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Direct observation of exercise counseling in community family practice

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Abstract

Background: Although physical activity is important for the prevention and management of a variety of common chronic diseases, the prevalence and patient and visit characteristics associated with provision of physical activity advice by community family physicians is not well understood.

Methods: In a cross-sectional multi-method study of 138 family physicians in northeast Ohio, exercise advice was measured by direct observation and patient report of consecutive patient visits to 138 practicing family physicians. The association of exercise advice with patient and visit characteristics, assessed by direct observation, medical record review, patient exit questionnaire, and billing data, was determined by logistic regression analysis.

Results: In 4215 visits by patients older than 2 years of age, exercise counseling was observed during 927 visits (22.3%), but reported by only 13% of patients returning questionnaires. The mean time spent counseling about exercise was 0.78 minutes, with a range of 0.33 to 6.00 minutes (SD = 0.67). Exercise advice was more common during longer visits, visits for well care, and visits by patients who were older, male, and had chronic illnesses for which lack of physical activity is a risk factor.

Conclusions: Exercise counseling is relatively common during outpatient visits to family physicians, and is more commonly given to patients with risk factors. Multiple patient visits over time present opportunities to integrate exercise counseling among the competing demands of primary care practice.

Introduction

S edentary behavior has been associated with a variety of illnesses.1, 2 Yet, 24% of individuals over 18 years of age engage in no physical activity,3 and 30% engage in such a minimal amount of physical activity that they fail to derive any significant physiologic benefit.4

Despite the well-established benefit of physical activity for health, the U.S. Preventive Services Task Force found insufficient evidence to support the effectiveness of exercise counseling by clinicians (“C” recommendation).1 Nonetheless, various medical organizations recommend that physicians assume an active role in this area.1 Several studies have found a beneficial effect of clinician exercise advice.5, 6, 7 Furthermore, patients have made it clear that they would like to receive information about exercise from their health care providers.8

Despite the potential benefits of exercise advice, one survey found that physicians report low but variable rates of exercise counseling.3 However, the actual frequency of exercise counseling is not known, since physician self-report has been shown to overestimate rates of service delivery, while medical record review underestimates provision of health habit counseling.9, 10

The objective of this study was to assess the true prevalence of exercise counseling by community family physicians by directly observing outpatient visits, and to ascertain patient and visit characteristics associated with provision of exercise counseling. Such information would be useful in understanding current medical practice and in designing interventions to increase provision of exercise advice in community primary care practice.

Section snippets

Study design and data collection

This study was part of the Direct Observation of Primary Care (DOPC) Study, for which the methods have been described in detail previously.10, 11 Briefly, members of the Ohio Academy of Family Physicians practicing in northeastern Ohio were invited to participate in a study of the content of family practice. Of the 531 physicians solicited, 138 agreed to participate.

Research nurses visited participating physicians on two separate days and enrolled consecutive outpatients who provided verbal

Results

The demographics of the physician sample have been described previously.10, 11 The sample is similar to national samples of family physicians in age and number of patients seen per week, but over-represented residency-trained and female physicians.17 The patient profile was similar to the National Ambulatory Care Survey.10

Of the 4215 visits for which direct observation data were available, exercise counseling was performed in 20.1% of visits. Among 3152 patients completing an exit

Discussion

Approximately one in five visits to community family physicians involved exercise advice. Physicians tailored their provision of exercise advice to patients with specific diseases for which increased physical activity is known to have clinical benefit. The continuity of care that these clinicians provide this patient population (averaging slightly over four visits per year)11 shows the opportunity of primary care practice to provide health habit advice over time. However, the observation that

Acknowledgements

The authors are further indebted to the physicians and office staff members of the Research Association of Practicing Physicians, and to their patients, without whose participation this study would not have been possible.

This study was supported by grants from the National Cancer Institute (1RO1 CA80862 and 2RO1 CA80862), a Family Practice Research Center grant from the American Academy of Family Physicians, and a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar Award to Dr.

References (27)

  • B.A. Swinburn et al.

    The green prescription studya randomized control trial of written exercise advice provided by general practitioners

    Am J Public Health

    (1998)
  • D.E. Montaño et al.

    Cancer screening by primary care physiciansa comparison of rates obtained from physician self-report, patient survey, and chart audit

    Am J Public Health

    (1995)
  • K.C. Stange et al.

    How valid are medical records and patient questionnaires for physician profiling and health service research? A comparison with direct observation of patient visits

    Medical Care

    (1998)
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