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Increasing Screening and Interventions for Four Unhealthy Behaviors. Jim Mold, M.D., M.P.H. Dept. of Family and Preventive Medicine OUHSC, OKC. Jim Mold Cheryl Aspy Zsolt Nagykaldi Millisa Ellefson Eileen Merchen Cara Vaught Katy Smith. Mike Aaron Sharad Swami Tamara Hartsell

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increasing screening and interventions for four unhealthy behaviors

Increasing Screening and Interventions for Four Unhealthy Behaviors

Jim Mold, M.D., M.P.H.

Dept. of Family and Preventive Medicine


research team
Jim Mold

Cheryl Aspy

Zsolt Nagykaldi

Millisa Ellefson

Eileen Merchen

Cara Vaught

Katy Smith

Mike Aaron

Sharad Swami

Tamara Hartsell

Heather Tipsword

Ingrid Jackson

Suben Naidu

Zack Bechtol

Rene Russell

Shawn Anderson

Research Team
funding source
Funding Source

The Robert Wood Johnson Foundation

Project Period 7/1/2005 – 9/30/2007

  • More than 50% of premature deaths in the U.S. are the result of one or more of the four unhealthy behaviors: unhealthy diet, inadequate exercise, use of tobacco, abuse of alcohol
  • Effective screening methods exist for all four and effective brief counseling strategies are available for tobacco and alcohol and possibly exercise
  • Primary care clinicians are not consistently screening for these behaviors or intervening when they are discovered.
research question
Primary Research Question

Will a multi-component translational strategy result in the consistent and sustainable delivery of effective screening, very brief interventions, and counseling for improving diet, increasing exercise, and reducing cigarette and alcohol use among patients 14 years old and older being seen in primary care practices.

Research Question
research aims
Research Aims
  • Offer and provide the translational strategies - training, practice facilitation, quality circles, and peer support - to geographically clustered primary care practices, and determine rates of adoption, implementation, reach, and sustainability;
  • Estimate the cost of the translational intervention and the cost to the practices of implementation; and
  • In conjunction with other RWJF funded teams, estimate the effectiveness of systematic screening and behavioral interventions delivered in primary care settings.
practice interventions
Practice Interventions

Screening: Addition of evidence-based screening questions to the vital signs process

Very Brief Interventions: Referral to a community-based resource or provision of written educational material

Brief Counseling: 5 - 15 minute evidence-based counseling provided by the clinician

translational strategies
Translational Strategies

Chart Audit and Feedback: Chart audits Q1month to document proportion of patients screened and proportion receiving interventions

Training Modules: Three evidence-based training sessions (five modules) for clinicians and staff

Practice Facilitation: Coordination of QI activities and assistance with obstacles (e.g. form/template redesign; identification of community resources, etc.) by PEA

translational strategies9
Translational Strategies

Quality Circles: Q2month lunch meetings during which geographical clusters of practices met to review progress, address problems, and share successes

PI Visits: Q6month visits by PI during patient care activities to observe and ask questions about the processes, answer questions, and make suggestions.

training modules
Training Modules
  • Stages of change and motivational interviewing
  • Healthy eating and weight control
  • Exercise
  • Smoking cessation
  • Alcohol use reduction
training modules11
Training Modules
  • Pretest
  • General Information
  • Evidence regarding effectiveness of screening and brief interventions
  • Role play scenarios
  • Post-test

Training time was reimbursed and evidence-based (double) CME was awarded.

qi process pdsa cycles
QI Process: PDSA Cycles

PLAN: Small change proposed

DO: Trial in a small number of patient encounters

STUDY: Documentation of what happened

ACT: Decision regarding what to do next (expand, abandon, modify)

practice facilitation cont
Practice Facilitation (cont)
  • Identification of community resources
    • Weight loss programs
    • Alcohol counselor
  • Development of materials
    • Adolescent high-risk behaviors
  • Flow sheets and templates
    • Vital signs flow sheets
    • EHR templates
    • Wall charts

Interventions were introduced in 6-month cycles, each group of practices adding different interventions each cycle.

data collection
Data Collection
  • Practice Information Form (by practice facilitators)
  • Practice Assessment Template (by research assistant)
  • Knowledge Tests pre- and post-training (by clinicians and MA/nurse)
data collection16
Data Collection

Chart audits: 75 randomly-selected records; screening, VBI, BC at that visit

Patient surveys (pre-office visit and 1-month later via mail): patients recruited/enrolled by practice facilitator in practices’ waiting rooms; f/u surveys mailed by project manager

data collection17
Data Collection

Practice facilitator diaries

Field notes from quality circle meetings

PI and Co-PI notes










Field Notes

Patient Surveys






Plan-Do-Study-Act Cycles

Baseline Audit


PEA Audit

PEA Audit

PEA Audit

PEA Audit

PEA Audit

participating practices
Participating Practices

1. W. Oklahoma (Clinton/Weatherford)

  • Mike Aaron, M.D.
  • Sharad Swami, M.D.
  • Tamara Hartsell, NP

2. Central Oklahoma (OKC)

  • Heather Tipsword, D.O.
  • Ingrid Jackson, M.D.
  • Suben Naidu, M.D.

3. E. Oklahoma (Grove)

  • Zack Bechtol, M.D.
  • Rene Russell, M.D.
  • Shawn Anderson, M.D.
cost of the intervention
Cost of the Intervention

(Per 1000 patient encounters estimate)

Screening (1000): $200

Very brief interventions (400): $ 80

Brief counseling (50): $830

TOTAL: $1,110

cost of implementation
Cost of Implementation

(Per Cluster Estimate)

Project management: $2,080

Training and CME:

Trainers: $ 450

Trainees: $15,120

Practice facilitation: $6,750

Quality circles: $ 900

PI visits: $2,700

Travel and food: $8,000

TOTAL: $36,000

challenges and caveats
Challenges and Caveats
  • Alcohol screening
    • How to comfortably and effectively ask
    • Who should do it
    • How often (every encounter?)
  • Alcohol treatment resources
    • Availability
    • Issues of confidentiality in small towns
  • Overweight and obesity
    • Lack of effective approaches
    • Insurance coverage of surgery
  • EHR limitations
challenges and caveats33
Challenges and Caveats
  • Inadequate instruction and monitoring of exercise screening and interventions
  • Documentation issues in the practices