Systematic Evidence Review

Number 9

Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 2101 East Jefferson Street Rockville, MD 20852

http://www.ahrq.gov/

Contract No. 290-97-0018 Task Order No. 2 Technical Support of the U.S. Preventive Services Task Force

Prepared by: Oregon Health Sciences University Evidence-based Practice Center, Portland, Oregon Karen B. Eden, PhD C. Tracy Orleans, PhD Cynthia D. Mulrow, MD, MSc Nola J. Pender, PhD, RN, FAAN Steven M. Teutsch, MD, MPH

August 2002

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

AHRQ is the lead Federal agency charged with supporting research designed to improve the quality of health care, reduce its cost, address patient safety and medical errors, and broaden access to essential services. AHRQ sponsors and conducts research that provides evidence-based information on health care outcomes; quality; and cost, use, and access. The information helps health care decisionmakers -- patients and clinicians, health system leaders, and policymakers -- make more informed decisions and improve the quality of health care services.

The Agency for Healthcare Research and Quality (AHRQ) sponsors the development of Systematic Evidence Reviews (SERs) through its Evidence-based Practice Program. With guidance from the third U.S. Preventive Services Task Force* (USPSTF) and input from Federal partners and primary care specialty societies, two Evidence-based Practice Centers -- one at the Oregon Health Sciences University and the other at Research Triangle Institute-University of North Carolina -- systematically review the evidence of the effectiveness of a wide range of clinical preventive services, including screening, counseling, immunizations, and chemoprevention, in the primary care setting. The SERs -- comprehensive reviews of the scientific evidence on the effectiveness of particular clinical preventive services -- serve as the foundation for the recommendations of the third USPSTF, which provide age- and risk-factor-specific recommendations for the delivery of these services in the primary care setting. Details of the process of identifying and evaluating relevant scientific evidence are described in the "Methods" section of each SER.

The SERs document the evidence regarding the benefits, limitations, and cost-effectiveness of a broad range of clinical preventive services and will help to further awareness, delivery, and coverage of preventive care as an integral part of quality primary health care.

AHRQ also disseminates the SERs on the AHRQ Web site (http://www.ahrq.gov/uspstfix.htm) and disseminates summaries of the evidence (summaries of the SERs) and recommendations of the third USPSTF in print and on the Web. These are available through the AHRQ Web site (http://www.ahrgq.gov/uspstfix.htm), through the National Guideline Clearinghouse (http://www.ncg.gov), and in print through the AHRQ Publications Clearinghouse (1-800-358-9295).

We welcome written comments on this SER. Comments may be sent to: Director, Center for Practice and Technology Assessment, Agency for Healthcare Research and Quality, 6010 Executive Blvd., Suite 300, Rockville, MD 20852.

To determine whether counseling adults in primary care settings improves and maintains physical activity levels.

The Cochrane Registry of Controlled Trials, MEDLINE, HealthStar and Best Evidence databases were searched for papers published from 1994 to June 2001.

We reviewed controlled trials, case-control studies, observational studies, and systematic reviews that reported behavioral outcomes of counseling interventions aimed at increasing physical activity in general primary care populations. For inclusion, (1) a patient's primary care clinician (physician, nurse, nurse practitioner, or physician assistant) had to perform some component (assessment, advising, counseling, referral, etc.) of the intervention, (2) behavioral outcomes (physical activity) were reported, (3) the study was of "good" or "fair" quality using criteria developed by the U.S. Preventive Services Task Force (USPSTF).

We abstracted from each study: information on the design and execution; quality information; details of the providers, patients, setting, and counseling intervention; and self-reported physical activity at follow-up.

Nine trials involving 9,227 adults met the inclusion criteria for this report. Most counseling interventions in the studies were relatively brief (3-5 minutes). Two of six fair to good quality trials reported statistically significant improvements in physical activity for intervention patients compared with patients receiving usual care. The remaining three trials compared two or more interventions (contained no usual care comparison). These trials reported an increased effect: when the patient was given advice in combination with a written prescription; for female patients, when the intervention included behavior counseling and extended phone call support; or when the patient (male or female) set a physical activity goal.

Most studies had at least one of the following limitations: provided limited details on the counseling intervention, had follow-up on only 60-79% of subjects, excluded nonresponders from the analysis, studied selected provider populations, reported differences in physical activity levels at baseline between treatment groups, and/or had uncertain or low provider compliance. It was often difficult to assess whether patients had actually received a physical activity behavioral intervention. Most trials only assessed the patients' activity levels short-term (less than six months). These methodological problems made it hard to rigorously assess the efficacy or effectiveness of the interventions. More research is needed to clarify the effect, benefits and/or potential harms of counseling patients in primary care to increase physical activity.

Evidence that counseling adults in the primary care setting to increase physical activity is inconclusive.