Physical Activityy y
Maximising potential inMaximising potential in primary care: Options for
ti t t t dprevention, treatment and management.g
Dr Richard WeilerDr Richard WeilerMBChB, MRCGP (Distinction), MSc Sport & Exercise Medicine (Distinction), MFSEM (UK)
Specialist Registrar in Sport & Exercise Medicine and General PractitionerGPSI in Sports & Musculoskeletal MedicineExternal Lecturer University College LondonExternal Lecturer, University College London
Aims:S i h f• Start in the future
• Work our way swiftly back to the present• Recognise primary care benefits
• Challenge current practice• Present evidence & guidancePresent evidence & guidance• Recognise strengths & weaknesses
• Provoke discussion
The pledges
• HM Treasury proposed the proportion of children who spend a minimum of two hours per week on high quality sport should increase from 25% intwo hours per week on high quality sport should increase from 25% in 2002 to 75% by 2006 and 85% by 2008
• 2002 Government’s Strategy Unit: to increase the proportion of the adult l ti h ti i t i 30 i t f d t h i l ti it fipopulation who participate in 30 minutes of moderate physical activity five
or more times a week to 70% by 2020!
• 2003 Scottish Health Executive set a target that by 2022, 50% of the adult2003 Scottish Health Executive set a target that by 2022, 50% of the adult population should participate in 30 minutes of moderate activity on 5 or more occasions each week. The Scottish target for children is to increase the number of children taking at least one hour a day of moderate activity on 5 or more days a week to 80% by 2022on 5 or more days a week to 80% by 2022.
• There are no physical activity targets set for Wales or Northern Ireland
Lifestyle disease & deaths
• 60% of global deaths from non-communicable diseases (WHO)
• Genetics impact minimal• I.e. Environment & Lifestyleinduced
Economics – Annual costEconomics – Annual cost
• Physical inactivity £8.2bn* (DoH, 2002)• Smoking £1 5 billion (Parrott BMJ 2004)• Smoking £1.5 billion (Parrott, BMJ 2004)• Alcohol £3.0 billion (Balakrishnan, J PH 2009)
Ob it £4 2 billi (HSE 2008)• Obesity £4.2 billion (HSE, 2008)
*But physical inactivity cost was estimated on ~5 diseases
Physical inactivity – 40+ diseases
• osteoporosis• muscle atrophy
• dyslipidemia• metabolic syndrome• muscle atrophy
• arthrosis• rheumatoid arthritis
• metabolic syndrome• asthma• some cancer (e.g. breast)
• low back pain• coronary artery disease• peripheral artery disease
• degenerative problems (e.g. in brain)
• depression• peripheral artery disease• stroke• high blood pressure
depression • pain• sleep problems
bl d l i• diabetes 1 and 2• obesity / overweight
• blood clotting• erectile disfunction
H lth b fit f h i l ti itH lth b fit f h i l ti itHealth benefits of physical activityHealth benefits of physical activity
Regular physical activity at the correct intensity:
• Reduces the risk of heart disease by 40%• Lowers the risk of stroke by 27%• Reduces the incidence of diabetes by almost 50%y• Reduces the incidence of high blood pressure, by almost 50%• Can reduce mortality and the risk of recurrent breast cancer by almost
50%50%• Can lower the risk of colon cancer by over 60%• Can reduce the risk of developing of Alzheimer’s disease by one-third• Can decrease depression as effectively as Prozac or behavioural therapy• Can decrease depression as effectively as Prozac or behavioural therapy
Physical inactivity worse than smoking?
• Increased physical activity reduces mortality by as much as smoking cessation, even in later lifeas much as smoking cessation, even in later life
• Statistically a week spent inactive has similar• Statistically a week spent inactive has similar health costs to smoking a packet of cigarettes
Smoking cessation universally endorsed but is it effective?
• Abstinence rates for smoking cessation ~5-25% (BMJ 2007)(BMJ, 2007)
• In many areas GP’s paid ~£30 per abstinent patientpatient
• So on computer systems & rewarded in QOF
• Smoking cessation universally accepted?!
“What do points make?”What do points make?
Indicator Details Points Payment stages% CHD in whom the last blood pressure reading (measured in
CHD 6. % CHD in whom the last blood pressure reading (measured in the previous 15 months) is 150/90 or less 17 40-70%
CHD 8. % CHD whose last measured total cholesterol (measured in the previous 15 months) is 5mmol/l or less 17 40-70%% diagnosed with hypertension diagnosed after 1 April 2009 who are given lifestyle advice in the last 15 months for:
PP 2. increasing physical activity, smoking cessation, safe alcohol consumption and healthy diet. 5 40-70%
STROKE 6. % with TIA or stroke in whom the last blood pressure reading (measured in the previous 15 months) is 150/90 or less. 5 40-70%
STROKE 8% with TIA or stroke whose last measured total cholesterol ( d i th i 15 th ) i 5 l/l l 5 40 60%STROKE 8. (measured in the previous 15 months) is 5mmol/l or less. 5 40-60%
BP 5. % with hypertension in whom the last blood pressure (measured in the previous 9 months) is 150/90 or less. 57 40-70%
DM 23. % with DM in whom the last HbA1c is 7 or less in the previous 15 months 17 40-50%% with DM in whom the last HbA1c is 8 or less in the previous
DM 24. % with DM in whom the last HbA1c is 8 or less in the previous 15 months 8 40-70%
DM 25. % with DM in whom the last HbA1c is 9 or less in the previous 15 months 10 40-90%
DM 12. % with DM in whom the last blood pressure is 145/85 or less 18 40-60%% with DM whose last measured total cholesterol within the
DM 17. previous 15 months is 5mmol/l or less 6 40-70%The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses with a review recorded in the preceding 15 months. In the review there should be evidence that the patient has been offered routine health promotion and
MH 9. preventi 23 40-90%
CKD 3. % on CKD register in whom the last blood pressure reading, measured in the previous 15 months, is 140/85 or less 11 40-70%TOTAL 199 ~£124.03TOTAL CLINICAL 697Percentage 29%Percentage 29%Equivalent income £24,682
E i l iEquivalent income
£24 682£24,682
Ph i l A ti itPhysical Activity
P tiPrevention or Treatment
Physical activity:Physical activity: only for disease?only for disease?
Effect of Fitness (CRF) on Mortality
40 842 Men & 12 943 Women ACLS
( ) yAttributable Fractions (%) for All-Cause Deaths
141618
MenWomen
40,842 Men & 12,943 Women, ACLS
8101214 Women
468
02
L O S H H DLow CRF*
ObeseSmoker
Hypertension
High Chol
Diabetes*cardio respiratory fitness on
Cooper Aerobics Center Longitudinal Study, 1970-2004. In progress
cardio respiratory fitness
Blair SN. Physical inactivity: the biggest public health problem of the 21st century. Br J Sports Med 2009; 43:1-2.
P l ti tt ib t bl i k (PAR)Population attributable risk (PAR):‘estimate of proportion of public health burden for one risk factor’ – i.e. Physical inactivity/sedentary behaviour
Powell & Blair (1994, MSSE) Ruwaard & Kramers (1997, Utrecht: Elsevier/De Tijdstroom)( , ) Elsevier/De Tijdstroom)
• CHD = 35%• Colon cancer= 32%
• For CHD alone:▫ Smoking = 43%
• Type 2 DM = 35% ▫ Diet = 13%▫ Obesity = 14%▫ Sedentary= 40%▫ Sedentary= 40%
P l ti tt ib t bl i k (PAR)Population attributable risk (PAR):‘estimate of proportion of public health burden for one risk
Ruwaard & Kramers (1997, Utrecht: Elsevier/De Tijdstroom)
factor’ – i.e. Physical inactivity/sedentary behaviour
Elsevier/De Tijdstroom)• CHD = 35%• Colon cancer= 32%
• For CHD alone:▫ Smoking = 43%
• Type 2 DM = 35% ▫ Diet = 13%▫ Obesity = 14%▫ Sedentary= 40%▫ Sedentary= 40%
A physically active lifestyle helps maintainA physically active lifestyle helps maintain body weight, leads to favourable dietary habits and a decline in smokinghabits and a decline in smoking. (1995, Vuori & Fentem, Strasburg: Council of Europe Press:11-90)
Are there institutional and research failings?
QRISK2 – Risk of CHD/CVD• Patient age (35-74)• Patient gender• Current smoker (yes/no)(y )• Family history of heart disease aged <60 (yes/no)• Existing treatment with blood pressure agent (yes/no)• Postcode (postcode related Townsend score) - an area measure of• Postcode (postcode related Townsend score) - an area measure of
deprivation• Body mass index (height and weight)
Systolic blood pressure (use current not pre treatment value)• Systolic blood pressure (use current not pre-treatment value)• Total and HDL cholesterol• Self assigned ethnicity• Rheumatoid arthritis• Chronic kidney disease• Atrial fibrillation
JBS2 CHD & Stroke RiskJBS2 – CHD & Stroke Risk Assessmentssess e t
Risk FactorsMove through RISK FACTOR boxes to enter & amend data.Use cursor keys to move through boxesUse cursor keys to move through boxes.
Female?(yes=1,no=0) 0Age(years) 0g (y )SBP (mmHg) 0DBP (mmHg) 0Smokes?(yes=1,no=0) 0
C ( / )Total - C (mmol/ l) 0HDL - C (mmol/ l) 0Diabetes(yes=1,no=0) 0
Known to haveECG-LVH? (yes=1,no=0) 0
Period of predicted risk 10(years)
CVD risk predictionCVD risk prediction
• Existing scores determine whether an asymptomatic patient needs preventive intervention & relies on surrogate outcomes– E.g. cholesterol, diabetes, BMI, blood pressure,
smoking
• No physical activity, no cardiorespiratory fitness:– Are they not causal factors? – Why are they ignored?
Consider incentives - QOF
• Annual average extra payments for the clinical care domain is ~ £65 000clinical care domain is £65,000
• Cost of new QOF point ~£1million
“PP2 Primary Prevention of CVD: The percentage of people diagnosed with hypertension who are givenpeople diagnosed with hypertension who are given lifestyle advice for: increasing physical activity, smoking cessation, safe alcohol consumption and healthy diet”healthy diet
QOF – Primary care incentivesQOF – Primary care incentives• Often a tick box on computerOften a tick box on computer
system• Is GP trained for complex p
behaviour change?• Why one lifestyle factor and
h ?not another?• Why not train GP’s in
behaviour changebehaviour change techniques? (Motivational interviewing)interviewing)
Who’s responsibility?Who s responsibility?
A selection of National Guidelines recommending physical activity promotionpromotion…
Duty of careDuty of care• Medico-legal duty of care to follow guidelines• Medico legal duty of care to follow guidelines
where appropriate
• Need to document in medical records/notes
Why deliver PA in primary care?• Powerful voice
• Perceived as most reliable/credible source of health information[L b l F D l J F k E B J S t M d 2009 43 89 92][Lobelo F, Duperly J, Frank E. Br J Sport Med 2009;43:89-92].
• 185million GP consultations/year• 185million GP consultations/year
• Regular contacts with patients (~3/yr): reinforces• Regular contacts with patients (~3/yr): reinforces messages & allows regular follow up
REALITY
• 54% of patients said their GP had not• 54% of patients said their GP had not even provided advice on diet and
iexercise[Lord Darzi's NHS Next Stage Review Final Report]
• ~1 in 4 people in England say they would b ti if th d i d t dbe more active if they were advised to do so by a GP or nurse[HSE 2007]
NICE public health guidance PH2Primary care practitioners should whenever possible:
( ) f• Using a validated tool (GPPAQ) to identify inactive adults and advise them to aim for at least 30 minutes of moderate activity on 5 days of the weeky y
• Take account of individual needs, preferences and i t l d id ittcircumstances; agree goals; and provide written information about the benefits of activity and the local opportunities to be active
• Follow up at appropriate intervals over a 3 to 6 month periodperiod
NICE Guidance on PA Promotion
•Evidence basedEvidence based
• ‘Exceptional value for money’• Exceptional value for money
[NICE & Department of Health]
Let’s Get Moving• Behaviour change programme with a Physical Activity
Care Pathway based on NICE recommendations
• LGM designed to assist practitioners in guiding inactive adults aged 16-74 towards gradually become more active
Let’s Get Moving – Uptake?
• GPRD Gold database: of 9 556 849• GPRD Gold database: of 9,556,849 patients, 660 patients (0.007%) have GPPAQ codes across 524 practices in theGPPAQ codes across 524 practices in the UK. (March 2010)[Weiler R Stamatakis E Br J Sports Med 2010 Oct;44(13):912 4 ][Weiler R, Stamatakis E. Br J Sports Med. 2010 Oct;44(13):912-4.]
Evaluation of PA Care Pathway – London yFeasibility Pilot
• Only 4/300 patients were signposted to exercise on referralreferral
• GPPAQ awareness elsewhere lowGPPAQ awareness elsewhere low• Felt to be time-consuming• Other priorities in average 9-minute consultationp g
Are we equipped in primary care?PA b t f i l l 13% f US• PA absent from curriculum: only 13% of US medical schools have any PA element at all
• Survey in 32 UK medical schools in progress. Anecdotal evidence suggests that the UK reality is gg ysame as US: i.e. Physical Activity education is non-existent
• What about behaviour modification skills?
• Active doctors prescribe PA, inactive do not [Lobelo F, Duperly J, Frank E. Br J Sport Med 2009;43:89-92]
NHS Health CheckNHS Health CheckExample Care Pathway - 2010
• NHS Health Check invitation first letter• NHS Health Check invitation second letter• NHS Health Check telephone invitation• NHS Health Check verbal invitation• Failed to respond to NHS Health Check invitation
• FH: Ischaemic heart dis. >60• FH: Diabetes mellitus in first degree relative• Ethnic status• O/E height• O/E weight• Failed to respond to NHS Health Check invitation
• NHS Health Check completed• Did not attend NHS Health Check• Dietary history• Patient advised re diet• Tobacco consumption
• O/E weight• BMI• Waist circumference• Advice about weight• Refer to weight management programme• Referral to weight management service declinedp
• Smoking Cessation Advice• Smoking cessation advice declined• Referral to smoking cessation advisor• DNA - Did not attend smoking cessation clinic• Seen by smoking cessation advisor
g g• Lifestyle counselling• Referral to health trainer• Referral to health trainer Declined• Seen by health trainer• O/E - pulse rate
• Exercise grading• Patient advised re exercise• Referred for exercise programme• Declined referral to physical exercise programme• Alcohol use disorder identification test consumption questionnaire
Alcohol screen AUDIT C completed
• O/E - pulse rhythm• Cholesterol• Serum cholesterol:HDL ratio• Blood sugar result • Plasma random glucose level
Plasma fasting gl cose le el• Alcohol screen – AUDIT C completed• Alcohol consumption screening test declined• Patient advised about alcohol• Referral to specialist alcohol treatment service• Declined referral to specialist alcohol treatment service• H/O: rheumatoid arthritis
• Plasma fasting glucose level• HbA1c level (DCCT aligned) • HbA1c level – IFCC standardised• Glomerular filtration rate calculated by abbreviated Modification of
Diet in Renal Disease Study Group calculation• Advised to contact general practitionerH/O: rheumatoid arthritis
• FH: CVD• No FH: CVD• FH: Ischaemic heart dis. <60
• QRISK cardiovascular disease 10 year risk score• NHS Health Check completed
NHS Health CheckNHS Health CheckExample of real Care Pathway - 2010
• NHS Health Check invitation first letter• NHS Health Check invitation second letter• NHS Health Check telephone invitation• NHS Health Check verbal invitation• Failed to respond to NHS Health Check invitation
• FH: Ischaemic heart dis. >60• FH: Diabetes mellitus in first degree relative• Ethnic status• O/E height• O/E weight• Failed to respond to NHS Health Check invitation
• NHS Health Check completed• Did not attend NHS Health Check• Dietary history• Patient advised re diet• Tobacco consumption
• O/E weight• BMI• Waist circumference• Advice about weight• Refer to weight management programme• Referral to weight management service declinedp
• Smoking Cessation Advice• Smoking cessation advice declined• Referral to smoking cessation advisor• DNA - Did not attend smoking cessation clinic• Seen by smoking cessation advisor
g g• Lifestyle counselling• Referral to health trainer• Referral to health trainer Declined• Seen by health trainer• O/E - pulse rate
• Exercise grading• Patient advised re exercise• Referred for exercise programme• Declined referral to physical exercise programme• Alcohol use disorder identification test consumption questionnaire
Alcohol screen AUDIT C completed
• O/E - pulse rhythm• Cholesterol• Serum cholesterol:HDL ratio• Blood sugar result • Plasma random glucose level
Plasma fasting gl cose le el• Alcohol screen – AUDIT C completed• Alcohol consumption screening test declined• Patient advised about alcohol• Referral to specialist alcohol treatment service• Declined referral to specialist alcohol treatment service• H/O: rheumatoid arthritis
• Plasma fasting glucose level• HbA1c level (DCCT aligned) • HbA1c level – IFCC standardised• Glomerular filtration rate calculated by abbreviated Modification of
Diet in Renal Disease Study Group calculation• Advised to contact general practitionerH/O: rheumatoid arthritis
• FH: CVD• No FH: CVD• FH: Ischaemic heart dis. <60
• QRISK cardiovascular disease 10 year risk score• NHS Health Check completed
Traditional interventions Vs Physical ActivityPhysical Activity
A (simplified) physical activity centred model of CVD causalityA (simplified) physical activity-centred model of CVD causality
Ph i l
Knowledge/Information
Cultural values
Personal l / ttit d
Physical Environment
values/attitudes/health consciousness
Physical CARDIOVASCULAR CardioRespiratory Fitness
SURROGATE: MARKERS:
Activity DISEASE
Psychological(Positive & negative affect)
Fitness
BiomarkersAdiposity
Socioeconomi
Genetic makeup
affect) Smoking
Diet
c circumstances
A (simplified) physical activity centred model of CVD causality
Ph i l
Knowledge/Information
Cultural values
A (simplified) physical activity-centred model of CVD causality
Personal l / ttit d
Physical Environment
values/attitudes/health consciousness
Physical CARDIOVASCULAR CardioRespiratory Fitness
SURROGATE: MARKERS:
Activity DISEASE
Psychological(Positive & negative affect)
Fitness
BiomarkersAdiposity
Socioeconomi
Genetic makeup
affect) Smoking
Diet
c circumstances Current focus of CVD prevention:
pharmacological intervention, obesity, & smoking cessationg
Task : prevent CVD in primary care
GP’s OPTIONS 1: Prescribe medication 2. Lifestyle modification
INCENTIVES OFFERED •QOF payments boosting •None (altruism and idealism?)annual income substantially
SUPPORT SYSTEM IN •Not needed •Let’s Get Moving PLACE
gdocumentation
SKILLS /KNOWLEDGE •Basic pharmacology •Understanding of PA benefitsNEEDED
p gy•Read (drug leaflet)•Write (prescription)
g•Behaviour modification •Counselling skills •Negotiation skills R t ith ti t•Rapport with patient
GP OWNS SKILLS? •Yes •Extremely unlikelyGP OWNS SKILLS? Yes Extremely unlikely
EXTERNAL INFLUENCES/PRESSURES
•Intense “marketing” from drug companies
•None, PA RCTs with “hard outcomes” not feasible/ethical
•Detailed NICE guidance•Large (pharma-funded) trials published in the best medical journals
•PA research sparingly funded
C id T 2 di b tConsider Type 2 diabetesCG66 Type 2 diabetesyp• 3 months treatment with lifestyle measures – focus on
diet with dietician• What about PA support?
• Some experts still recommend going straight to drugs!• “…because lifestyle measures never work”
• Where is the evidence that diabetic medication d t lit & bidit ?reduces mortality & morbidity?
• Risk of macro vascular disease starts 6 8 years• Risk of macro-vascular disease starts 6-8 years before onset of clinical diabetes
Drugs: Adverse effect on survival?ADVANCE StudyADVANCE Study
Medication Physical Activity
Hypoglycaemic events • Risk • No riskyp g y
Hypoglycaemic events associated with hazard ratios 3 3 3 8 for:• Hypoglycaemic events associated with hazard ratios 3.3-3.8 for:
Major macrovascular events
CVD liCVD mortality
All-cause mortality
Changes in weight, fitness, and cardiovascular risk factors for participants in the Intensive lifestyle intervention (ILI) and diabetes
support and education (DSE) groups of the Look AHEAD (Action forsupport and education (DSE) groups of the Look AHEAD (Action for Health in Diabetes) trial
The Look AHEAD Research Group,The Look AHEAD Research Group,Arch Intern Med 2010;170:1566-1575.
Copyright restrictions may apply.
Proportion of Participants in DSE and ILI Who Achieved the ADA Treatment Goals p pat Baseline and Years 1 Through 4
Copyright restrictions may apply.
The Look AHEAD Research Group, Arch Intern Med 2010;170:1566-1575.
Proportion of DSE and ILI Participants Who Initiated or Maintained Use of Medication p pfor Diabetes, Hypertension, or Lowering Lipid Levels
The Look AHEAD Research Group, Arch Intern Med 2010;170:1566-1575.
Copyright restrictions may apply.
SolutionsSolutions• £25,000 up for grabs with QOF!, p g• Awareness & education• Better care - Think guidelines & legal responsibility
E b d PA ti t t k i t l t• Embed PA promotion computer note-keeping templates▫ GPPAQ & development of 1 question PAQ
• Where is PA promotion in QOF? 1 QOF point=£1m• Where is PA promotion in QOF? 1 QOF point £1m• Role models – Exercise yourself• PA Vs Drugs • Education & training: But who?▫ Can Nurses/HCAs/Physiotherapy/Pharmacists
Practice staff deliver physical activity promotion?▫ Practice staff deliver physical activity promotion?• Strategy – prevention for all or targeted treatment?• GP Consortia: Consider physical activity promotion whenGP Consortia: Consider physical activity promotion when
commissioning local services
Plato427 BC - 347 BC
Greek Philosopherp
“Lack of activity destroys the good condition of every human being whilecondition of every human being, while movement and methodical physical exercise save it and preserve it ”exercise save it and preserve it.
A Case StudyA Case Study• A Hertfordshire General Practice• A Hertfordshire General Practice• List size 12386• 7 partners 2 salaried 3 registrars• 7 partners, 2 salaried, 3 registrars• Audit of Physical Activity Advice
• Use of the Vision clinical system as an aide i d t l t f i t timemoire and template for intervention
• Tie in with local “exercise on prescription” initiative
Hertfordshire Audit Physical Activity AdviceHertfordshire Audit – Physical Activity Advice In Standard Consultations
12th May 2010
4
1
2
171
Out of 202 clinician in house consults
Hertfordshire Audit – Obesity Register
54
Partners/Salaried/Locum
12
Registrars
413
1
2
1
2
413 79
Oth li i iOther clinician
14
Nursing
6
5 1
2
14
1
2
106
689 Patients on Practice Obesity Disease Register
ShortcutsVision
Shortcuts
Vision Vision Guideline
ss
Practical Reminders within Practice
Are you physically active?Are you physically active?Would you like to be more active?
Fill out a physical activity questionaire and ask your GP how we can helphow we can help.
Collaboration with ExerciseCollaboration with Exercise Provider
Hertfordshire Interventions• Embed by design into electronic notes system• Media within patient waiting areasp g▫ GPPAQ in waiting rooms and offered by
receptionistsp▫ Posters on LGM▫ Use of Electronic notice board/TV
• Engage locality exercise providers• EducationEducation▫ All clinicians: “5-a-week”; moderate exercise
Analysis of the Data - SEF
LGM Pilot IslingtonLGM Pilot Islington
Global Initiatives
Exercise Is Medicine™Medicine•“To make physical activity and exercise aactivity and exercise a standard part of a disease prevention anddisease prevention and treatment paradigm in the United States”
•Guiding principles•Program Elements•Program ResourcesS t d b th•Supported by the
surgeon general
Discussion Group AnalysisDiscussion Group Analysis
• Strengths• Weaknesses
• Barriers• RequirementsWeaknesses
• Opportunities• Threat
Requirements• Aims
• Discuss…• Discuss…
Practical TipsPractical Tips• Collaborate with stakeholders and primary care• Collaborate with stakeholders and primary care• Internet resources and global initiatives
• Feel free to contact us:t h h @d t k• [email protected]
ResourcesResources• http://www noo org uk/evaluation portal/SEF• http://www.noo.org.uk/evaluation_portal/SEF• http://www.dh.gov.uk/en/Publicationsandstatistic
s/Publications/PublicationsPolicyAndGuidance/Ds/Publications/PublicationsPolicyAndGuidance/DH_105945
• http://exerciseismedicine org/index htm• http://exerciseismedicine.org/index.htm
Thank you
Questions?Questions?
Thank you to:Dr Emmanuel Stamatakis for his help preparing the presentation