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What is a physician’s greatest opportunity to influence patients’ long-term health outcomes? It’s not a particular treatment, prescription, or procedure. It’s a simple dose of advice. Physician counseling helps patients reduce their health risk behaviors and their chances of developing life-threatening diseases.
That is a maxim of preventive medicine. But here’s another reason to improve your delivery of preventive health care: It will bring you a higher "quality" score. Physicians are being measured not just according to the screening tests they provide patients, but also by the advice they give, and health plans collect and review those measurements.
For example, the Health Plan Employer Data and Information Set (HEDIS) 3.0 of the National Committee for Quality Assurance in Washington, DC, measures whether or not physicians counsel patients to quit smoking. Future measures may include substance abuse counseling and management of cholesterol among heart disease patients. (For information about a program that can help improve your HEDIS scores, see story, p. 77.)
The Foundation for Accountability (FACCT), a health care purchaser and consumer coalition based in Portland, OR, also incorporates both risk assessment and counseling into its measures. Health plans also can delegate their preventive health accreditation requirements to physician organizations, and medical groups can now receive certification from the NCQA in preventive health. (See related story, p. 73.)
"We know that lifestyle and health risk behaviors have an enormous impact on health," says Christina Bethell, PhD, MPH, MBA, director of accountability measurement for FACCT. "We need to make them a priority and try to be innovative and successful in addressing them."
Most physicians believe they already do a good job counseling their patients about health risks such as smoking. But most do not. A recent analysis of the Behavioral Risk Factors Surveillance Survey in Connecticut found that only 29% of obese patients who had a routine checkup in the past year said they had been advised to lose weight by a physician, nurse, or other health professional.
Other studies have found similar low rates of advise about smoking cessation, exercise, and diet. (For tips on improving preventive services, see related story, p. 78.)
Do you assume that patients already know what they should be doing and wouldn’t listen to a physician, anyway? Think again. The Connecticut study found that 89% of those who had been advised to lose weight were trying to do so, compared with 52% of those who had not received medical advice.
"Physicians need to understand that they do have a really important role here in motivating their patients," says Mary L. Adams, MPH, MS, an epidemiologist with the Connecticut Department of Public Health.
In the new preventive care paradigm, a health risk assessment produces a patient’s "diagnosis" and indicates necessary interventions, such as smoking cessation counseling. Outcomes measures determine whether the patient received the assessment and counseling and whether he or she complied with intervention, such as cutting back on the number of cigarettes or quitting completely.
Getting patients to change their lifestyles is difficult. But so is altering physicians’ priorities.
"[Physicians] went to medical school to take care of sick people," says Edwin Hutchins, PhD, president of the Healthier People Network, which promotes risk assessment and counseling through a software-based appraisal. (For more information on the Health Risk Appraisal, see story, p. 78.) "Our culture and society is in a quantum shift in how we think about medicine."
The Health Risk Appraisal, which was developed by the federal Centers for Disease Control and Prevention and The Carter Center, both in Atlanta, computes a patient’s individual risk of dying of various diseases or events, such as homicide, based on scientific findings about risk factors and epidemiological data.
Within minutes of filling out a 43-question survey, patients receive a computer printout that gives them a risk profile and tells them how many years they could add to their lives by making lifestyle changes.
Physicians can then suggest specific programs or diets or provide educational material, Hutchins says. Failing to give patients a "prescription" for better health is akin to diagnosing a patient’s disease then sending them away without any treatment, he says.
"[The Health Risk Appraisal] helps patients prioritize a group of risks and understand how important they are [to them personally]," says Hutchins. In one example, a risk appraisal computed for an overweight woman with diabetes indicates that smoking and high blood pressure are her greatest risk factors. Therefore, focusing on those issues would bring her the greatest benefit.
Why do you need a risk assessment if you already take a complete medical history? Often, risk assessments include questions or details not included in the typical history.
For example, FACCT’s risk assessment questionnaire that can be used to survey patient populations or assess individual patients, includes questions about firearms ownership and storage, as well as smoking, exercise, and alcohol use. "We wanted to make it standardized and simple," says Bethell, who adds that research and testing found the risk factor questions elicit both reliable and important information from patients.
The Texas Department of Health annually uses a 19-topic health risk profile that guides physicians, nurses, or other health professionals as they ask questions of patients, says Crystal Wilkinson, MSN, RN, CNS. Wilkinson is an adult health program specialist with the Texas Department of Health in Austin. The profile includes such items as nutrition, seat belt use, smoke detectors, and family planning. Clinic sites that receive funding from the department must use the assessment with patients at least once a year.
Alert stickers are placed on the charts of patients identified with risks such as high blood pressure, heart disease, or smoking to remind physicians and nurses that they require follow-up or patient education.
Patients appreciate the advice and attention to health-related lifestyle issues, says Wilkinson. "The patients love having someone sit down and talk to them and give them education in a way they can understand it," she says.
"You establish a trusting relationship and a teaching relationship," she says. "You figure out what their interests are and how you can influence behavior change."
This may sound like one more burden when the physician visit is already under increasing time pressure. But preventive medicine experts say risk appraisal and counseling don’t have to be time-consuming for the physician.
A nurse or patient education specialist can administer the risk assessment, patient education, and follow-up, preventive medicine experts say. Still, at some point, the physician needs to address the important risk factor issues with the patient directly, says Bethell.
"The doctor doesn’t need to be the one to do a lot of the work," she says. "But the doctor has a lot of power in the patient’s mind, so hearing it from the doctor can make a difference."