From the 2024 HVPA National Conference
Paul Nurse D.O. (Cleveland Clinic Foundation), Christina Hermanns M.D., Elizabeth Hahn M.D., Daniel Cancilla M.D., Meghna Nagam M.D., Christopher Black M.D., Bianca Honnekeri M.D., Aqieda Bayat M.D., Mohammad Alamer M.D., Helene Puzio D.O., Jessica Donato M.D.
Background:
Exercise has been proven to be one of the most effective lifestyle changes patients can make to combat chronic diseases and increase lifespan, yet primary care physicians do not routinely prescribe exercise to their patients.
Objectives:
A quality improvement project was initiated to increase the percentage of patients in the primary care clinics of internal medicine residents prescribed exercise as measured by documentation in the clinic note. We sought to increase the percentage of patients with documented exercise prescriptions in the primary care panels of internal medicine residents by 20% in 6 months.
Methods:
Baseline data was collected on 90 patients in the panels of nine internal medicine residents, who were seen for annual physicals or primary care follow-up visits within the prior three months at three ambulatory sites of our large academic medical center. Data included patient demographics, Charleston Comorbidity Index, and whether there was a documented discussion about exercise from their most recent clinic visit. The Key Performance Indicator (KPI) was calculated by taking the number of patients with documentation of exercise discussions in the note assessment/plan divided by the total number of patients seen. Given that most internal medicine residents did not feel they had enough knowledge about how to prescribe exercise, nor adequate resources to develop exercise prescriptions, our initial intervention incorporated the use of disease-specific exercise prescription handouts from the Exercise is Medicine® website, which have been developed by subject matter experts from the American College of Sports Medicine. To aid in this use of this resource and documentation of exercise prescriptions, the residents incorporated a smart phrase into the clinic note template, which provided access to the resources via a hyperlink and served as a prompt for documentation in the assessment/plan of the note of an exercise prescription.
Results:
Baseline data from the initial 90 patients showed an average age of 55.7 years, average BMI of 31, and an average Charleston Morbidity Score of 2.4. At baseline, only 6.5% of patients had documentation of a discussion about an exercise plan in their most recent clinic note’s assessment/plan. After the final Plan-Do-Study-Act (PDSA) cycle, the percentage of patients with documented exercise prescriptions had increased to 15.1%, resulting in a net increase of 8.6%. Qualitative feedback from residents was overwhelmingly positive.
Conclusions:
Prescribing exercise in the primary care panels of internal medicine residents is currently low, as measured by documentation in the clinic notes, and represents an important opportunity. By utilizing the disease-specific exercise prescription handouts from the Exercise is Medicine® website incorporated as a readily accessible resource with prompting in clinic note templates, the percentage of exercise prescriptions more than doubled after the final PDSA cycle as compared to baseline.
Clinical Implications:
Exercise is proven highly effective for reducing disease burden and increasing lifespan. This is a promising intervention to increase incorporation of exercise prescriptions into primary care practice, while also enhancing confidence and ability to prescribe exercise. Our intervention to increase exercise prescriptions has high generalizability to other ambulatory practices, and increased exercise prescriptions will improve the health of our patients.