Implementing and Evaluating the Comprehensive Integration of Physical Activity into a Major Health System and Connecting Patients to Community-Based Physical Activity Programs

美国医疗保健部门在促进慢性病的体力活动(PA)方面具有巨大的潜力 预防和治疗；然而，执行方面存在障碍，从实践整合到 信息流。2016年，大型学术医疗保健公司之间的第一个多组织合作伙伴关系 系统和一个全国性的PA组织发起的演习是MedicGreenville(EIMG®)，一个全面的 诊所到社区的方法，包括PA评估、处方和慢性阻塞性肺疾病患者的转诊 疾病到量身定做的、基于社区的PA计划。自2016年以来，EIMG®已发展到包括18个提供商 覆盖342个城市/农村里程的诊所2和覆盖213个城市/农村里程的6个社区PA中心2。然而， 各参与诊所在正确识别符合条件的患者、提供转诊、 并让患者参与基于社区的PA计划。务实的、阶梯式的、随机化的集群 使用混合方法的试验将检查EIMG®的实施情况和覆盖范围 加入初级保健诊所(即诊所工作流程、转诊流程)，最终导致患者参与 在以社区为基础、以证据为基础的PA项目中。RE-AIM框架将通知评估 执行成果，而i-PARIHS框架将用于更充分地了解背景 影响患者和临床水平结果的因素(即决定因素)。我们的具体目标是：(1) 确定提供商级别采用的差异(即启动使用的提供商比例)、实施 (即交付保真度)和覆盖范围(即患者数量、比例和代表性)，地址为 新入职的初级卫生诊所；(2)评估患者参与证据的有效性- 知情的，社区PA中心为期12周的PA计划，以患者自我报告的PA水平和健康状况为基础 在他们的电子健康中捕获的结果(即体重、血压、血红蛋白A1c、血脂谱) 记录，以及(3)评估实施EIMG®的成本和成本效益(即PA的变化 健康结果相对于医疗保健利用成本的水平和改善) EIMG®与标准护理(即，不参与EIMG®)。作为一个探索性目标，我们将长期评估 适应EIMG®在初级保健诊所的实施和可持续性。最后，我们会付出代价 认真关注所有RE-AIM层面的健康公平问题。这项研究有可能 通过为未来的战略提供信息，显著改变临床实践并改善人口健康结果 优化和扩大综合PA模式与美国卫生系统的整合。本研究 还将提供有关可能实施PA的医疗系统潜在节省的成本估计信息 作为一种人口健康管理工具，通过使用临床-社区联系。

The U.S. healthcare sector has great potential for promoting physical activity (PA) for chronic disease prevention and treatment; however, implementation barriers exist, ranging from practice integration to information flow. In 2016, the first multi-organizational partnership between a large academic healthcare system and a national PA organization launched Exercise is Medicine Greenville (EIMG®), a comprehensive clinic-to-community approach that involves PA assessment, prescription, and referral of patients with chronic diseases to tailored, community-based PA programs. Since 2016, EIMG® has grown to include 18 provider clinics covering 342 urban/rural miles2 and 6 community PA centers covering 213 urban/rural miles2. However, great variability across participating clinics exists in correctly identifying eligible patients, providing referrals, and engaging patients in the community-based PA programs. A pragmatic, stepped wedge, cluster randomized trial using a mixed methods approach will examine the implementation and reach of EIMG® across newly onboarded primary care clinics (i.e., clinic workflow, referral process), ultimately leading to patient engagement in community-based, evidence-informed PA programs. The RE-AIM framework will inform the assessment of implementation outcomes, while the i-PARIHS framework will be used to more fully understand contextual factors (i.e., determinants) influencing patient and clinic level outcomes. Our specific aims are to: (1) to determine differences in provider-level adoption (i.e., proportion of providers that initiate use), implementation (i.e., delivery fidelity), and reach (i.e., number, proportion, and representativeness of patients) of EIMG® at newly onboarded primary health clinics; (2) assess the effectiveness of patient engagement in the evidence- informed, 12-week PA programs at the community PA centers on patient self-reported PA levels and health outcomes (i.e., body weight, blood pressure, hemoglobin A1c, lipid profiles) captured in their electronic health records, and (3) evaluate the cost of implementing EIMG® and the cost-effectiveness (i.e., changes in PA levels and improvements in health outcomes versus health care utilization costs) of patients participating in EIMG® vs. standard of care (i.e., no engagement in EIMG®). As an exploratory aim, we will evaluate long-term adaptations to the implementation and sustainability of EIMG® in the primary care clinics. Finally, we will pay careful attention to issues of health equity across all RE-AIM dimensions. This study has the potential to significantly change clinical practice and improve population health outcomes by informing future strategies on optimizing and scaling up the integration of comprehensive PA models into U.S. health systems. This study also will provide information on cost estimates of potential savings to health systems that may implement PA as a population health management tool through the use of clinical-community linkages.