A Medical Assistant–Based Program to Promote Healthy Behaviors in Primary Care

Earlier in this decade, the United States Preventive Services Task Force concluded that there is insufficient evidence to recommend for or against routine behavioral counseling to promote a healthy diet or physical activity in unselected patients in primary care settings. 1, 2 Simply put, the occasional advice that we clinicians can deliver in our offices is no match for the intense and repeated behavior modeling that our patients receive every day from mass media and social contacts: “Sit, watch TV, snack, and, when your belly sticks out too far, wear your shirt outside of your pants.”

Not giving up on the goal of promoting healthy behaviors, Ferrer et al. used medical assistants to identify and refer patients who might benefit from behavior change support.3 They evaluated the intervention with a randomized trial. This innovative program tripled the rate at which patients were referred to various lifestyle support programs, but the five percentage-point improvement in behavioral outcomes was not statistically significant. Perhaps the improvement might have been significant if the sample size had been as large as they had planned, but even so, the improvement would have been modest.

This forward thinking trial documents that, as are clinical services, the resources that are currently available in a community are no match for the physical and social environment that promotes unhealthy behaviors. New approaches are needed to help patients adopt healthy lifestyles. We suggest that partnerships between primary care practices and worksite based health promotion programs might meet this need.

Because the majority of adult Americans are employed and the worksite is the dominant social setting for employed individuals, the Institute for Clinical Systems Improvement (ICSI) guideline for the prevention of chronic disease risk factors emphasizes the importance of the worksite as a partner in the promotion of healthy lifestyles.4 When delivered both systematically and intensely, worksite health promotion services improve health indicators, reduce health care costs, and increase productivity to such an extent that the employer experiences a positive return on investment within an acceptable period of time.5, 6 Worksite programs can’t help everyone, but when directed at both employees and dependents, it appears that at least 80% of the adult population would be covered.

As a next phase of research, we would like to see primary care groups partner with worksite health promotion programs and employers to implement interventions that address the very important lifestyles that Ferrer at al3 addressed. Because these behaviors are responsible for about half of all deaths in the United States7, 8 and because more than 80% of all health care costs for Americans are delivered to patients who have preventable chronic conditions,9 success would transform the health and health economics of our patients and our communities.

Thomas E. Kottke, MD, MSPH Medical Director for Evidence-Based Health HealthPartners Minneapolis, Minnesota thomas.e.kottke@healthpartners.com
Nicolaas P. Pronk, PhD Vice President and Health Science Officer, JourneyWell HealthPartners Minneapolis, Minnesota nico.p.pronk@healthpartners.com

References
1. U.S. Preventive Services Task Force. Physical Activity Counseling. 2002. (Accessed at http://www.ahrq.gov/clinic/uspstf/uspsphys.htm.)
2. U.S. Preventive Services Task Force. Counseling for a Healthy Diet. 2003. (Accessed at http://www.ahrq.gov/clinic/uspstf/uspsdiet.htm.)
3. Ferrer RL, Mody-Bailey P, Jaen CR, Gott S, Araujo S. A medical assistant-based program to promote healthy behaviors in primary care. Ann Fam Med 2009;7:504-12.
4. Chronic Disease Risk Factors, Primary Prevention of (Guideline). Minneapolis, Minnesota: Institute for Clinical Systems Improvement; 2008 March.
5. Thygeson NM, Gallagher J, Cross K, Pronk NP. Employee health at BAE Systems: An employer-health plan partnership approach. In: Pronk NP, ed. ACSM’s Worksite Health Handbook A Guide to Building Healthy and Productive Companies. 2nd ed. Champaign, IL: Human Kinetics; 2009.
6. Pronk NP, Kottke TE. Physical activity promotion as a strategic corporate priority to improve worker health and business performance. Prev Med 2009.
7. McGinnis JM, Foege WH. Actual causes of death in the United States. Jama 1993;270:2207-12.
8. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. Jama 2004;291:1238-45.
9. Partnership for Solutions, Chronic Conditions: Making the Case for Ongoing Care. September 2004 Update. Robert Wood Johnson Foundation, 2004. (Accessed November 14, 2009, at http://www.rwjf.org/pr/product.jsp?id=14685.)

Competing interests:   None declared