sparse and dated. Using data from a nationally representative survey of PCPs conducted in 2008, we found that most PCPs have limited practice supports for providing this care. Although more than 80% of PCPs have information resources on diet, physical activity, or weight control available in waiting or exam rooms, only a minority bill, use reminder systems, or receive incentive payments for energy balance care. Furthermore, only one quarter have full EHRs, and less than 20% have a dietician, nutritionist, or health educator on staff in the practice. Although we were primarily interested in examining the influence of practice and system characteristics on PCPs’ provision of energy balance care, and showed that several of these characteristics were associated with this care, we also found that physician characteristics—including age, female gender,


p

0.200

Systematically Track/Follow Patients Always/Often % (95% CI) 43.8 (41.4–46.2)

48.1 37.8 41.6

p

0.007

nonwhite race/ethnicity, and particularly specialty—were strongly related to energy balance care, even after incorporating features of the physician’s practice environment. Our survey documented that most PCPs are in practices with more than one clinician and with support staff. It is widely believed that PCPs’ delivery of energy balance care must be supported by the resources and systems of the medical group and/or health care organization in which the physician practices.25,33,36,40–43 Our study provides further evidence of the importance of the practice environment in PCPs’ delivery of energy balance care. PCPs in practices with full EHRs were more likely to regularly assess BMI, as well as provide counseling and systematically track patients over time for progress related to diet, weight control, and physical activity. Those in practices with reminder systems for patients receiving energy balance care were more likely to counsel about physical activity or weight control, refer patients for further evaluation and/or management, and systematically monitor them for progress. EHRs and reminder systems have also been shown to support guideline-appropriate recommendation and delivery of cancer screening by PCPs.34,44–46 Our finding that EHRs are associated with more frequent and comprehensive delivery of energy balance care, including BMI assessment, by PCPs has particular relevance for clinicians and practices engaged in implementing the new Healthcare Effectiveness Data and Information Set requirement for docu-

menting BMI during outpatient office visits.47 We also showed that PCPs in practices that bill for energy balance care were more likely to provide energy balance counseling and to systematically track patients compared with PCPs in practices that do not bill for this care. Lack of reimbursement is an oft-cited barrier to energy balance care3,17,48; our study provides further evidence that reimbursement facilitates this care in primary care practice. The Institute of Medicine has called for health insurers, both public and private, to review and modify their coverage and access provisions as an important component in addressing the obesity epidemic in the United States.9 Reimbursement barriers may also be lessened by provisions in the Patient Protection and Affordable Care Act for coverage of preventive services with A- or B-level recommendations from the U.S. Preventive Services Task Force49; the Task Force has given Blevel ratings for obesity screening and counseling in children, adolescents, and adults, as well as for intensive dietary counseling among at-risk adults.4–7 Another contribution of this study is its assessment of the extent to which PCPs comprehensively provide energy balance care to patients who have an unhealthy diet, are insufficiently active, or are overweight (but without weightrelated chronic disease) by regularly assessing BMI, providing counseling, and tracking such patients for progress over time. We found that only 26% of PCPs reported a comprehensive approach to energy balance care. PCPs in practices with full EHRs or that bill for energy balance care were more likely than those in practices using paper charts or that do not bill to comprehensively provide this care. These findings complement and extend other analyses from the EB-PCP survey showing low levels of assessment and behavioral management of obesity for discrete care components, as well as a lack of knowledge of energy balance guidelines, among many U.S. PCPs.28,29,32 Our study documented the strong influence of PCP specialty on energy balance care, even after controlling for various features of physicians’ practice


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Table 3 Ordinal Logistic Regression Models† Assessing the Association of Physician and Practice/System Characteristics With Physicians’ Self-Reported Energy Balance Care Practices (N ¼ 1740 Primary Care Physicians)‡ Model 1: Regularly§ Assess BMI, OR (95% CI)

Model 7: Model 6: Refer for Further Systematically Model 5: Model 4: Model 3: Model 2: Provide General Provide Guidance Provide Guidance Provide Guidance Evaluation and Track/Follow Patients, on Diet/Nutrition, on Physical Activity, on Weight Control, Management, Counseling, OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

Physician characteristics Specialty Internal medicine Family medicine–adult Family medicine–child OB/GYN Pediatrics

1.28 1.25 0.68 3.71

1.00 (0.99–1.65) (0.90–1.74) (0.50–0.92) (2.59–5.30)

0.82 1.08 0.44 2.22

1.00 (0.61–1.10) (0.82–1.42) (0.33–0.59) (1.69–2.93)

0.92 0.90 0.55 2.41

1.00 (0.66–1.30) (0.68–1.19) (0.41–0.75) (1.82–3.18)

0.82 0.82 0.48 1.47

1.00 (0.59–1.16) (0.62–1.08) (0.34–0.67) (1.12–1.91)

0.87 0.53 0.43 0.62

1.00 (0.67–1.12) (0.40–0.70) (0.33–0.57) (0.47–0.83)

0.96 0.92 1.47 1.76

1.00 (0.70–1.32) (0.66–1.29) (1.05–2.05) (1.33–2.33)

0.69 0.53 0.17 0.89

1.00 (0.50–0.97) (0.39–0.71) (0.12–0.24) (0.68–1.17)

Years since medical school graduation ,10 10–19 20–29 30

1.00 1.00 1.27 (0.90–1.81) 1.14 (0.86–1.50) 0.99 (0.69–1.42) 1.44 (1.05–1.98) 0.80 (0.56–1.13) 1.30 (0.91–1.85)

1.00 1.10 (0.80–1.51) 1.39 (1.02–1.91) 1.38 (0.96–1.99)

1.00 1.07 (0.77–1.49) 1.47 (1.05–2.04) 1.61 (1.10–2.37)

1.00 1.61 (1.16–2.24) 2.07 (1.46–2.94) 3.10 (2.11–4.56)

1.00 1.00 1.03 (0.76–1.39) 1.08 (0.82–1.43) 1.07 (0.78–1.49) 1.46 (1.12–1.91) 1.23 (0.89–1.68) 1.69 (1.22–2.35)

1.00 1.00 1.22 (0.93–1.61) 1.57 (1.26–1.97)

1.00 1.80 (1.44–2.25)

1.00 1.31 (1.04–1.65)

1.00 1.18 (0.95–1.47)

1.00 1.00 1.28 (1.08–1.52) 1.16 (0.95–1.41)

1.00 1.00 1.81 (1.31–2.52) 1.62 (1.22–2.16) 1.63 (1.20–2.23) 1.64 (1.18–2.27)

1.00 1.75 (1.31–2.33) 1.44 (1.07–1.95)

1.00 1.89 (1.43–2.48) 1.37 (1.03–1.84)

1.00 1.75 (1.31–2.32) 1.72 (1.31–2.26)

1.00 1.00 1.14 (0.85–1.54) 1.30 (0.98–1.74) 1.46 (1.08–1.98) 1.20 (0.95–1.53)

1.00 1.00 0.98 (0.68–1.41) 0.76 (0.56–1.03) 0.70 (0.49–0.98) 0.53 (0.40–0.71) 0.85 (0.59–1.23) 0.73 (0.51–1.05)

1.00 0.66 (0.51–0.87) 0.58 (0.45–0.75) 0.58 (0.42–0.81)

1.00 0.76 (0.57–1.01) 0.62 (0.47–0.83) 0.62 (0.44–0.87)

1.00 0.78 (0.59–1.02) 0.70 (0.55–0.90) 0.71 (0.51–0.98)

1.00 1.00 0.77 (0.58–1.02) 1.02 (0.78–1.33) 0.48 (0.36–0.64) 0.87 (0.65–1.15) 0.60 (0.44–0.81) 0.81 (0.58–1.14)

1.00 1.00 1.13 (0.84–1.52) 0.75 (0.57–0.99) 0.97 (0.74–1.27) 0.85 (0.63–1.16) 1.18 (0.82–1.70) 0.69 (0.50–0.96)

1.00 0.64 (0.47–0.87) 0.65 (0.49–0.86) 0.60 (0.43–0.84)

1.00 0.73 (0.55–0.96) 0.83 (0.62–1.10) 0.64 (0.45–0.90)

1.00 0.72 (0.54–0.96) 0.89 (0.68–1.15) 0.68 (0.50–0.92)

1.00 1.00 0.86 (0.65–1.12) 0.73 (0.56–0.97) 0.77 (0.60–1.00) 0.88 (0.68–1.15) 0.60 (0.44–0.82) 0.75 (0.55–1.04)

1.00 0.80 (0.59–1.08) 0.79 (0.56–1.11) 0.65 (0.46–0.93)

1.00 0.88 (0.63–1.23) 0.88 (0.60–1.28) 0.87 (0.60–1.27)

1.00 0.87 (0.64–1.17) 0.67 (0.47–0.95) 0.61 (0.41–0.89)

1.00 1.00 1.07 (0.83–1.37) 0.63 (0.47–0.84) 1.37 (0.97–1.92) 0.70 (0.48–1.01) 1.30 (0.87–1.96) 0.52 (0.34–0.80)

Gender Male Female Race/ethnicity Non-Hispanic white Non-Hispanic Asian Other|| Practice characteristics Census region Northeast Midwest South West Urban/rural location Large city Medium city Small city Rural Size Solo (1 clinician) 1.00 Small group (2–5 clinicians) 1.15 (0.84–1.56) 0.80 Medium group (6–20 clinicians) 1.13 (0.83–1.52) 0.92 Large group (.20 clinicians) 0.91 (0.62–1.34) 0.75

1.00 (0.60–1.06) (0.65–1.30) (0.52–1.10)

Information resources on diet, weight control, and/or physical activity in waiting or exam rooms Yes No

1.38 (1.04–1.82) 1.24 (0.95–1.60) 1.00 1.00

1.27 (0.97–1.67) 1.00

1.40 (1.07–1.82) 1.00

1.56 (1.19–2.04) 1.00

1.21 (0.94–1.55) 1.47 (1.15–1.87) 1.00 1.00

0.93 (0.72–1.20) 1.27 (0.92–1.74) 1.14 (0.82–1.59) 1.00 0.87 (0.53–1.44)

1.07 (0.80–1.42) 1.35 (0.99–1.85) 1.16 (0.81–1.67) 1.00 1.13 (0.68–1.87)

1.07 (0.81–1.42) 1.19 (0.86–1.66) 0.84 (0.58–1.22) 1.00 0.76 (0.47–1.22)

0.94 (0.73–1.21) 0.84 (0.66–1.07) 0.99 (0.71–1.36) 0.93 (0.70–1.24) 1.17 (0.79–1.74) 0.96 (0.70–1.32) 1.00 1.00 1.21 (0.71–2.06) 0.76 (0.43–1.33)

1.31 (1.02–1.68) 1.00

1.12 (0.87–1.45) 1.00

1.20 (0.93–1.53) 1.36 (1.05–1.76) 1.00 1.00

1.26 (0.96–1.63) 1.00

1.39 (1.06–1.83) 1.00

1.38 (1.07–1.78) 1.19 (0.95–1.49) 1.00 1.00

System characteristics Type of medical record system used Full EHR In transition to full EHR Partial EHR Paper charts Other

4.72 (3.50–6.36) 1.09 (0.84–1.41) 2.21 (1.62–3.03) 1.41 (1.05–1.89) 1.30 (0.85–1.99) 1.22 (0.85–1.75) 1.00 1.00 1.41 (0.84–2.37) 0.74 (0.41–1.33)

Uses reminder system for patients receiving energy balance counseling within the practice Yes¶ No#/don’t know

1.21 (0.91–1.62) 1.30 (1.00–1.68) 1.00 1.00

1.20 (0.95–1.52) 1.00

Uses reminder system for patients referred out of the practice for energy balance care Yes¶ No#/don’t know

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1.10 (0.83–1.46) 1.14 (0.87–1.50) 1.00 1.00


1.28 (0.98–1.67) 1.00



Table 3, Continued Model 1: Regularly§ Assess BMI, OR (95% CI)

Model 2: Provide General Counseling, OR (95% CI)

Model 3: Provide Guidance on Diet/Nutrition, OR (95% CI)

Model 4: Provide Guidance on Physical Activity, OR (95% CI)

Model 5: Provide Guidance on Weight Control, OR (95% CI)

Model 6: Refer for Further Evaluation and Management, OR (95% CI)

Model 7: Systematically Track/Follow Patients, OR (95% CI)

1.39 (1.07–1.80) 1.00 1.26 (0.98–1.64)

1.45 (1.09–1.93) 1.00 1.42 (1.05–1.93)

1.38 (1.06–1.79) 1.00 1.35 (1.04–1.75)

1.20 (0.95–1.52) 1.00 1.31 (1.00–1.71)

0.90 (0.70–1.14) 1.00 1.01 (0.76–1.34)

1.71 (1.29–2.27) 1.00 1.42 (1.04–1.95)


1.25 (0.94–1.67) 1.00 1.07 (0.82–1.41)

† Other model covariates included practice type; whether the practice has a dietician, nutritionist, and/or health educator in staff; and whether a practice newsletter or Web site provided information about diet/nutrition, physical activity, and/or weight control in the past 12 months. These covariates were not statistically significant in any of the multivariate models. ‡ BMI, body mass index; OR, odds ratio; CI, confidence interval; OB/GYN, obstetrics/gynecology; HMO, health maintenance organization; EHR, electronic health record; and NA, not ascertained. § Every well-patient visit, every visit, and annually. || Includes non-Hispanic black, Hispanic, other race/ethnicity. ¶ Includes mail, telephone, e-mail, personalized Web page, other reminders. # Includes verbal reminder during office visit. * Results that were statistically significant at p , 0.05 are noted in boldface type.

environments. We showed that, compared with general internists, obstetrician/gynecologists were significantly less likely and pediatricians significantly more likely to provide specific components of energy balance care, regardless of practice organization. These same relationships were demonstrated for our measure of comprehensively providing energy balance care, with obstetrician/gynecologists less likely and pediatricians more likely to regularly assess BMI, provide counseling, and track at-risk patients for progress in diet, physical activity, and weight control. Our findings point to the potential strong influences of specialty-specific PCP training and continuing medical education on care practices, and indicate the need for training and educational interventions targeted to obstetrician/gynecologists. Components of pediatricians’ training and continuing medical education programs that address energy balance care might help to inform interventions developed for obstetrician/gynecologists. This study has limitations. It is based on physician self-reports of their involvement in energy balance care, and it focused mainly on physicians’ roles as opposed to whether and how a team of staff in the practice may be delivering this care. We did not ascertain


physicians’ views on which provider type should assume lead responsibility for various components of energy balance care, nor whether the practice has a ‘‘prevention champion’’ and/or orientation toward providing preventive services.50 Our measure of information technology in the practice to support this care was limited to a single item assessing type of medical record system and did not explore availability and use of more advanced features of EHRs, such as electronic reminders and clinical alerts, that might further facilitate energy balance care. The measurement of practice activities related to billing for energy balance care was derived from the practice environment questionnaire, which was predominantly completed by physicians, some of whom indicated that they do not regularly review or work with billing data in the practice, and this contributed to a 36% don’t know/not ascertained rate for this measure. Survey methodology studies to elucidate reasons for physicians’ decisions to complete the practice environment questionnaire themselves rather than delegate this task to a practice administrator are needed.51 Our study also focused on PCPs’ care of patients at risk for chronic illness because of poor nutritional choices, sedentary behavior, and/or obesity. Future work should

address PCP practices related to energy balance care for all patients, in order to more comprehensively assess progress toward achieving the Institute of Medicine’s goal of preventing obesity and attaining better population health.9 Obesity is a serious and costly public health problem in the United States. Health professionals, including PCPs, have an integral role in addressing the problem. As noted in the recent Institute of Medicine report,9 health care providers should ‘‘increase the support structure for achieving better population health and obesity prevention’’ and ‘‘have standards of practice including routine screening of BMI, counseling, and behavioral interventions for children, adolescents, and adults to improve physical activity behaviors and dietary choices.’’ Our study shows that U.S. PCPs’ practices are not well organized for providing energy balance care, and it adds to a body of literature that documents low levels of and barriers to PCPs’ provision of this care. Recent national policy developments, including enhanced reimbursement of preventive services, implementation of patientcentered medical homes, and incentives to promote use of comprehensive EHR systems in primary care, hold promise for improved delivery of en-


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Figure 2 Physicians Reporting That They Comprehensively* Provide Energy Balance Care

*Regularly assess body mass index, always/often provide energy balance counseling, and always/often systematically track/follow patients over time for progress.

ergy balance care. Realignment of primary care practices to emphasize teamwork, expanded roles for nonphysician office staff, routine and

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systematic assessment of health behaviors, and linkages to community resources may also lead to better care and outcomes.52 Our study provides an

SO WHAT? Implications for Health Promotion Practitioners and Researchers What is already known on this topic? Although national public health objectives and clinical practice guidelines prescribe a role for physicians to counsel their patients regarding better nutrition, physical activity, and/or weight control, only a minority of PCPs routinely provide diet and exercise counseling to their patients. What does this article add? This study uses data from a large, nationally representative survey to assess the organization of U.S. PCPs’ practices for providing energy balance care (i.e., assess, counsel, and/or monitor patients regarding diet, physical activity, and weight control). Prior literature on this topic is sparse and dated. We examined associations between specific features of PCPs’ practice settings (e.g., use of electronic medical records and reminders, and billing practices) with more frequent provision of energy balance care. What are the implications for health promotion practice or research? Improved support structures for providing energy balance care in PCP practices are needed. Further research to understand low levels of energy balance care delivery among obstetrician/gynecologists relative to other PCPs is also needed.

important baseline for assessing how anticipated improvements in primary care delivery may enhance the assessment, counseling, and referral of individuals who might benefit from energy balance care. Ongoing monitoring and evaluation of energy balance care delivery in primary care practice are imperative. Research to assess the effectiveness of system-level interventions is needed, as is further research to elucidate reasons for the particularly low levels of delivery of energy balance care among obstetri-



Table 4

2.

Logistic Regression Model† Assessing Physician and Practice/System Characteristics Associated With Physicians Who Reported Comprehensively‡ Providing Energy Balance Care (N ¼ 1740 Primary Care Physicians)§

3.

Comprehensively Provides‡ Energy Balance Care vs. Does Not, OR (95% CI) Physician characteristics

4.

Specialty Internal medicine Family medicine–adult Family medicine–child OB/GYN Pediatrics

0.93 0.73 0.28 1.78

1.00 (0.66–1.30) (0.50–1.09) (0.17–0.44) (1.26–2.51)

5.

Race/ethnicity Non-Hispanic White Non-Hispanic Asian Other||

1.00 1.63 (1.11–2.39) 1.87 (1.33–2.63)

6.

Practice/system characteristics Practice type Physician (owner) Physician (employee) Large medical group, health care system, HMO Hospital/clinic Other

1.61 0.99 1.17 1.07

1.00 (1.08–2.40) (0.68–1.44) (0.77–1.76) (0.61–1.89)

8.

Type of medical record system used Full EHR In transition to full EHR Partial EHR Paper charts Other

7.

1.74 (1.25–2.41) 1.33 (0.93–1.90) 1.02 (0.59–1.75) 1.00 0.74 (0.34–1.64)

9.


1.49 (1.07–2.09) 1.00 1.24 (0.87–1.76)

† Other model covariates included years since medical school graduation; gender; Census region; urban/rural location; practice size; whether the practice has a dietician, nutritionist, and/or health educator on staff; whether information resources on diet, weight control, and/or physical activity are available in waiting or exam rooms; whether a practice newsletter or Web site provided information about diet/nutrition, physical activity, and/or weight control in the past 12 months; and whether the practice uses reminder systems for patients receiving energy balance counseling within the practice or for patients referred out of the practice for this care. These covariates were not statistically significant in the multivariate model. ‡ Regularly assesses body mass index, always/often provides energy balance counseling, and always/often systematically tracks/follows patients over time for progress. § OR indicates odds ratio; CI, confidence interval; OB/GYN, obstetrics/gynecology; HMO, health maintenance organization; EHR, electronic health record; and NA, not ascertained. || Includes non-Hispanic black, Hispanic, other race/ethnicity. * Results that were statistically significant at p , 0.05 are noted in boldface type.

cian/gynecologists relative to other PCPs. Acknowledgments Data collection for the National Survey of Energy Balance– Related Care among Primary Care Physicians was supported by the National Cancer Institute under contract number N02-PC-61301. Survey cosponsors included the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute on Diabetes and Digestive and Kidney Diseases, the National Institutes of Health Office of Behavioral and Social Sciences


Research, and the Centers for Disease Control and Prevention. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the National Cancer Institute. We thank Richard Lee of Information Management Services Inc., Silver Spring, Maryland, for programming support.

References

1. Eheman C, Henley SJ, Ballard-Barbash R, et al. Annual report to the national on the status of cancer, 1975–2008, featuring cancers associated with excess weight and

10.

11.

12.

13.

14.

15.

16.

17.

lack of sufficient physical activity. Cancer. 2012;118:2338–2366. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among U.S. adults, 1999–2008. JAMA. 2010;303:235–241. US Department of Health and Human Services. The Surgeon General’s Vision for a Healthy and Fit Nation. Rockville, Md: US Department of Health and Human Services, Office of the Surgeon General; 2010. US Preventive Services Task Force. Behavioral counseling in primary care to promote a healthy diet: recommendations and rationale. Am J Prev Med. 2003;24:93– 100. US Preventive Services Task Force. Screening for obesity in adults: recommendations and rationale. Ann Intern Med. 2003;139:930–932. US Preventive Services Task Force. Screening for obesity in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Pediatrics. 2010;125:361–367. Moyer VA; U.S. Preventive Services Task Force. Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157:373–378. US Department of Health and Human Services. Healthy People 2020. Available at: http://www.healthypeople.gov. Accessed January 9, 2013. Institute of Medicine. Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation. Washington, DC: The National Academies Press; 2012. National Cancer Institute. Energy balance: weight and obesity, physical activity, diet. Available at: http://www.cancer.gov/ cancertopics/prevention/energybalance. Accessed April 4, 2013. Galuska DA, Will JC, Serdula MK, Ford ES. Are health care professionals advising obese patients to lose weight? JAMA. 1999; 282:1576–1578. Kreuter MW, Cheda SG, Bull FC. How does physician advice influence patient behavior?: evidence for a priming effect. Arch Fam Med. 2000;9:426–433. Petrella RJ, Lattanzio CN. Does counseling help patients get active?: systematic review of the literature. Can Fam Physician. 2002; 48:72–80. Dorsey R, Songer T. Lifestyle behaviors and physician advice for change among overweight and obese adults with prediabetes and diabetes in the United States, 2006. Prev Chronic Dis. 2011;8:A132. Grandes G, Sanchez A, Montoya I, et al. Two-year longitudinal analysis of a cluster randomized trial of physical activity promotion by general practitioners. PLoS One. 2011;6:e18363. Kottke TE, Foels JK, Choi T, Fenderson DA. Nutrition counseling in private practice: attitudes and activities of family physicians. Prev Med. 1984;13:219–225. Kushner RF. Barriers to providing nutrition counseling by physicians: a


e79


18.

19. 20.

21.

22.

23. 24.

25.

26.

27.

28.

29.

30.

31.

e80

survey of primary care practitioners. Prev Med. 1995;24:546–552. Ewing GB, Selassie AW, Lopez CH, McCutcheon EP. Self-report of clinical preventive services by U.S. physicians: comparing specialty, age, setting of practice, and area of practice. Am J Prev Med. 1999;17:62–72. Wee CC, McCarthy EP, Davis RB, Phillips RS. Physician counseling about exercise. JAMA. 1999;282:1583–1588. Ma J, Urizar G, Alegn T, Stafford RS. Diet and physical activity counseling during ambulatory care visits in the United States. Prev Med. 2004;39:815–822. Ma J, Xiao L. Assessment of body mass index and association with adolescent preventive care in U.S. outpatient settings. J Adolesc Health. 2009;44:502–504. Walsh JME, Swangard DM, Davis T, McPhee SJ. Exercise counseling by primary care physicians in the era of managed care. Am J Prev Med. 1999;16: 307–313. Briscoe JS, Berry JA. Barriers to weight loss counseling. J Nurse Pract. 2009;5:161–167. Kristeller JL, Hoerr RA. Physician attitudes toward managing obesity: differences among six specialty groups. Prev Med. 1997;26:542–549. Honda K. Factors underlying variation in receipt of physician advice on diet and exercise: applications of the behavioral model of health care utilization. Am J Health Promot. 2004;18:370–377. Hung DY, Rundall TG, Tallia AF, et al. Rethinking prevention in primary care: applying the chronic care model to address health risk behaviors. Milbank Q. 2007;85:69–91. Sesselberg TS, Klein JD, O’Connor KG, Johnson MS. Screening and counseling for childhood obesity: results from a national survey. J Am Board Fam Med. 2010; 23:334–342. Smith AW, Borowski LA, Liu B, et al. U.S. primary care physicians’ diet-, physical activity-, and weight-related care of adult patients. Am J Prev Med. 2011;41:33–42. Huang TTK, Borowski LA, Liu B, et al. Pediatricians’ and family physicians’ weight-related care of children in the U.S. Am J Prev Med. 2011;41:24–32. Rose SA, Turchin A, Grant RW, Meigs JB. Documentation of body mass index and control of associated risk factors in a large primary care network. BMC Health Serv Res. 2009;9:236. Arterburn DE, Alexander GL, Calvi J, et al. Body mass index measurement and


32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

obesity prevalences in ten U.S. health plans. Clin Med Res. 2010;8:126–130. Pronk NP, Krebs-Smith SM, Galuska DA, et al. Knowledge of energy balance guidelines and associated clinical care practices: the U.S. National Survey of Energy Balance Related Care among Primary Care Physicians. Prev Med. 2012; 55:28–33. Anis NA, Lee RE, Ellerbeck EF, et al. Direct observation of physician counseling on dietary habits and exercise: patient, physician, and office correlates. Prev Med. 2004;38:198–202. Pham HH, Schrag D, Hargraves JL, Bach PB. Delivery of preventive services to older adults by primary care physicians. JAMA. 2005;294:473–481. Christian AH, Mills T, Simpson SL, Mosca L. Quality of cardiovascular disease preventive care and physician/practice characteristics. J Gen Intern Med. 2006;21: 231–237. Balasuramanian BA, Cohen DJ, Clark EC, et al. Practice-level approaches for behavioral counseling and patient health behaviors. Am J Prev Med. 2008;35(5 suppl):S407–S413. Judkins D, Krenzke T, Piesse A, et al. Preservation of skip patterns and covariate structure through semi-parametric whole questionnaire imputation. Proceedings of the Joint Statistical Meetings [CD-ROM], pp. 3211–3218. Alexandria, Va: American Statistical Association; 2007. Judkins D, Piesse A, Krenzke T. Multiple semi-parametric imputation. Proceedings of the Joint Statistical Meetings [CDROM], pp. 48–58. Alexandria, Va: American Statistical Association; 2008. Piesse A, Judkins D, Fan Z. Item imputation made easy. Proceedings of the Survey Research Methods Section of the American Statistical Association [CDROM], pp. 2540–2546. Alexandria, Va: American Statistical Association; 2005. Abid A, Galuska D, Khan LK, et al. Are healthcare professionals advising obese patients to lose weight?: a trend analysis. MedGenMed. 2005;7:10. Lin SX, Gebbie KM, Fullilove RE, Arons RR. Do nurse practitioners make a difference in provision of health counseling in hospital outpatient departments? J Am Acad Nurse Pract. 2004; 16:462–466. Forman-Hoffman V, Little A, Wahls T. Barriers to obesity management: a pilot study of primary care clinicians. BMC Fam Pract. 2006;7:35.

43. Boyle M, Lawrence S, Schwarte L, et al. Health care providers’ perceived role in changing environments to promote healthy eating and physical activity: baseline findings from health care providers participating in the healthy eating, active communities program. Pediatrics. 2009;123(suppl 5):S293–S300. 44. Saraiya M, Berkowitz Z, Yabroff KR, et al. Cervical cancer screening with both human papillomavirus and Papanicolaou testing vs. Papanicolaou testing alone: what screening intervals are physicians recommending? Arch Intern Med. 2010;170: 977–985. 45. Yabroff KR, Klabunde CN, Yuan G, et al. Are physicians’ recommendations for colorectal cancer screening guidelineconsistent? J Gen Intern Med. 2011;26:177– 184. 46. Haggstrom DA, Klabunde CN, Smith JL, Yuan G. Variation in primary care physicians’ colorectal cancer screening recommendations by patient age and comorbidity. J Gen Intern Med. 2013;28:18– 24. 47. National Committee for Quality Assurance. Body mass index (BMI) assessment (BAA). Available at: http:// www.ncqa.org/portals/0/hedisqm/ hedis2009/2009_Measures.pdf. Accessed January 9, 2013. 48. Tsai AG, Asch DA, Wadden TA. Insurance coverage for obesity treatment. J Am Diet Assoc. 2006;106:1651–1655. 49. Internal Revenue Service; Employee Benefits Security Administration; Centers for Medicare & Medicaid Services. Group health plans and health insurance issuers relating to coverage of preventive services under the Patient Protection and Affordable Care Act final rules. Fed Regist. 2012;77:8725–8730. 50. Carpiano RM, Flocke SA, Frank SH, Stange KC. Tools, teamwork, and tenacity: an examination of family practice office system influences on preventive service delivery. Prev Med. 2003;36:131–140. 51. Klabunde CN, Willis GB, McLeod CC, et al. Improving the quality of surveys of physicians and medical groups: a research agenda. Eval Health Prof. 2012;35:477–506. 52. Green LA, Cifuentes M, Glasgow RE, Stange KC. Redesigning primary care practice to incorporate health behavior change: prescription for health round-2 results. Am J Prev Med. 2008;35(5 suppl): S347–S349.


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