This post is the sixth in a seven-part series that explores Exercise as a Vital Sign (EVS), a clinical initiative designed to systematically ascertain patient-reported exercise levels at the beginning of each outpatient visit. By focusing on frontline clinical experience, policies and organizational practice, I intend to shed light on an important clinical strategy to address obesity and physical inactivity. In this article, I report the results of peer-reviewed scientific studies that directly examine different aspects of the EVS initiative.
EVS Research and Evaluation
Early evaluations of EVS look promising, according to a 2012 study by research scientist Karen J. Coleman et al., published in Medicine & Science in Sports and Exercise. The report evaluated EVS’s ability to accurately collect patient’s physical activity levels, as well as statistics on patient demographics and health status. The study reviewed the electronic medical records of nearly 1.8 million Southern California Kaiser Permanente adult members over the course of a year and found that:
- 18 months after implementation, most eligible patients (86 percent or over 1.5 million people) did indeed have EVS data recorded in the electronic medical record. The process of asking the two questions worked.
- Among patients with EVS data in their medical record, about a third were getting the recommended physical activity for sustained health (150 minutes per week) while the remaining patients were not. In fact, a third of patients were not getting any activity in whatsoever!
The study found EVS to be a valid tool in ascertaining patients’ physical activity levels that may provide more accurate estimates of physical activity behavior when compared with national surveys. The researchers also concluded that “EVS has the potential to provide information about the relationship between exercise and health care use, cost, and chronic disease that has not been previously available at the population level.”
A second study, this time conducted in Northern California by Research Scientist Richard Grant et al., and published in December 2013 in the Journal of General Internal Medicine found that overweight patients who were asked the EVS questions lost slightly more weight than those who weren’t asked. Additionally, patients with diabetes experienced a slight drop in blood sugar level.
The changes were modest for the individual patient (0.2 pounds lost and 0.1 percent drop in HgA1c levels). However, if you were to extrapolate the weight loss measures over all of Kaiser Permanente’s Northern California overweight members, the EVS data collection would result in an estimated weight loss of over 46,000 pounds. These results, like those noted in the previous study, reveal the power of organized healthcare systems like Kaiser Permanent to take on challenges towards improving population-level health outcomes.
More Research Needed to Understand EVS
The most recent research on the benefits of behavioral counseling by the U.S. Preventive Service Task Force acknowledges the need for physical activity behavior counseling in primary care, but cautions that challenges arise when making specific recommendations for clinical practice based on aggregate research. This suggests that there is still a lot of evaluation needed on this subject.
Questions for Future Research:
- How has EVS prompted provider-behavior change in addressing physical activity with patients?
- What types of physical activity referrals are given to patients?
- What proportion of those referrals is internal to Kaiser Permanente versus community interventions?
- How is EVS contributing to overall fitness? Does asking the vital questions predict overall health outcomes or change life expectancy?
What research questions do you have? How do you think EVS data can be used to improve individual and population health?
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Latifat T. Apatira, MD, MPH is a fourth year Internal Medicine and Preventive Medicine Resident at Kaiser Permanente San Francisco Medical Center