44: Evidence-Based Behavioral Practice

Human behavior has a major impact on health and well-being. The patients that you see in medical practice are likely to have behaviors (e.g., smoking, drinking, and eating habits) that place them at risk of developing chronic disease. Equally likely, they may have psychological problems (e.g., depression) that impair their quality of life and undermine their motivation to follow your treatment recommendations. Moreover, if you treat families and see the same patients over many years, you may observe unhealthy behaviors long before you see the emergence of biological risk factors like hypertension, hypercholesterolemia, or hyperglycemia. By helping your patients to address unhealthy behaviors, you have the opportunity to help them prevent the onset or worsening of chronic diseases. Just as in evidence-based medicine, you should know how to find and appraise the evidence base for behavioral (nondrug, nonsurgical) treatments, so you can help your patients with the most appropriate behavioral treatment option. Below is a case you might encounter in the primary care clinic.

This patient has several risk factors and behaviors that put his health at risk and that are potential targets for behavior change interventions. You are probably familiar with how to practice evidence-based care when making medical decisions about the use of medications or procedures. There is also a scientific evidence base about how to treat most unhealthy behaviors. For the purposes of this chapter, we use the broader term “evidence-based practice” (EBP) that includes both traditional evidence-based medicine and evidence-based behavioral practice.

EBP 5A’s: Ask Questions

A practical way to approach EBP is by using a 5-step process better known as the “5A’s,”: Ask, Acquire, Appraise, Apply, and Analyze & adjust (see Figure 44-1).

The first step is to ask focused questions that can be answered through review of the scientific literature. Two kinds of questions connect health care providers with the knowledge base needed to offer best preventive care. The first (prognostic questions), asks which factors (i.e., biomarkers, behaviors, environmental conditions) convey risk or protection with respect to the likelihood of developing a chronic disease. The second (treatment questions) asks which treatments are most effective at reversing disease risk factors and promoting health protection.

Early in their careers, most physicians become familiar with the evidence base that evaluates which biomarkers warrant consistent clinical attention because they are risk factors for the development of chronic disease. They also learn to monitor and treat elevated cholesterol, blood pressure, and glucose to slow the patient’s progression toward clinical disease. For disease prevention to be effective, it is important for physicians to recall that many unhealthy behaviors (e.g., substance use, physical inactivity, overeating) warrant as urgent attention as risk biomarkers. By asking prognostic questions and consulting the scientific literature, you can master the knowledge base that supports the contention that lifestyle behaviors are just as strongly associated as risk biomarkers with the onset of disease. With that awareness, you can then inquire about the best ways to treat unhealthy lifestyle behaviors.

EBP 5A’s: Acquire and Appraise

Next steps in the EBP process are to acquire the evidence and critically appraise it for its quality and relevance to your patient. As a health care practitioner, you are a consumer of research; sometimes you will look for primary research evidence such as individual research studies, including clinical trials. More often you will turn to a secondary, synthesized evidence base that has been assembled in the form of systematic reviews.

Much research exists about the lifestyle risk behaviors and treatment options for the patient described in the case. This evidence has often undergone systematic reviews to develop evidence-based treatment guidelines. For example, the Guide to Clinical Preventive Services, prepared by the US Preventive Services Task Force (USPSTF), rigorously evaluates and makes recommendations about the merits of preventive measures, including screening tests, counseling, and preventive medications. Another guideline, Treating Tobacco Use and Dependence, prepared by the US Public Health Services (USPHS), evaluates and makes recommendations about treating tobacco use. The National Heart, Lung, and Blood Institute has systematic reviews and guidelines about obesity treatment and about lifestyle interventions to reduce the risk of cardiovascular disease. Each review grounds interpretation of the evidence in an analytic framework that summarizes observational epidemiologic studies showing evidence of harms from the unhealthy behavior, as well as evidence of reduction in these harms when the behavior is stopped. These guidelines offer many recommendations relevant to your patient’s smoking, unhealthy use of alcohol, obesity, and sedentary lifestyle.

Brief Versus Intensive Behavioral Interventions

The act of having a healthcare professional identify an unhealthy behavior, provide brief counseling to promote change, and follow up produces measureable improvement in several risk behaviors, including cigarette smoking. Usually, however, behavior changes are small and most patients do not respond. It is very important that the physician not interpret this experience to mean that behavior cannot be changed. After all, most unhealthy habits were acquired over a period of many years and have become deeply ingrained. More intensive treatments (that involve more and longer counseling sessions with specially trained providers) produce larger behavioral improvements in a greater proportion of those treated. For example, the Diabetes Prevention Program and Look AHEAD established that multiple sessions of diet, exercise, and behavior change counseling could produce a 7–8% weight loss, improved glycemic control, delayed progression of diabetes, and improved cardiovascular risk factors. Similarly, many studies synthesized to develop the USPHS Tobacco Guideline show that providing a greater number of counseling sessions or offering counseling combined with quit smoking medications substantially improves the patient’s odds of becoming smoke free for the long term.

Multiple Unhealthy Behaviors

While the evidence supporting the effectiveness of intensive health behavior change treatments is strong, derived from well-executed multisite randomized controlled trials, the research on health behavior change is particularly sparse in terms of indicating how to treat multiple co-occurring unhealthy behaviors. A majority of treatments directed at health behavior change address a single behavior, for example, excess alcohol intake, obesity, or risky sexual behavior. It has not been well studied how many behaviors are feasible to change at once, whether attempts to change multiple behaviors should be made simultaneously or sequentially, how to prioritize which behavior(s) to tackle first, or whether it is more effective to encourage patients to increase healthy behaviors or decrease unhealthy ones. If several behaviors in sequence will be changed, there is little research to guide the practitioner about how long to wait before tackling a new behavior and what sequence of behaviors will maximize the chances of success. These are important gaps in knowledge that clinicians and patients need researchers to fill.

EBP 5A’s: Apply

Having asked key questions about the patient’s health risks and treatment options, and having acquired and appraised the evidence, you have now reached the apply step in the EBP process. Deciding how to apply the evidence is the heart of how clinicians translate research into practice. As Figure 44-2 illustrates, making decisions about how to apply evidence requires integrating data from each of the three circles: best available research, patient characteristics (including preferences and values), and resource considerations (including practitioner expertise or skills).

For this patient, there are a number of effective interventions, some brief and some intensive, to address his risk behaviors. With so many unhealthy behaviors, the real challenge is to know where to begin. To prioritize which behaviors to treat, you will want to consider all three circles. An important first step is to evaluate the magnitude and immediacy of risks associated with each of the patient’s health behaviors. Research evidence informs you that, ordinarily, smoking and obesity top the list of risk factors that have the greatest harmful impact. For this patient, though, his alcohol use could pose a greater immediate risk of harm. You might also want to evaluate whether a coexisting mental health disorder like depression or anxiety is present that warrants treatment in its own right and that could complicate efforts at behavior change.

To address the patient’s risk of drinking, you will probably want to start off with a procedure called SBIRT (Screening, Brief Intervention, and Referral for Treatment). Based on the patient’s responses to a screening questionnaire, you would inform him about how his amount of drinking corresponds to a level of intake that is considered low risk. You would then assess his motivation or level of readiness to change. Depending on his readiness, you and the patient might collaboratively set a goal that falls somewhere between touching base about drinking at the next medical appointment, to reducing his number of drinks per week, to beginning intensive treatment with a substance abuse counselor. Alternatively, the patient may not be interested in changing his drinking, but motivated to become more physically active. The more the patient can be engaged in collaborating to formulate a behavior change goal, the greater the likelihood that he will follow through, thereby growing more confident and motivated to attempt new healthy changes (see Chapter 19).

Another key consideration arises from the third circle: resources. What assets are available to support your patient’s behavior change? Financial resources will probably factor in, as may your team’s time and professional skills. As practitioners acquire knowledge of evidence-based interventions to change behavior, they need to maintain self-awareness of their own skills, time, and resources. They need to be aware of their own limitations and understand when the evidence suggests that a behavior change intervention that they cannot provide is likely to be more effective than what they can offer. If they are unable to develop those services in their practice, they should refer patients to practitioners and programs in their community that can provide them. To adequately support health promotion, the physician needs to cultivate a professional referral network that includes experts in behavior change (psychologists), nutrition (dieticians), and exercise (kinesiologists, exercise physiologists). To serve those without resources to pay for intensive behavioral treatments, the doctor will also want to keep on hand a roster of no- or low-cost resources, including free telephone counseling services (e.g., smoking quit line), community programs (e.g., training clinics that offer free or sliding scale billing, church-based programs, YMCA), Internet or mobile treatment programs, and books.

EBP 5A’s: Analyze and Adjust

At the end of the day, the best intervention is not necessarily the one supported by the highest quality clinical trial evidence, but rather the one that works for the particular patient. The treatment supported by the best available evidence is the best initial treatment to try, but decision making about intervention begins rather than ends when an initial treatment is selected and delivered. The important rest of the story unfolds by measuring and analyzing what benefits (positive behavior changes) and harms (side effects, distress, worsening of other health behaviors) accrue to the patient as a result of receiving the chosen treatment. If the balance of benefits and harms continues in an unfavorable direction, the provider will want to consider adjusting the type, dose, or administrator of the treatment.

Physicians should not be surprised if the benefits they observe from any treatment in actual clinical practice are smaller than those seen in research studies. There are many reasons for this discrepancy. Clinicians who provide an intervention in actual practice may be less well-trained, exert fewer checks on the quality of treatment delivery, and provide less intensive care because they have competing priorities. Cost may also be a barrier that constrains patients’ full engagement in treatment; behavioral interventions may be expensive, and third-party coverage may be less generous or nonexistent for these services. Out-of-pocket costs to the patient can pose a real obstacle to full engagement with treatment.

Prospects for preventive medicine hinge upon making evidence-based behavioral practice a reality. Because lifestyle behaviors constitute the major preventable causes of chronic disease, monitoring and treating them effectively through the entire health care system and across the lifespan offers the greatest hope of real primary prevention. Useful tools that fit into the clinical workflow can help make it easier for clinical practices to systematically complete screenings for risky behaviors. Changing the roles played by care team members can take some of the burden off the physician and may make the delivery system more reliable. Electronic health record tools like clinical reminders can encourage completion of standardized health behavior assessments that serve as screeners or that track progress over time. Tools like Internet portals connected to patients’ electronic health records can allow patients to complete assessments prior to a medical visit so that the patient can self-monitor personal progress over time. Mechanisms that simplify and expedite the process of referring patients to expert interventionists are also needed so that the barriers to referral are reduced when patients require more than just brief behavioral treatment. Because we cannot manage what we do not measure, effective health promotion through lifestyle intervention would be enhanced by increased use of performance measures that assess screening for and treatment of risk behaviors. Some of these exist (such as those developed by the Physicians Consortium for Performance Improvement convened by the American Medical Association) and are used to varying degrees. Assessing and intervening with risk behaviors in a manner that integrates best available research, patient characteristics and resources is the pathway to integrative care that prevents illness in addition to managing disease.

Evidence-based behavioral practice. www.ebbp.org. Free online modules that illustrate the EBBP process for both individual and public health. Accessed February 2014.

Duke and UNC Chapel Hill online EBP module.

http://www.hsl.unc.edu/services/tutorials/EBM/index.htm. Accessed February 2014.

Physicians Consortium for Performance Improvement. http://www.ama-assn.org/apps/listserv/x-check/qmeasure.cgi?submit=PCPI. Accessed February 2014.