Sue Flocke, PhD Eileen L. Seeholzer, MD MS Heidi Gullett, MD MPH

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2 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

3 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

4 Overweight/obesity High prevalence in US and many other developed countries Risk factor for many chronic conditions, including several cancers

5 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.

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7 Overweight/obesity prevalence US % of adults with BMI 30 ; - 35% are overweight BMI Ohio - 30.%* Cuyahoga County 26.3%^ Cleveland 34.4%^ NHANES data 2011,

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9 Overweight/obesity prevalence Primary care practices: ~70-90% of adults obese or overweight with a chronic condition.

10 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

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12 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

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14 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.

15 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

16 Primary Care Resident Training Programs in Ohio Specialty Total N Study Sample Family Medicine 21 9 Internal Medicine Obstetrics/Gynocology 11 6 Total Target sample (24)

17 Senior residents Third year residents for Family Medicine and Internal Medicine. Third and fourth year residents for OB/GYN

18 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.

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21 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

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25 In-person survey= 145 Mailed surveys = 5 Online survey = 65 Online survey with raffle = 10

26 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 sessions/week, mean (SD) 2 (1) Elective rotation in ONPA 16

27 Table 2. Summary scores on 100 point scale ONPA domain Mean SD Min Max Counseling knowledge Cancer risk knowledge Attitude Self-efficacy

28 Table 3a. Associations between residents ONPA counseling knowledge and demographic and training characteristics Demographic characteristics B SE P Female Age Race White Black/African American Asian Other US citizen US medical school Chief resident Training characteristics Specialty Family Medicine Internal Medicine OB/GYN Half day outpatient clinic sessions/week Counseling knowledge score reference reference Elective rotation in ONPA

29 Table 3b. Associations between residents cancer risk knowledge and demographic and training characteristics Demographic characteristics B SE P Female Age Race White Black/African American Asian Other US citizen US medical school Chief resident Training characteristics Specialty Family Medicine Internal Medicine OB/GYN Half day outpatient clinic sessions/week Cancer risk knowledge score reference reference Elective rotation in ONPA

30 Table 3c. Associations between residents attitudes and demographic and training characteristics Demographic characteristics B SE P Female Age Race White Black/African American Asian Other US citizen <0.001 US medical school <0.001 Chief resident Training characteristics Specialty Family Medicine Internal Medicine OB/GYN Half day outpatient clinic sessions/week Attitude score reference reference Elective rotation in ONPA <0.001

31 Table 3d. Associations between residents self-efficacy and demographic and training characteristics Demographic characteristics B SE P Female Age Race White Black/African American Asian Other US citizen US medical school Chief resident Training characteristics Specialty Family Medicine Internal Medicine OB/GYN <0.001 Half day outpatient clinic sessions/week Self-efficacy score reference reference Elective rotation in ONPA <0.001

32 Table 3e. Associations between residents professional norms and demographic and training characteristics Demographic characteristics B SE P Female Age Hispanic/Latino Race White Black/African American Asian Other US citizen <0.001 US medical school <0.001 Chief resident Training characteristics Specialty Family Medicine Internal Medicine OB/GYN <0.001 Half day outpatient clinic sessions/week Professional norms reference reference Elective rotation in ONPA <0.001

33 United States Medical Licensing Exam (USMLE) Step 1 after first two years of medical school USMLE Step 2CK (clinical knowledge) and 2CS (clinical skills)

34 Eligible to take USMLE Step 3 when all 3 parts passed, may obtain unlimited medical license

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39 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 affiliated hospital Community-based hospital Setting Urban Suburban 3 12 Semirural/Rural 0 0 mean % SD Payor mix Commercial Medicaid Medicare Self-pay/Uninsured Other mean SD First year positions available annually Total current residents Current foreign medical graduates Year program established Core faculty

40 Table 4b. Program characteristics (n=25) Formal opportunities for ONPA training n (%) mean (SD) Hours of didactics per year (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)

41 Table 4c. Program characteristics (n=25) Informal opportunities for ONPA training n (%) mean (SD) Half-days per week in continuity clinic 1.7 (0.9) Clinical care blocks 39.2 (4.4) Hospital (inpatient) 18.8 (4.6) Specialty rotations** 10.4 (4.3) Ambulatory (outpatient) 7.5 (3.7) Emergency Department 1.2 (1.0) Allied health professional engagement Type Dietitian / Nutritionist 18 (78) Diabetes educator 11 (48) Nurse educator 7 (30) Nurse practitioner / Nurse-midwife 7 (30) Role Available for referrals 19 (83) Provides didactics 9 (39) Available for questions/consults 8 (35) Part of outpatient group visit/team approach 6 (26) Patient care only 6 (26) Part of inpatient rounding 4 (17) ** Includes elective blocks

42 Table 5. Program characteristics (n=25) Mean SD P-value Counseling knowledge ONPA related didactics N Y HB change counseling techniques taught N Y ONPA related fellowship(s) N Y Allied health professional provides didactics N Y Attitudes ONPA related didactics N Y <0.001 HB change counseling techniques taught N Y ONPA related fellowship(s) N Y Allied health professional provides didactics N Y Self-efficacy ONPA related didactics N Y HB change counseling techniques taught N Y ONPA related fellowship(s) N Y Allied health professional provides didactics N Y

43 Table 6. ICCs ProgramID Residual ICC % Attitude Self-efficacy Counseling knowledge Cancer risk knowledge

44 High level of variability in primary care residents preparedness to counsel for obesity. There is significant room for improvement in knowledge of recommended methods of obesity assessment and treatment and self-efficacy for behavior change counseling. We did not expect or find significant associations between resident demographic characteristics and outcomes. Participation in an elective on an ONPA topic was strongly associated with increased self-efficacy

45 Our assessment of the program curriculum relatively few hours of formal curriculum devoted to ONPA topics informal opportunities through precepting and engagement of allied health professionals were more common. However, the degree of exposure to informal opportunities is difficult to assess.

46 Study limitations Modest response rate, despite multiple strategies to maximize participation Ohio-centric sample of programs Imprecise measurement of some program features; curriculum cycles. Study strengths Relatively large sample of programs; multiple specialties represented Resident survey and program features assessed Strong survey measures with good variability

47 Evaluate the association of program features with resident knowledge, attitudes and self-efficacy. Multi-level analysis

48 For primary care clinicians to effectively play a part in addressing the obesity epidemic, 1) Clinicians need to be better equipped with knowledge and counseling skills to be effective team players. 2) Better systems for documenting and tracking, 3) Better alignment of incentives for training and practice

49 We wish to thank the residency programs and resident physicians that participated in this study. This project was funded by a grant to Susan A. Flocke, U48-Supplement 3U48DP S3 to

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52 Four Components of Successful Weight Loss Low calorie diet Set a weight goal Regular physical activity Monitor weight loss

53 Key Knowledge about obesity that change treatment approach

54 Key Knowledge about obesity that changes treatment approach