Exercise Recommendations in Primary Care: A Quality Improvement Initiative

By Jordan Feigenbaum, Emily Sanchez, Brandon Schabacker, and Movicque King

Updated 3/30/2016

Readers, I’m posting part of a quality improvement project I’ve been working on that I’ve referenced in an upcoming interview. I’m putting this on the website so people can access it, if needed, in the hopes that exercise- specifically resistance training and high intensity interval training will become more widely recommended at the doctor’s office. That said, this article by no means encompasses my thoughts on optimizing exercise recommendations in the primary care setting. Rather, those thoughts will be fully fleshed out in detail at a later date. Still, what follows below is what I consider to be the minimum acceptable recommendation for current healthcare providers in clinical practice.

Exercise promotion is generally considered to be a “good idea” by many in the medical field, however many physicians are unfamiliar with the current data on exercise as preventative medicine and subsequently do not provide adequate health promotion in this way. Unfortunately, “walk more” or exercise 30 minutes 3 times per week are the go-to recommendations for many practitioners despite the latest American College of Sports Medicine (ACSM) recommendations suggesting other modalities should be recommended or encouraged, e.g. high intensity interval training, moderate to vigorous activity, and resistance training. The usual quibble is that these modalities may be safe for healthy persons, but they are not appropriate for elderly or those with pre-existing conditions like hypertension, COPD, or osteoporosis. Interestingly, robust data exists supporting the efficacy and safety of the aforementioned exercise modalities in both the healthy and complicated patient population alike.

There are many obstacles to overcome to optimize exercise promotion in the primary care setting, such as the time limitations of a patient encounter, knowledge of evidence-based recommendations, and proper coding of the encounter that includes exercise promotion. In this quality improvement project we aim to provide an easily accessible resource for the primary care physicians to overcome these obstacles. The intent is to increase the percentage of the adult population in the clinic who meet or exceed the minimum activity recommendations to 20%. Those meeting the minimum activity recommendations set forth by the latest ACSM recommendations, which update the previous guidelines set forth by the American Heart Association (AHA) and ACSM, and the 2008 Physical Activity Guidelines for Americans (PAGA) [1]. The ACSM recommends that most adults engage in the following to meet activity minimums:

• Moderate-intensity cardiorespiratory exercise training for ≥30 min·d on ≥5 d·wk for a total of ≥150 min·wk; or
• Vigorous-intensity cardiorespiratory exercise training for ≥20 min·d on ≥3 d·wk (≥75 min·wk) or;
• A combination of moderate- and vigorous-intensity exercise to achieve a total energy expenditure of ≥500-1000 MET·min·wk.
• On 2-3 d·wk, adults should also perform resistance exercises for each of the major muscle groups

Currently, it is estimated that less than 10% of U.S. adults meet the physical activity guidelines set forth by the ACSM, AHA, or PAGA when objective measurements of activity, e.g. accelerometer, heart rate monitors, etc. are used to assess compliance [2]. Additionally, a large knowledge gap exists about the best practices for exercise counseling, prescription, and follow up in the adult population as evidenced by Walsh et al. who found that less than 12% (~6%)of the physicians surveyed were familiar with the current ACSM recommendations [3, 4]. Interestingly, only about half of physicians who felt they had adequate knowledge on exercise actually counseled their patients on exercise [4]. Finally, Schultzer et al. found that older patients are more likely to change behaviors as suggested by their doctor because they have both increased respect for their physician’s advice and they have regular contact with their family doctor [5].

In the latest ACSM position stand on exercise, Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently Healthy Adults, an update to their and the AHA’s recommendations published in the 2008 Physical Activity Guidelines for Adults, the current recommendation is for each adult to obtain ≥30 min·d on ≥5 d·wk moderate-intensity cardiorespiratory exercise training for for a total of ≥150 min·wk or ≥20 min·d on ≥3 d·wk vigorous-intensity cardiorespiratory exercise training for ≥75 min·wk) or a combination of moderate- and vigorous-intensity exercise to achieve a total energy expenditure of ≥500-1000 MET·min·wk. The Borg-Warner Rate of Perceived exertion scale, originally published in 1970, has been validated for exercise intensity estimation [7,8]. In addition, AHA advises that patients can use this scale to make sure they are complying with the current exercise recommendations [6]. In sum, our project aims to use the latest ACSM exercise recommendations along with the Borg-Warner RPE scale to improve exercise promotion such that the at least 20% of the adult patient population at PFM meets the minimum recommended activity recommendations.

To begin, most practices have an initial encounter form that nurses fill out with information pertaining to that day’s visit (vitals, reason for visit, etc.). A few simple questions could be added to this form to begin the discussion and have the patient start thinking and considering their exercise habits. Question 1 would include: How many days per week are you exercising? Question 2 would include: Rate the level of intensity of exercise you are performing based on the Borg Warner Scale (see Figures 1 and 2).

Figure 1. Introductory questions for patient. This is known as the Patient Activity Vital Sign (PAVS)

Figure 2. Borg-Warner Rate of Perceived Exertion Scale for patient determination of current activity levels.

These two questions would give the physician an initial idea of how often, and at what level that person is exercising. As with the other information that is taken on the initial encounter form, this information would also be added into that day’s note in the patient’s electronic medical record. This way, the physician can quickly look back at the previous notes and assess progress in the patient’s exercising habits. Carrying out the process in this way will also allow for patient’s to be asked the same question at every visit, hopefully encouraging them to make progress.

To assist patient’s in rating the level of their exercise, and to make sure they are following current recommendations, a handout will be given to them explaining the Borg Rating of Perceived Exertion Scale (See Figure 3).

Figure 3. Proposed handout for patients.

Lastly, exercise counseling can be included in billing purposes. Under the previous ICD-9 codes, V65.41 is specific for exercise counseling and underICD 10 codes use Z71.89 . Also, coding guidelines for CPT Preventative Medicine Services include individual preventive medicine counseling codes 99401–99404 which are used to report counseling services in areas such as family problems, diet, and exercise

All graphics, text, etc. are free from copyright and are open for use if desired. Please contact us at info@barbellmedicine.com if you are using these materials. We’d love to help!

Update:

For medical students, residents, and other healthcare professionals, my colleagues and I have generated a learning module that we’re sharing via SlideShare. We’re also including a pre-test (to be taken before viewing the powerpoint) and a post-test for data collection and quality improvement. If you have a few spare moments, go ahead and take them at the appropriate times 🙂

Pre Test (click here)

[slideshare id=60241505&doc=eimcccproject-160330195627]

References:

1. Garber, Carol Ewing, Bryan Blissmer, Michael R. Deschenes, Barry A. Franklin, Michael J. Lamonte, I-Min Lee, David C. Nieman, and David P. Swain. “Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently Healthy Adults.” Medicine & Science in Sports & Exercise (2011): 1334-359.

2. Tucker, Jared M., Gregory J. Welk, and Nicholas K. Beyler. “Physical Activity in U.S. Adults Compliance with the Physical Activity Guidelines for Americans.” American Journal of Preventative Medicine4 (2011): 454-61.

3. King, Abby C., W. Jack Rejeski, and David M. Buchner. “Physical Activity Interventions Targeting Older Adults A Critical Review and Recommendations.” American Journal of Preventative Medicine4 (1998): 316-33.

4. Walsh, J., DM Swangard, T. Davis, and SJ McPhee. “Exercise Counseling by Primary Care Physicians in the Era of Managed Care.” American Journal of Preventive Medicine4 (1999): 307-13.

5. Schultzer, K., and B. Sue Graves. “Barriers And Motivations To Exercise In Older Adults.” Preventive Medicine5 (2004)

6. Moderate to Vigorous – What is your level of intensity? American Heart Association -Fitness Basics. American Heart Association, 20 Mar. 2014. Web. 2 Feb. 2015. http://www.heart.org/HEARTORG/GettingHealthy/PhysicalActivity/FitnessBasics/Moderate-to-Vigorous—What-is-your-level-of-intensity_UCM_463775_Article.jsp

7. Utter, Alan C.. “ACSM Current Comment Perceived Exertion.” American College of Sports Medicine . ASCM, n.d. Web. 2 Feb. 2015. <http://www.acsm.org/docs/current-comments/perceivedexertion.pdf?sfvrsn=4>.

8. Borg, G. “Perceived exertion as an indicator of somatic stress”. Scandinavian journal of rehabilitation medicine 2 (2). 1970 92–98.