BMJ  2004;328:E272-E274 (28 February), doi:10.1136/bmj.328.7438.E272

BMJ USA: Editorial

Obesity trial: knowledge without systems

Not enough, again

In this issue of BMJ USA, Moore et al (p 35) report a practice-based randomized trial that assessed a 4.5 hour training program delivered by dietitians to general practitioners and practice staff to improve their knowledge and management of obesity in adults. The primary outcome was patients' weight change at 12 months, and secondary outcomes included practitioners' knowledge and process measures. While knowledge improved and intervention practices appear to have "tried harder," there was no weight loss in patients. The authors reported that the intervention strategy was only partially implemented in study practices. Combining this partial implementation with the known limited effects of increased knowledge alone on changing practice, the study's findings are exactly the results one would expect.

This intervention focused on clinician knowledge rather than how frontline practice happens. It further supports the view that interventions loaded into primary care practices without consideration of competing demands¹ and practice redesign will likely continue to fail until a new model of primary care practice emerges.

As in the United Kingdom, primary care physicians in the United States are confronted with nearly chaotic practice conditions. They lack the time, skills, and resources to counsel patients about the choices they make, choices that have a huge impact on mortality.² Faced with these challenges, primary care clinicians typically are armed with some knowledge, a lot of desire, and few practical tools. In addition, US insurance companies tend not to reimburse clinicians for time spent counseling patients.³

The opportunity is great. Primary care clinicians in the US and the UK have repeated access to the public, even those not currently ill, and are influential, usual sources of care for patients. By building on these strengths and continuing personalized relationships, primary care is well positioned to promote healthy behaviors.

The opportunity is great. Primary care clinicians... have repeated access to the public, even those not currently ill, and are influential, usual sources of care.... By building on these strengths..., primary care is well positioned to promote healthy behaviors.

The US Institute of Medicine reported in Crossing the Quality Chasm that the American health care system is in need of fundamental change.⁴ The report states with confidence that "Americans can have the healthcare system of the quality they need, want, and deserve, but this higher quality cannot be achieved by further stressing current systems of care. The current system cannot do the job. Trying harder will not work. Changing systems of care will."⁴ This landmark report's recommendations, combined with what is known about the critical role of primary care in successful, sustainable health care systems,⁵ make it clear that now is not the time to abandon or dilute primary care, but rather to fully achieve it.

Progress has been made, but there is much more to do. For example, the Chronic Care Model⁶ provides a functional blueprint and a set of organizational principles for basic changes to support care that is evidence-based, population-based, and patient-centered. This model defines the broad areas that must be considered within the community and in the health system. The Chronic Care Model is a framework in which improvement strategies can be tailored to specific conditions, and practices across the US are succeeding in improving care and outcomes using this framework.⁷

This tailoring and improvement effort is at the heart of Prescription for Health: Promoting Healthy Behaviors in Primary Care Research Networks.⁸ In its first phase, this initiative of the Robert Wood Johnson Foundation and the Agency for Healthcare Research and Quality has awarded $2.4 million to 17 practice-based research networks to field-test evidence-based strategies to improve the delivery, feasibility, and/or reach of behavior change counseling in the single largest setting of formal health care in the US: the offices of primary care physicians.⁹

Examples of the innovations being tested by Prescription for Health innovators include:

• A handheld tool providing patient-tailored counseling at the point of care. Through a series of point-and-click questions, clinicians receive a stage-based multidimensional course of action to effect behavior change, including scripted motivational interview and stage-relevant clinical resources.
  
• A community resource and patient education web site with a searchable database of local community resources and topic-specific patient education materials that clinicians refer to using a health promotion prescription pad.
  
• An integrated health improvement plan with individual categorization of patients by stage of change, referral by clinicians using a prescription pad, tailored telephone counseling using motivational techniques, goal setting, and follow-up.
  

Instead of concluding from the Moore trial that more intense education is needed, primary care is unlikely to get the job done, and dedicated obesity specialists are necessary, we conclude that frontline practices need to be enabled with the cues, tools, techniques, staffing, and linkages needed to fulfill their historic, vital role in high-performance, sustainable health care systems. Now is not the time to diminish primary care. Rather it is time to achieve primary care by correcting the mismatch between what is expected and what it is designed and resourced to do. Bring on the new model primary care practice as soon as possible. The people are waiting.

Maribel.Cifuentes{at}uchsc.edu

Prescription for Health: Promoting Healthy Behaviors in Primary Care Research Networks (A Robert Wood Johnson National Program) Department of Family Medicine, University of Colorado, Aurora, CO lgreen{at}aafp.org

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Paper p 35

Competing interests: None declared.

References

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5. Institute of Medicine, Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds. Primary care America's health in a new era. Washington DC: National Academy Press, 1996.
6. Glasgow RE, Orleans CT, Wagner EH. Does the chronic care model serve also as a template for improving prevention? Milbank Q 2001;79: 579-612, iv-v.[CrossRef][Web of Science][Medline]
7. Wagner EH, Glasgow RE, Davis C, Bonomi AE, Provost L, McCulloch D, et al. Quality improvement in chronic illness care: a collaborative approach. Jt Comm J Qual Improv 2001;27: 63-80.[Medline]
8. Prescription for health: promoting healthy behaviors in primary care research networks. Available at: http://www.prescriptionforhealth.org.
9. Green LA, Fryer GE Jr, Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med 2001;344: 2021-2025.[Free Full Text]

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