Exercise as a vital sign: a quasi-experimental analysis of a health system intervention to collect patient-reported exercise levels

Abstract

Background: Lack of regular physical activity is highly prevalent in U.S. adults and significantly increases mortality risk.

Objective: To examine the clinical impact of a newly implemented program ("Exercise as a Vital Sign" [EVS]) designed to systematically ascertain patient-reported exercise levels at the beginning of each outpatient visit.

Design and participants: The EVS program was implemented in four of 11 medical centers between April 2010 and October 2011 within a single health delivery system (Kaiser Permanente Northern California). We used a quasi-experimental analysis approach to compare visit-level and patient-level outcomes among practices with and without the EVS program. Our longitudinal observational cohort included over 1.5 million visits by 696,267 adults to 1,196 primary care providers.

Main measures: Exercise documentation in physician progress notes; lifestyle-related referrals (e.g. exercise programs, nutrition and weight loss consultation); patient report of physician exercise counseling; weight change among overweight/obese patients; and HbA1c changes among patients with diabetes.

Key results: EVS implementation was associated with greater exercise-related progress note documentation (26.2 % vs 23.7 % of visits, aOR 1.12 [95 % CI: 1.11-1.13], p < 0.001) and referrals (2.1 % vs 1.7 %; aOR 1.14 [1.11-1.18], p < 0.001) compared to visits without EVS. Surveyed patients (n = 6,880) were more likely to report physician exercise counseling (88 % vs. 76 %, p < 0.001). Overweight patients (BMI 25-29 kg/m(2), n = 230,326) had greater relative weight loss (0.20 [0.12 - 0.28] lbs, p < 0.001) and patients with diabetes and baseline HbA1c > 7.0 % (n = 30,487) had greater relative HbA1c decline (0.1 % [0.07 %-0.13 %], p < 0.001) in EVS practices compared to non-EVS practices.

Conclusions: Systematically collecting exercise information during outpatient visits is associated with small but significant changes in exercise-related clinical processes and outcomes, and represents a valuable first step towards addressing the problem of inadequate physical activity.

Figure 1

Sequential implementation of the “Exercise as a Vital Sign” program at four medical centers (EVS 1 – 4) from 4/2010 to 10/2011; 11 other medical centers (Non-EVS) in the same geographic region did not implement the EVS program during the study analysis period. N/A = not applicable. Note: The month during initial program implementation at each pilot medical center had <50 % exercise data collection per visit; these months were grouped with the “pre-EVS” months.