Sue Flocke, PhD Eileen L. Seeholzer, MD MS Heidi Gullett, MD MPH Brigid Jackson, MA Samantha Smith, MA Elizabeth Antognoli, PhD Sue Krejci, MBA Peter J. Lawson, MA MPH MBA Practice-based Research Network Core staff Funding by a Cooperative Agreement from the CDC
• Background and context • Obesity prevalence • Primary care context • Current practice • Findings from part 1 of study: resident survey • Findings from part 2: curriculum audit • Preliminary findings from part 3: testing associations • Discussion
• Overweight/obesity • High prevalence in US and many other developed countries • Risk factor for many chronic conditions, including several cancers
• Overweight/obesity • Risk factor for many chronic conditions Coronary heart disease, stroke, and high blood pressure. Type 2 diabetes. Cancers, such as endometrial, breast, and colon cancer. Liver and gallbladder disease. Sleep apnea and respiratory problems. Osteoarthritis. Reproductive health complications such as infertility.
• Overweight/obesity prevalence • US - 34.9% of adults with BMI ≥30†; - 35% are overweight BMI 25-30 • Ohio - 30.%* • Cuyahoga County 26.3%^ • Cleveland 34.4%^ † NHANES data 2011,
• Overweight/obesity prevalence • Primary care practices: ~70-90% of adults obese or overweight with a chronic condition.
• Opportunity in primary care context • Potential to reach a large portion of the population • US Preventive Services Task Force recommendations • National Heart Lung & Blood Institute guidelines for clinicians • Assessment • Treatment
• Weight-related counseling is: • Not systematic • Not aligned with recommended methods shown to support behavior change. • Barriers include: • Physicians feel inadequately trained • Report low confidence (self-efficacy) • Report lack of time
1. Assess residents’ knowledge, attitudes, and self -efficacy to provide obesity, nutrition, and physical activity (ONPA) counseling. 2. Identify the scope and modalities of training for preparing primary care residents to provide ONPA counseling. 3. Examine resident characteristics and features of primary care programs including discipline, program settings, and modes of training associated with variation of resident knowledge, attitudes and self-efficacy for ONPA counseling.
• Cross sectional study design • Survey • Interview and document review • Analyses • Descriptive statistics • Structured coding of interview data • Bi-variate associations – t-test, chi square, anova, regression
Primary Care Resident Training Programs in Ohio Specialty Total N Study Sample Family Medicine 21 9 Internal Medicine 22 10 Obstetrics/Gynocology 11 6 Total 54 25 Target sample (24)
Senior residents – Third year residents for Family Medicine and Internal Medicine. Third and fourth year residents for OB/GYN
Survey conducted in person at scheduled conference session. Attendance was noted. Other strategies for follow up were pursued. A presentation about obesity management was offered.
Example items: “I’m confident in my ability to assist patients in developing a plan for physical activity” “Counseling patients to lose weight is not an efficient use of my time”
In-person survey= 145 Mailed surveys Online survey = 5 = 65 Online survey with raffle = 10
Table 1. Resident Characteristics n=220 Demographic characteristics % Female 59 Age, mean (SD) 30 (3) Race White 57 Black/African American 5 Asian 29 Other 10 US citizen 70 US medical school 69 Chief resident 27 Training characteristics % Specialty Family Medicine 22 Internal Medicine 55 OB/GYN 23 Half day outpatient clinic 2 (1) sessions/week, mean (SD) Elective rotation in ONPA 16
Table 2. Summary scores on 100 point scale ONPA domain Mean SD Min Max Counseling knowledge 54.41 12.87 22 83 Cancer risk knowledge 70.94 8.56 39 87 Attitude 54.86 13.97 21 92 Self-efficacy 51.66 16.90 0 100
Table 3a. Associations between residents’ ONPA counseling knowledge and demographic and training characteristics Counseling knowledge score B SE P Demographic characteristics Female 0.92 2.03 0.65 Age -0.02 0.30 0.94 Race White reference Black/African American -6.41 4.96 0.20 Asian -6.61 2.25 0.004 Other -6.22 3.33 0.06 US citizen 6.26 2.12 0.004 US medical school 5.11 2.16 0.02 Chief resident -4.04 2.20 0.07 Training characteristics Specialty Family Medicine reference Internal Medicine -4.35 2.43 0.08 OB/GYN -3.86 2.85 0.18 Half day outpatient clinic 0.00 0.72 1.00 sessions/week Elective rotation in ONPA 5.17 2.66 0.05
Table 3b. Associations between residents’ cancer risk knowledge and demographic and training characteristics Cancer risk knowledge score B SE P Demographic characteristics Female -0.12 1.45 0.93 Age -0.05 0.21 0.82 Race White reference Black/African American 2.19 3.67 0.55 Asian 0.29 1.62 0.86 Other -1.43 2.50 0.57 US citizen 0.24 1.61 0.88 US medical school 0.59 1.60 0.71 Chief resident 3.39 1.58 0.03 Training characteristics Specialty Family Medicine reference Internal Medicine -1.88 1.69 0.27 OB/GYN 3.43 1.95 0.08 Half day outpatient clinic 0.40 0.51 0.44 sessions/week Elective rotation in ONPA -2.63 1.81 0.15
Table 3c. Associations between residents’ attitudes and demographic and training characteristics Attitude score B SE P Demographic characteristics Female -2.34 2.14 0.28 Age 0.49 0.33 0.13 Race White reference Black/African American 3.52 4.85 0.47 Asian 5.52 2.31 0.02 Other 11.49 3.47 0.001 US citizen -9.12 2.23 <0.001 US medical school -11.17 2.20 <0.001 Chief resident -1.50 2.42 0.54 Training characteristics Specialty Family Medicine reference Internal Medicine 0.02 2.53 0.99 OB/GYN -5.97 2.97 0.05 Half day outpatient clinic -0.67 0.75 0.37 sessions/week Elective rotation in ONPA 13.99 2.75 <0.001
Table 3d. Associations between residents’ self -efficacy and demographic and training characteristics Self-efficacy score B SE P Demographic characteristics Female -5.69 2.63 0.03 Age 0.71 0.41 0.08 Race White reference Black/African American 1.11 6.32 0.86 Asian 1.76 3.03 0.56 Other 8.24 4.52 0.07 US citizen -4.08 2.83 0.15 US medical school -9.17 2.82 0.001 Chief resident -4.23 2.97 0.16 Training characteristics Specialty Family Medicine reference Internal Medicine -8.52 2.96 0.004 OB/GYN -16.98 3.46 <0.001 Half day outpatient clinic 2.21 0.93 0.02 sessions/week Elective rotation in ONPA 17.79 3.32 <0.001
Table 3e. Associations between residents’ professional norms and demographic and training characteristics Professional norms B SE P Demographic characteristics Female -2.62 1.92 0.17 Age 0.24 0.30 0.43 Hispanic/Latino 1.60 4.28 0.71 Race White reference Black/African American 7.16 4.29 0.10 Asian 5.72 2.09 0.01 Other 2.57 3.58 0.47 US citizen -7.86 2.05 <0.001 US medical school -7.89 2.12 <0.001 Chief resident -5.17 2.20 0.02 Training characteristics Specialty Family Medicine reference Internal Medicine -1.74 2.34 0.46 OB/GYN -11.31 2.78 <0.001 Half day outpatient clinic 0.01 0.72 0.99 sessions/week Elective rotation in ONPA 13.95 2.62 <0.001
• United States Medical Licensing Exam (USMLE) Step 1 after first two years of medical school • USMLE Step 2CK (clinical knowledge) and 2CS (clinical skills)
• Eligible to take USMLE Step 3 – when all 3 parts passed, may obtain unlimited medical license
Table 4a. Program characteristics (n=25) Total n=25 n % Location North Coast 9 36 Northeast 7 28 Northwest 3 12 Central/Southwest 6 24 Context University-based hospital 6 24 Community-based, university 17 68 affiliated hospital Community-based hospital 2 8 Setting Urban 22 88 Suburban 3 12 Semirural/Rural 0 0 mean % SD Payor mix Commercial 22.3 18.4 Medicaid 39.2 20.0 Medicare 23.9 14.8 Self-pay/Uninsured 13.5 12.3 Other 1.1 2.2 mean SD First year positions available annually 13 12.3 Total current residents 41 36.6 Current foreign medical graduates 11 13.2 Year program established 1970 13.7 Core faculty 11 6.2
Table 4b. Program characteristics (n=25) Formal opportunities for ONPA training n (%) mean (SD) Hours of didactics per year 254.7 (96.0) Hours of ONPA related didactics per year 2.7 (4.9) ONPA guidelines taught: Formally 4 (17) Informally 3 (13) Not taught 17 (71) Health behavior change counseling techniques taught 10 (42) HB change counseling techniques applied to ONPA 1 (10) Offers ONPA related track(s) 0 (0) Offers ONPA related fellowship(s) 6 (24) Blocks designated for electives 5.1 (3.6) Offers ONPA related elective(s)* 6 (86) Type of electives offered From list or create your own 6 (24) From list only 8 (32) Create your own only 10 (40) Not offered 1 (4) *Only includes programs that provided an electives list (n=7)
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