1. Effective Screening for Health-Related Behaviors in Primary Care Michelle M. McKenney, D.O., OGME-3, Kent Hospital Family Medicine Program Research Advisor: Elisabeth Farnum, M.D. Research Collaborator: Paul Block, PhD. KENT HOSPITAL/ UNECOM FAMILY MEDICINE RESIDENCY PROGRAM As the gatekeepers for the health of a community, it is the role of the primary care physician to identify and intercept mental disorders and behavioral health patterns at an early stage. Various screening tools have been developed to aid the primary care physician in detecting these disorders and behaviors; however, they are vast in length and number. When combined, they are cumbersome and time consuming. No gold standard measure for mental health and behavior screening in primary care exists. Utilizing even a portion of the screens available would be unrealistic and overly demanding to the PCP and ultimately serve as an impediment to diagnosis. Mental health is significant for community health and disease burden and accounts for more than 15% of the overall burden of disease from all causes. 1 5 of the 10 leading causes of disability worldwide were psychiatric or addictive conditions: 1 unipolar depression alcohol use bipolar affective disorder or manic depression Schizophrenia obsessive-compulsive disorder Behavioral health patterns, including the decision to maintain a healthy weight, have comparable implications. Significant sequelae of obesity include heart disease, stroke, type 2 diabetes and cancer, yet, the trend towards obesity continues to grow. ▪ 33.8% of adults are obese 2 Only 27% of adults participate in leisure time strengthening activities 3 ▪ States with an obesity prevalence of 30% or more has increased from 0 states in 2000 to 12 states in 2010 4 Patterns of addiction and chemical dependency are also a component of mental and behavioral health. Alcohol and tobacco addiction are two of the most widely socially acceptable forms of adverse health behaviors. ▪ Alcohol causes over 60 types of diseases and injuries and accounts for almost 4% of all deaths worldwide, greater than deaths caused by HIV/AIDS, violence or tuberculosis. 5 ▪ Cigarette smoking is the leading cause of preventable death in the United States and accounts for approximately 1 of every 5 deaths in the United States each year. 6- 8 Figure 4. Comparison of patient only reported problems and patient/ PCP match Purpose: To evaluate the concurrent validity and practical utility of a brief (20 item), readily scored screener addressing a broad sampling of health related behaviors, mental health and substance abuse concerns of relevance to primary care. Two specific questions are being proposed: 1) Does the screener identify health related behaviors that are not already recognized by primary care physicians from their routine clinical assessments? 2) Are the health related behaviors identified actually of clinically relevance and thus worth screening? This study is designed only to answer question 1 and is considered phase 1. Once we identify that this screen is in fact recognizing health related behaviors not identified by their primary care physicians, and is a valid screening tool, we will then proceed to phase 2 of the study where question 2 will be tested. Hypotheses: The proposed health related behaviors screen will serve to both identify those behaviors that are not already recognized by their primary care physicians and these behaviors actually be of significant clinical relevance. BACKGROUND PURPOSE AND HYPOTHESIS MATERIALS AND METHODS RESULTS The screening tool developed consisted of a 20 item questionnaire targeting health-related behaviors. Items in the screener include yes or no questions regarding the presence of the following mental health and behavioral health issues: Target population: Patient panel of a small outpatient primary care teaching facility located in a suburban setting Inclusion Criteria: English speaking patients, 18 years of age and older, presenting for their yearly physical exam Patients were randomly selected by the researching physician. The patients completed the screening tool (Figure 1) prior to or after their visit. The examining physician then completed the PCP validation screen (Figure 2) in which the patient’s behaviors were rated without knowledge of the patient responses. Once 30 screen pairs (patient screen and physician validation) were completed, patient and PCP responses were compared. Social Support Social Support Irritability Irritability Relationship Problems Relationship Problems Stress/ Coping Stress/ Coping Compliance Compliance History of Trauma History of Trauma Sleep/ Insomnia Sleep/ Insomnia Smoking Smoking Varied Diet Varied Diet Sad/ Depressed Mood Sad/ Depressed Mood Regular Exercise Regular Exercise Anxiety/ Panic Anxiety/ Panic Trouble Communicating Trouble Communicating Alcohol Use Alcohol Use Drug Misuse Drug Misuse Sexual Difficulties Sexual Difficulties Chronic Pain Chronic Pain Specialist Referral Specialist Referral This study illustrates that this screening tool is successful in identifying health related behaviors that are not already identified by the PCP using current best practices. It is also helpful in identifying behaviors that need more focus and attention and areas where PCPs identify problems about which more patient education and counseling would be helpful. These results warrant further investigation in phase 2 where we predict that these patient reported behaviors will be of significant clinical relevance. Figure 2. Physician Survey Form CONCLUSIONS Positive responses overall account for 24.7% of all possible problems Patients self report 14.7% of total possible problems Physicians match patient report on 7% of all problems, accounting for less than half of what patients self report Figure 1. Patient Survey Form Figure 5. Comparison of PCP only reported problems and patient/ PCP match Figure 3. Rate of Identification of Health Related Behaviors Problems most reported by patient only (not by PCP): − insomnia (30%) − trauma (20%) − interest in referral (16%) − pain (13%) − irritability, stress/ coping, varied diet, relationship problems (10%) Problems most identified by PCP only (not by patient): − adequate sleep (30%) − anxiety/ panic (27%) − exercise, compliance (20%) − varied diet (17%) − sadness/ depression (13%) BIBLIOGRAPHY 100% of patients report having at least 1 health related behavioral problem and 24.7% of all possible problems are reported and identified. This reveals that there are a significant amount of health related behavioral problems that need to be managed. This screen also revealed that physicians only identify less than half of what the patient self reports. Current standards of care, therefore, are ineffective. Problems physicians are not identifying, such as insomnia and trauma, should be considered areas that need more focus and attention by examining PCP’s. Problems identified by PCP only, such as inadequate sleep hours and the presence of an anxiety or panic disorder, should be considered areas that deserve patient education and counseling. Other interesting findings include the mutually reported absence of problems related to alcohol, drugs, and cigarettes. It is more likely that this absence is related to insensitivity of screening rather than their true absolute absence. Also notable were differences in problem reporting between participating PCPs. This tells us that a standardized screening tool would be of benefit. 1) WHO: Global Burden of Disease study conducted by the World Health Organization, World Bank, and Harvard University. Murray & Lopez, 1996. 2) CDC: Percentage of Adults Aged 18 Years Who Engaged in Leisure- Time Strengthening Activities, by Age Group and Sex- National Health Interview Survey, United States, 2008. MMWR, September 4, 2009 / 58(34); 955 3) Flegal, K, Journal of the American Medical Association: Prevalence and Trends of Obesity among US Adults, 1998- 2008. 4) CDC: State-Specific Obesity Prevalence among Adults- United States, 2009 MMWR, August 6, 2010 / 59(30); 951-955 5) WHO: Global Status Report on Alcohol and Health Conducted by the World Health Organization. 2011. 6) CDC: Annual Smoking- Attributable Mortality, Years of Potential Life Lost, and Productivity Losses- United States, 2000-2004. MMWR 2008; 57(45):1226–8. 7) U.S. DHHS: The Health Consequences of Smoking: A Report of the Surgeon General. 2004. 8) CDC: Sustaining State Programs for Tobacco Control: Data Highlights. 2006.