24 Assessment and Treatment of Risk in the Clinic Setting

24 Assessment and Treatment of Risk in the Clinic Setting

William E. Kraus, MD

C

Assessment of Risk in the Cardiac Rehabilitation

Setting 271

Assessment and Modification of Risk in the Clinic

Setting 273

Developing A Behavior-Change Plan 275

Summary and Outstanding Questions 276

References 276

The assessment of global cardiovascular risk at baseline and in response to therapy is an important component in both cardiac rehabilitation (CR) and the clinic setting that accompanies it. At our institution, we assess risk before and following a period of CR using established modifiable markers of cardiovascular risk, including status of lipids, blood pressure, metabolic syndrome, diabetes mellitus, central adiposity, depression, social support, and others. The goal is then to modify the risk to prevent downstream cardiovascular morbidity and mortality. Although much is accomplished in the setting of the CR program itself, much can be accomplished in the clinic-based visits with physicians and physician extenders to reinforce messages from the CR program, to titrate and optimize medical therapy, as addressed in previous chapters, and to further refine risk modification strategies when CR is completed. For lifestyle modification to be successful in the clinic setting, the provider must base the approach on a behavioral construct that to the clinician makes sense and can readily be employed.

We have found the standard Stages of Change construct (1) to be the most useful in our clinics.

ASSESSMENT OF RISK IN THE CARDIAC REHABILITATION SETTING

It is useful to assess modifiable cardiovascular risk using established markers prior to and following a period of CR. First, such an assessment can focus the attention of the individual participant and the CR staff on targeted areas of particular interest

From: Contemporary Cardiology: Cardiac Rehabilitation

Edited by: W. E. Kraus and S. J. Keteyian © Humana Press Inc., Totowa, NJ 271

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during the rehabilitation period. In addition, such information can be shared as a report of the program success to referring providers, thus becoming a reinforcing strategy for participant recruitment. Such assessments also can be added to the medical record for individual CR participants. Second, the staff can use these data to assess the effectiveness of the program in general, as well as the effectiveness of particular strategies to modify risk for particular risk markers [e.g., blood pressure, low- density lipoprotein (LDL) cholesterol, weight, and waist circumference]. Ineffective strategies can be modified and adapted to be more effective or abandoned if found to have no utility. Third, such longitudinal data can be extremely useful in research projects, conducted under the supervision of qualified personnel and the institutional Review Board, to address outstanding and untested hypotheses regarding CR programs in general. By adding to the general literature in this area, the entire field will be advanced.

We have used the format illustrated in Fig. 1 to collect relevant data on individual participants. Such data are shared with the referring health care provider and can become

Fig. 1.(Contd.)

Fig. 1.Initial and Exit Summaries for Use in Cardiac Rehabilitation. Such summaries can be useful in communication to referring caregivers about the course and response to the treatment program.

Also the collected data can be useful in program efficacy assessments and research.

part of the medical record of the individual patient. In addition, data are collected in a longitudinal database for subsequent program-wide assessments, as previously discussed.

ASSESSMENT AND MODIFICATION OF RISK IN THE CLINIC SETTING

As noted, the clinic visit, either by a member of the CR team or the referring physician, is an important ancillary component of the CR experience for the individual.

The potential effectiveness of such visits to the successful institution of prevention

strategies cannot and should not be underestimated. There is an evolving body of liter-

ature supporting the concept that attention of the physician and/or physician extender

to particular behaviors (e.g., smoking, inactivity, and poor eating habits) is likely the

most important component of a behavior-change strategy. We have found that there

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are at least four steps to a successful intervention with an individual in the behavioral change arena: (i) bringing attention to the behavior, (ii) discussion of the behavior with the individual, (iii) developing an effective strategy for changing behavior, and (iv) following up with the progress of the strategy at the next encounter. It is clear, however, that such approaches take time and the pressures of current medical practice require that strategies to address behavior change in the medical clinic require strategies that are at once effective and time-efficient. I will discuss some methods that we have found effective in our clinics for accomplishing each of these ends.

Steps in Successful Clinic-based Behavior Change Strategies

Bring Attention to the Behavior – Surveying Discussion of Importance of Changing the Behavior Agreeing on Plan and Contracting

Follow-up

Bringing Attention to the Behavior

There are several conceivable methods whereby one might bring a particular behavior to the attention of the individual. When this comes from the physician, the individual becomes aware that the physician believes that it is important. For example, taking weight or waist circumference or asking about eating and physical activity behaviors are important components of drawing the individual’s attention to the issue and stressing that the health care provider believes that the issue is important enough to seek and record this information. We have found that short surveys administered about eating and physical activity behaviors, administered in the waiting room while the individual is waiting to see the caregiver, also provide an effective strategy for collecting the information. It is essential, however, in order for this strategy to be effective that the information subsequently be addressed and referenced during the clinic encounter with the physician and reinforced by other health care team members. Such data should also become part of the clinic record, preferably in the clinic note.

Discussion of the Behavior in the Clinic with the Individual

As noted, it is important, once the data are collected on a given behavior, to discuss the behavior with the individual during the clinic encounter. That being said, it is clear, given the time pressures on practitioners in the clinic, that not all behaviors of interest can be effectively addressed in each clinic visit. That is, we have found it particularly ineffective to mention, as a parting comment during a clinic encounter that the individual “should lose weight, eat better and get more regular exercise.”

Although better than nothing, the absence of a detailed, if brief, encounter on important

behavioral issues will rarely lead to significant or long-term behavior change. Rather,

the care provider must spend some time, even if short, explaining the importance of the behavior under issue. We have found that addressing one of the four potentially important behaviors in each visit is an efficient and effective means to promote behavior change. In the prevention cardiovascular clinic, the important behaviors that should be addressed are smoking, poor nutrition choices, lack of sufficient physical activity, and type A behavior. How does one chose which behavior to address in a given clinic visit?

Choosing Which Risk Factor to Address: The Transtheoretical Model of Behavioral Change

In chapter 7, Dr Collins and colleagues discuss the background and use of the Transtheoretical Model of Behavior Change in assisting in developing a program for an individual. This model can also be used in the clinic setting to decide which behavior, of several that could be chosen, should be addressed in any given encounter. For example, should an individual be a smoker, have a poor diet, excessive job-related stress, and be physically inactive, one might ask which behavior might be best to address first. One approach might be to assess in which stage of precontemplation, contemplation, or planning the individual is, by prompting with questions such as “Have you considered stopping smoking?” and “Have you made plans to stop smoking within the next several months?” Depending upon this survey of prospective behaviors, it might make sense first to address those behaviors to which the individual is willing or even eager to direct their attention. For example, in an individual that responds to such queries with

“I enjoy smoking and do not wish to consider stopping at the present but I do want to consider changing my diet and getting more exercise,” it does not make sense to address first the smoking issue in preference to the diet and exercise issues.

A Series of Clinic Visits Becomes a Program for Behavior Change Given constraints on time that a practitioner can spend in any one clinic visit and limita- tions on the ability of any one individual can absorb in one visit, and given the other potential issues to address (e.g., medication changes), it is our habit to address only one behavior in each visit and attempt to move the behavior change along the spectrum of the Transtheoretical Model spectrum (precontemplation to contemplation to planning to action to maintenance and reinforcement) in each clinic encounter. This typically may take from 5 to 15 min. Thus, in reality, a series of clinic visits becomes a program of

to address and promote effective behavior change in each of four distinct behaviors.

DEVELOPING A BEHAVIOR-CHANGE PLAN

As noted, developing a behavior-change plan is an essential step in the process of

promoting lifestyle changes in the clinic setting. This may take as little as 5 min and

as much as 15 min in the clinic setting. Let us use increasing physical activity as an

example. One should probe the individual’s lifestyle and where, within the normal

routine, a dedicated period of physical activity and exercise might fit. As it does not

require large changes in physical activity to make a significant difference in health

parameters (2–4), and modest changes in physical activity are relatively easy to make,

formulating a plan with an individual in the clinic setting is facile. Often, for example,

to promote daily moderate level activity of about 30-min duration, we often suggest

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that the individual walk the dog daily – whether he has one or not! Once a plan is made, it is important to document it in the clinic record for later reference.

Follow-Up at the Next Encounter – the Importance of Contracting The final essential step in a clinic-based process promoting behavior change is follow-up and reinforcement. By recording the plan in the clinic note, the clinician is prepared to query progress at the next visit. In addition, we find contracting to be a useful exercise, as well. For example, if weight loss is a goal, one might agree on a target of a given amount of weight loss in the interim until the next visit (e.g., agreeing on a 10-lb weight loss in 5 months). One useful strategy to reinforce the understanding is to contract on the behavior (looking the individual in the eyes, shaking hands on the agreement, and recording it in the chart). This can be particularly effective in helping the individual recall the contract. The contract and progress in achieving the agreement is then reviewed at the next encounter and a new contract formed. Often, when it is important to reinforce behavior and when change is actively taking place, more as opposed to less frequent, clinic visits should be arranged.

SUMMARY AND OUTSTANDING QUESTIONS

In summary, assessing global cardiovascular risk is important in both the CR setting and the cardiovascular prevention clinic that works in parallel. Assessing risk permits one to assess the effectiveness and make necessary adaptation of procedures and tactics for promoting lifestyle changes in these settings. In the clinic setting, promotion of lifestyle change is a progressive process, often based on behavioral change strategies, such as the Transtheoretical Model, where a series of stepwise counseling can be considered a program. Although many of the suggestions presented in this summary are seemingly rational and self-evident, many questions are in need of scientific testing for efficacy in randomized trials. For example, an important question might be that, when multiple behaviors need to be addressed, whether it is better to address a behavior that the individual is open to change (i.e., contemplative) or one that potentially presents the greatest risk (e.g., smoking). Scientific studies addressing such questions will greatly assist those that promote lifestyle change strategies in the clinic setting.

REFERENCES

1. Prochaska J, DiClemente C. Stages and Processes of Self-Change for Smoking: Toward an Integrative Model of Change. J Consult Clin Psycho. 1983;51:390–395.

2. Kraus WE, Houmard JA, Duscha BD, et al. Effects of the Amount and Intensity of Exercise on Plasma Lipoproteins. N Engl J Med. 2002;347:1483–1492.

3. Houmard JA, Tanner CJ, Slentz CA, Duscha BD, McCartney JS, Kraus WE. Effect of the Volume and Intensity of Exercise Training on Insulin Sensitivity. J Appl Physiol. 2004;96:101–106.

4. Slentz CA, Duscha BD, Johnson JL, et al. Effects of the Amount of Exercise on Body Weight, Body Composition, and Measures of Central Obesity: STRRIDE–A Randomized Controlled Study. Arch Intern Med. 2004;164:31–39.