Implementation and evaluation of Exercise is Medicine in primary care clinics within a large academic health system

Abstract

Objective: Exercise is Medicine (EIM) is a global initiative encouraging healthcare providers to routinely assess and promote physical activity (PA) among patients. The objective of this study was to evaluate the feasibility, adoption, implementation and effectiveness of EIM from patient, clinician and healthcare staff perspectives using a combination of electronic health record (EHR), survey and interview data.

Design: This study used a combination of the Practical Robust Implementation and Sustainability Model (PRISM) and the Learning Evaluation model to implement EIM. Data captured from the EHR, including Physical Activity Vital Sign (PAVS) scores, and data collected from qualitative surveys and interviews were used to evaluate the programme's Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM, which is embedded within PRISM) from provider, staff and patient perspectives.

Setting: Five primary care clinics within a large academic health system.

Participants: A total of 24 443 patients from all participating clinics had at least one PAVS score during the study period. A total of 17 clinicians completed surveys, and 4 clinicians, 8 medical assistants and 9 patients completed interviews.

Results: Implementation fidelity metrics varied widely between components and across clinics but were generally consistent over time, indicating a high degree of programme maintenance. Fidelity was highest during the first 6 months of the COVID-19 pandemic when most visits were virtual. Mean PAVS scores increased from 57.7 (95% CI: 56 to 59.4) to 95.2 (95% CI: 91.6 to 98.8) min per week at 6 months for patients not meeting PA guidelines at baseline and decreased from 253.84 (95% CI: 252 to 255.7) to 208.3 (95% CI: 204.2 to 212.4) min per week at 6 months for patients meeting PA guidelines at baseline. After EIM implementation, clinician-estimated time spent discussing PA with patients increased for 35% of providers and stayed the same for 53%.

Conclusion: Overall, this study established EIM's feasibility, adoption, implementation and maintenance in routine primary care practice within a large academic health system. From a population health perspective, EIM is a model to emulate to help primary care providers efficiently address healthy lifestyle behaviours in routine primary care visits.

Keywords: Chronic Disease; Health Behavior; Health Promotion; Preventive Medicine; Primary Health Care.

Figure 1

EIM workflow at the UC San Diego health primary care clinics. AVS, After Visit Summary; EIM, Exercise is Medicine; PA, physical activity; PAVS, Physical Activity Vital Sign; PCPs, primary care providers.

Figure 2

(A) PAVS over time by meeting guidelines versus not at baseline; (B) PAVS over time by having type 2 diabetes versus not; (C) PAVS over time by having hypertension versus not; (D) PAVS over time by obesity status. BMI, body mass index; PA, physical activity; PAVS, Physical Activity Vital Sign.

Figure 3

(A) Body mass index (BMI) over time by baseline PAVS—meeting guidelines versus not meeting guidelines; (B) systolic blood pressure (SBP) over time by baseline PAVS—meeting guidelines versus not meeting guidelines; (C) diastolic blood pressure (DBP) over time by baseline PAVS—meeting guidelines versus not meeting guidelines. PA, physical activity; PAVS, Physical Activity Vital Sign.

Figure 4

PAVS over time according to health coaching question (HCQ) and visit (HCV) status. PA, physical activity; PAVS, Physical Activity Vital Sign.