The United States Preventive Services Task Force (USPSTF) has released new recommendations for adults with known cardiovascular disease (CVD) risk factors1 and an associated systematic literature review.2 The recommendations encourage medical practitioners to offer or refer adults with CVD risk factors to behavioral counseling interventions to promote healthy diet and physical activity (B recommendation).1,2 Notable changes from the 2014 recommendations are that recommendations are extended to patients who are not overweight or obese (individuals who are overweight or obese are covered in other recommendations), CVD risk factors are expanded to include patients with elevated blood pressure and a 10-year CVD risk of 7.5% or greater, research pertaining to patients with impaired fasting glucose or diabetes is no longer included in the review but discussed in separate recommendation statements, and it is no longer specified that behavioral interventions should be intensive.1 In addition, suggestions for implementation now state that behavioral counseling can be provided using media-based interventions. The systematic literature review2 concluded that behavioral interventions produced a moderate net benefit, and resulted in lower incidence of CVD events; reductions in blood pressure, lower total cholesterol, and low-density lipoprotein cholesterol; and weight loss.
Barriers to Implementation
There are several barriers to implementing these USPSTF recommendations1,2 in clinical settings. Owing to the expanded definition of CVD risk factors in this update,1,2 behavioral counseling is recommended for a large proportion of, perhaps most, US adults.3 Delivering behavioral counseling interventions to this large population would require substantial health systems change.
Of 120 interventions in 94 studies included in the USPSTF commissioned review,2 7 interventions (5.8%) were low intensity (ie, ≤30 minutes of contact), 59 interventions (49.2%) were medium intensity (ie, 31-360 minutes), and 54 interventions (45.0%) were high intensity (ie, >360 minutes). While some low-intensity interventions were effective, the most effective interventions in the studies reviewed included at least monthly contacts with patients over a period of 4 months or longer.2 Interventions of this intensity may not be feasible in primary care settings owing to time constraints, increased care requirements of an aging population, competing clinical demands, and impending workforce shortages, and suboptimal geographic distribution of primary care clinicians.4-6 While patients may want their primary care clinicians to provide lifestyle counseling, many primary care clinicians may not be familiar or experienced with communication techniques needed to engage and sustain behavior change in their patients4,5,7; therefore, it is critical that behavioral counseling interventions are available to patients outside of primary care visits.
As mentioned in the USPTF recommendations,1 behavioral counseling services can be provided by nurses, registered dietitians, nutritionists, exercise specialists, masters- and doctoral-level counselors trained in behavioral methods, and lifestyle coaches. However, referral rates to these services are low.4,5 Also, behavioral counseling by dietitians, exercise specialists, and lifestyle counselors is not covered by all health insurance plans. For instance, Medicare only reimburses for intensive behavioral counseling for weight loss and 1 face-to-face session per year for adults with CVD risk factors, if the individual providing the service is a physician, nurse practitioner, physician assistant, or auxiliary personnel in primary care settings, thus limiting access to these services.8 Referral to commercial weight loss programs is an alternative to provide intensive behavioral counseling, and these programs have demonstrated efficacy.9 However, commercial weight loss programs are not covered by all health insurance plans, and the out-of-pocket costs may be prohibitive.9 Another option, as the USPSTF suggests, is to use media-based interventions. However, the USPSTF did not define the term, and acknowledged that additional research examining the efficacy of media-based interventions for cardiovascular risk reduction is needed. The USPSTF commissioned systematic review included only 2 patient-facing interventions conducted entirely online without interactive communication between patients and health care practitioners.
A notable change from prior USPSTF guidelines is that recommendations for behavioral counseling now extend to individuals who are not overweight or obese, while individuals who are overweight or obese are covered in other recommendations.1 We believe that it is important to address CVD risk in individuals who are not overweight or obese, and early behavior change could help reduce long-term cardiovascular sequelae and prevent overweight and obesity before they develop. However, many behavioral counseling programs and commercial programs focus primarily on weight loss and would need to be adapted to be suitable for and inclusive of individuals who are not overweight or obese.
Lifestyle counseling interventions that largely focus on provision of education may overlook patient-level and environmental factors that affect patients’ ability to eat healthier diets and be more physically active (eg, health literacy, culture, lifestyle, poverty, discrimination, food deserts, lack of green space, crime). Interventions may not address the unique needs of members of racial and ethnic minority groups and individuals with limited English proficiency, groups that are disproportionately affected by CVD. Addressing racial/ethnic disparities is imperative, particularly in the non-Hispanic Black population. Compared with non-Hispanic White adults, a higher prevalence of CVD risk factors (eg, obesity, diabetes, hypertension) are evident in Black adults and translate to higher rates of fatal coronary heart disease, stroke, heart failure, and peripheral arterial disease.10 These conditions occur at an earlier age in Black adults than White adults and appear to be less amenable to pharmacotherapy, highlighting the importance of prevention.10
Additionally, the current coronavirus disease 2019 (COVID-19) pandemic may negatively impact implementation and success of the USPSTF guidelines.1,2 Individuals who are at greatest risk of CVD (eg, elderly individuals, members of racial/ethnic minority groups, and individuals with diabetes and hypertension) are also at greatest risk of poor COVID-19 outcomes and may forego preventive care out of fear of exposure.11 Also, owing to the need to prioritize care for patients who are acutely ill, COVID-19 is disrupting routine care for chronic conditions, such as hypertension. Thirdly, stay-at-home orders may impact lifestyle behaviors in a manner that increases CVD risks (eg, increased sedentary behavior and stress-eating).12 If COVID-19 becomes endemic, new solutions will be required to mitigate barriers to lifestyle counseling.
We propose several potential solutions. Reimbursement policy should be reexamined to support lifestyle counseling by professionals best prepared to deliver it. More referral options for behavioral counseling interventions are needed, which could be facilitated by expanded insurance coverage for services delivered by other interventionists, such as dieticians and exercise specialists, and sources, like commercial programs for all patients with CVD risk factors. To address the needs of rural and racial/ethnic minority communities, engaging peer counselors and community health workers to deliver CVD lifestyle counseling are solutions with demonstrated efficacy.13 In addition, electronic health records (EHRs), could be used to prompt primary care clinicians to assess CVD risk factors and initiate referrals.14 However, resources would need to be allocated to increase use of EHRs in smaller practices, provide the technical assistance needed to develop clinical decision-support systems within EHR systems, establish appropriate referral networks, and assist patients in accessing services.14
Additional barriers to behavioral counseling access could be mitigated by expanded use of telehealth. For example, videoconferencing is a reasonable alternative to in-person sessions and can accommodate group-based counseling that often is used in behavioral interventions. In response to COVID-19, Medicare and other health insurance organizations changed their policies to temporarily reimburse telehealth visits. Insurance companies should consider making these changes permanent, as telehealth can reduce patient-level barriers (eg, lost work, transportation, childcare) to accessing lifestyle counseling and can address workforce shortages and suboptimal geographic distribution of specialized health services.15 Through these mechanisms, telehealth may decrease racial, ethnic, and socioeconomic disparities in health risks and outcomes. However, some researchers, such as Jaffe et al,16 caution that widespread use of telehealth may widen disparities if precautions are not taken to address differential access to technology and broadband internet and concerns regarding confidentiality, privacy, and physical absence of a clinician. In addition, as highlighted in the USPSTF commissioned review,2 further research on the impact of telehealth interventions is needed.
Additionally, technology-based monitoring of diet and physical activity with automated feedback and connectivity with patients’ EHRs could be used to augment behavioral counseling interventions, improve diet, and increase physical activity.17 Self-monitoring is thought to enhance self-regulation, and results in real-time automated reports (eg, energy expenditure, or the accumulation of calories, fat, or sodium), that could reinforce healthy behaviors and permit the patient to self-correct. While the USPSTF commissioned literature review2 found that few studies examined the impact that the use of fitness trackers had on the effectiveness of behavioral counseling interventions, in general systematic reviews suggest that self-monitoring as a lifestyle behavior change strategy improves dietary behavior18 and reduces sedentary behavior.19 Furthermore, remotely accessible electronic logs generated from self-monitoring technologies could permit the interventionist to counsel patients regarding behaviors that are recorded in real time rather than relying on biased recall of eating and physical activity habits.
While behavioral counseling interventions are effective for CVD prevention, health systems change is needed to implement the new USPSTF guidelines1,2 broadly and equitably. First, primary care clinicians have limited capacity to deliver diet and physical activity behavioral counseling interventions. The referral rates to other practitioners who may be better equipped to deliver these interventions, such as dietitians and exercise physiologists, are low, and their services are often not covered by all insurances. The COVID-19 pandemic also complicates intervention delivery by reducing access for the patients who need them most. We offer several potential solutions. First, insurance reimbursement structures need to be amended to cover behavioral counseling for individuals with CVD risk factors. Second, the EHR could be leveraged to prompt clinicians to evaluate patients’ CVD risk and offer referrals. Third, telemedicine, commercial weight loss programs, technology that allows patients to self-monitor their diet and physical activity, and task shifting strategies that use community health workers can augment the health system’s ability to deliver behavioral counseling interventions and promote healthier lifestyles. However, as acknowledged in the USPSTF commissioned literature review,2 additional research is needed to test the effectiveness of telehealth interventions and self-monitoring technology, such as fitness trackers, on long-term cardiovascular health outcomes.
Published: November 24, 2020. doi:10.1001/jamanetworkopen.2020.29682
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Kharmats AY et al. JAMA Network Open.
Corresponding Author: Anna Y. Kharmats, PhD, MA, Department of Population Health, New York University Grossman School of Medicine, 180 Madison Ave, New York, NY 10016 (email@example.com).
Conflict of Interest Disclosures: Dr Kharmats reported receiving grants from NYU Grossman School of Medicine funded by the National Heart, Lung, and Blood Institute outside the submitted work. Dr Pilla reported receiving salary support from the Johns Hopkins KL2 Clinical Research Scholars Program outside the submitted work. No other disclosures were reported.
Kharmats AY, Pilla SJ, Sevick MA. USPSTF Recommendations for Behavioral Counseling in Adults With Cardiovascular Disease Risk Factors: Are We Ready? JAMA Netw Open. 2020;3(11):e2029682. doi:10.1001/jamanetworkopen.2020.29682
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