Integrating screening and interventions for unhealthy behaviors into primary care practices.

Background: Four unhealthy behaviors (tobacco use, unhealthy diet, physical inactivity, and risky alcohol use) contribute to almost 37% of deaths in the U.S. However, routine screening and interventions targeting these behaviors are not consistently provided in primary care practices.

Methods: This was an implementation study conducted between October 2005 and May 2007 involving nine practices in three geographic clusters. Each cluster of practices received a multicomponent intervention sequentially addressing the four behaviors in three 6-month cycles (unhealthy diet and physical inactivity were combined). The intervention included baseline and monthly audits with feedback; five training modules (addressing each behavior plus stages of change [motivational interviewing]); practice facilitation; and bimonthly quality-circle meetings. Nurses, medical assistants, or both were taught to do screening and very brief interventions such as referrals and handouts. The clinicians were taught to do brief interventions. Outcomes included practice-level rates of adoption, implementation, and maintenance.

Results: Adoption: Of 30 clinicians invited, nine agreed to participate (30%).

Implementation: Average screening and brief-intervention rates increased 25 and 10.8 percentage points, respectively, for all behaviors. However, the addition of more than two behaviors was generally unsuccessful. Maintenance: Screening increases were maintained across three of the behaviors for up to 12 months. For both unhealthy diet and risky alcohol use, screening rates continued to increase throughout the study period, even during the periods when the practices focused on the other behaviors. The rate of combined interventions returned to baseline for all behaviors 6 and 12 months after the intervention period.

Conclusions: It appears that the translational strategy resulted in increased screening and interventions. There were limits to the number of interventions that could be added within the time limits of the project. Inflexible electronic medical records, staff turnover, and clinicians' unwillingness to allow greater nurse or medical-assistant involvement in care were common challenges.