An initiative to implement a triage and referral system to make exercise and rehabilitation referrals standard of care in oncology

BACKGROUND

Clinical guidelines suggest that patients should be referred to exercise while undergoing cancer treatment. Oncology clinicians report being supportive of exercise referrals but not having the time to make referrals. Toward the goal of making exercise referrals standard of care, we implemented and evaluated a novel clinical workflow.

METHODS

For this QI project, a rehabilitation navigator was inserted in chemotherapy infusion clinics. Patients were offered a validated electronic triage survey. Exercise or rehabilitation recommendations were communicated to patients during a brief counseling visit by the rehabilitation navigator. The implementation approach was guided by the EPIS framework. Acceptability and feasibility were assessed.

RESULTS

Initial meetings with nursing and cancer center leadership ensured buy-in (exploration). The education of medical assistants contributed to the adoption of the triage process (preparation). Audit and feedback ensured leadership was aware of medical assistants' performance (implementation). 100% of medical assistants participated in implementing the triage tool. A total of 587 patients visited the infusion clinics during the 6-month period when this QI project was conducted. Of these, 501 (85.3%) were offered the triage survey and 391 (78%) completed the survey (acceptability). A total of 176 (45%) of triaged patients accepted a referral to exercise or rehabilitation interventions (feasibility).

CONCLUSIONS

Implementation of a validated triage tool by medical assistants and brief counseling by a rehabilitation navigator resulted in 45% of infusion patients accepting a referral to exercise or rehabilitation. The triage process showed promise for making exercise referrals standard of care for patients undergoing cancer treatment.

Including Lifestyle Medicine in Medical Education: Rationale for American College of Preventive Medicine/American Medical Association Resolution 959

Introduced by the American College of Preventive Medicine and released by the American Medical Association House of Delegates in 2017, Resolution 959 (I-17) supports policies and mechanisms that incentivize and/or provide funding for the inclusion of lifestyle medicine education and social determinants of health in undergraduate, graduate and continuing medical education. Resolution 959 was passed to help address the current healthcare costs of lifestyle-related, noncommunicable chronic diseases that exert a devastating economic burden on the U.S. healthcare system. Approximately 86% of $2.9 trillion is spent annually on obesity, cardiovascular disease, type 2 diabetes, and some cancers, with very poor return on investment for health outcomes. Lifestyle medicine provides an evidence-based solution to the noncommunicable chronic disease epidemic; however, medical education in lifestyle medicine is minimal to nonexistent. This paper provides the case for healthcare innovation to include lifestyle medicine in the prevention and treatment of noncommunicable chronic diseases. Our medical education system recommendation is to provide lifestyle medicine training for prevention and treatment of noncommunicable chronic diseases. Exemplar lifestyle medicine schools are showcased and guidance for reform is highlighted that can be used to aid lifestyle medicine integration across the medical school education continuum. With a transformation of curriculum and development of new policies to support a focus on lifestyle medicine education in medical education across the continuum, a new healthcare model could be successful against noncommunicable chronic diseases and U.S. citizen wellness could become a reality.

Including lifestyle medicine in undergraduate medical curricula

PURPOSE

Currently, there is no model to integrate the discipline of lifestyle medicine (LM) into undergraduate medical education. Furthermore, there are no guidelines, validated assessment tools, or evaluation or implementation plans in place.

BACKGROUND

The World Health Organization predicts that by 2020, two-thirds of disease worldwide will be the result of poor lifestyle choices. Fewer than 50% of US primary care physicians routinely provide specific guidance on nutrition, physical activity, or weight control.

METHODS

We are establishing a plan to integrate LM into medical school education in collaboration with the investing stakeholders, including medical school deans and students, medical curriculum developers and researchers, medical societies, governing bodies, and policy institutes. Three planning and strategy meetings are being held to address key areas of focus - with a particular interest in nutrition, physical activity, student self-care, and behavior change - to develop specific implementation guidelines and landmarks.

RESULTS

After the first two meetings, the proposed areas of focus were determined to be: 1) supporting of deans and key personnel, 2) creation of federal and state policy commitments, 3) use of assessment as a driver of LM, 4) provision of high-quality evidence-based curricular material on an easily navigated site, and 5) engaging student interest. Implementation strategies for each focus area will be addressed in an upcoming planning meeting in early 2015.

CONCLUSION

This initiative is expected to have important public health implications by efficiently promoting the prevention and treatment of non-communicable chronic disease with a scalable and sustainable model to educate physicians in training and practice.

22A. Neurogenesis: Implications for Integrative Care of Neurological Conditions

Focus Area: Integrative Approaches to Care

Chronic neurological illnesses such as Alzheimer's Disease are the most pressing public health problems in aging societies. Biomedical and mechanistic approaches to these degenerative conditions are limited by incomplete knowledge of the initiating causes and basic mechanisms of pathogenesis. Proposed treatments such as monoclonal antibodies are built on disputed notions of the role of pathological markers such as cerebral amyloid. They are unproven and likely to be very expensive, especially if used for millions of affected or at-risk individuals. Integrative approaches emphasize multimodal, holistic approach to support the body's self-healing abilities. This approach offers a safe, effective, and cost-effective alternative to conventional biomedical treatments.

There is growing evidence that neurogenesis, the birth of new neurons from neural stem cells, occurs under normal physiological conditions throughout life. The key steps in this process are under positive and negative modulation by environmental and behavioral factors. Effective management of these conditions and, indeed, prevention in populations is dependent on promoting modulatory influences that support neurogenesis and avoiding and mitigating those influences that negatively affect neurogenesis. In this session, we will hear from an interprofessional team consisting of a neurologist, an exercise physiologist, a psychotherapist and mind-body practitioner, and a traditional Chinese medicine physician who are actively developing integrative approaches to these problems.

Hydration during Exercise in Warm, Humid Conditions: Effect of a Caffeinated Sports Drink

Caffeine is regarded as a diuretic despite evidence that hydration is not impaired with habitual ingestion. The purpose of this study was to determine whether a caffeinated sports drink impairs fluid delivery and hydration during exercise in warm, humid conditions (28.5 °C, 60% relative humidity). Sixteen cyclists completed 3 trials: placebo (P), carbohydrate-electrolyte (CE), and caffeinated (195 mg/L) sports drink (CAF+CE). Subjects cycled for 120 min at 60–75%VO2max followed by 15 min of maximal-effort cycling. Heart rate and rectal temperature were similar until the final 15 min, when these responses and exercise intensity were higher with CAF+CE than with CE and P. Sweat rate, urine output, plasma-volume losses, serum electrolytes, and blood deuterium-oxide accumulation were not different. Serum osmolality was higher with CAF+CE vs. P but not CE. The authors conclude that CAF+CE appears as rapidly in blood as CE and maintains hydration and sustains cardiovascular and thermoregulatory function as well as CE during exercise in a warm, humid environment.

Caffeinated Sports Drink: Ergogenic Effects and Possible Mechanisms

This double-blind experiment examined the effects of a caffeinated sports drink during prolonged cycling in a warm environment. Sixteen highly trained cyclists completed 3 trials: placebo, carbohydrate-electrolyte sports drink (CES), and caffeinated sports drink (CES+CAF). Subjects cycled for 135 min, alternating between 60% and 75% VO2max every 15 min for the first 120 min, followed by a 15-min performance ride. Maximal voluntary (MVC) and electrically evoked contractile properties of the knee extensors were measured before and after cycling. Work completed during the performance ride was 15–23% greater for CES+CAF than for the other beverages. Ratings of perceived exertion were lower with CES+CAF than with placebo and CES. After cycling, the MVC strength loss was two-thirds less for CES+CAF than for the other beverages (5% vs. 15%). Data from the interpolated-twitch technique indicated that attenuated strength loss with CES+CAF was explained by reduced intrinsic muscle fatigue.