Implementation and Evaluation of the Exercise is Medicine Program in Primary Care

SARAH LINKE
University of California San Diego

Insufficient physical activity (PA) is a leading risk factor for most chronic health conditions. Identifying patients at higher risk of these conditions due to their insufficient levels of PA is one of the highest priorities given the evidence suggesting that insufficient PA poses as much of a risk to patients’ health as other established risk factors that are routinely addressed within the primary care setting (e.g., smoking, hypertension, obesity) and creates a significant financial burden on the healthcare system. Numerous interventions effectively increase PA, but few are integrated into primary care clinic workflows. Exercise is Medicine (EIM) is a global health initiative committed to the belief that PA is integral to the prevention and treatment of diseases and should be routinely assessed as a vital sign and treated in the healthcare setting.

This paper describes an in-progress embedded quality improvement (QI) project that integrates EIM into routine clinical practice. A combination of implementation science (IS) and QI models are used to adapt, implement, and evaluate the integration of EIM into six primary care clinics on a rolling basis.

The Practical, Robust Implementation and Sustainability Model (PRISM) guided pre-implementation evaluation and adaptation of EIM protocol, materials, and delivery strategies. The Learning Evaluation QI model is used to design, test, refine, and implement EIM using rapid, 3-month Plan Do Study Act micro-cycles. The Stirman Framework is used to document adaptations to the program throughout implementation. Reach, adoption, implementation, effectiveness, and maintenance (RE-AIM) outcomes embedded within PRISM are used to guide the program evaluation to determine sustainability and scalability. Data is obtained through the electronic medical record (EMR) and periodic patient surveys.

In terms of adoption and reach, a total of 38,899 PAVS (Physical Activity Vital Sign) self-reported questionnaires have been recorded in the EMR, representing a total of 17,275 unique patients, which translated to 35%, 43%, 82, and 87% of all patients seen in each of the four clinics (integrated on a rolling basis). Implementation of the different program components (screening, diagnosis, PCP discussion, documentation, prescription, and optional health coaching) has been high with the exception of documentation. Patients recalled discussing PA with their PCPs and/or receiving information about exercise in 73% of visits. Effectiveness and maintenance will be evaluated in the next 3 years. Discussion: Using an innovative approach of combining IS and QI methods to improve the identification of primary care patients with insufficient PA to increase their activity levels has great population health potential. Our work will inform best approaches for EIM integration in primary care.