Documentation of Behavioral Health Risk Factors in a Large Academic Primary Care Clinic

OBJECTIVE: To determine the prevalence of alcohol, smoking, and physical activity status documentation at a family health team in Toronto, Ontario, and to explore the patient characteristics that predict documentation of these lifestyle risk factor statuses. DESIGN: Manual retrospective review of electronic medical records (EMRs). SETTING: Large, urban, academic family health team in Toronto, Ontario. PARTICIPANTS: Patients over the age of 18 that had attended a routine clinical appointment in March, 2018. MAIN OUTCOME MEASURES: Prevalence and content of risk factor status in electronic medical records for alcohol, smoking, and physical activity. RESULTS: The prevalence of alcohol, smoking, and physical activity documentation was 86.4%, 90.4%, and 66.1%, respectively. These lifestyle risk factor statuses were most often documented in the “risk factors” section of the EMR (83.7% for alcohol, 88.1% for smoking, and 47.9% for physical activity). Completion of a periodic health review within 1 year was most strongly associated with documentation (alcohol odds ratio [OR] 9.79, 95% Confidence Interval [CI] 2.12, 45.15; smoking OR 1.77 95% CI 0.51, 6.20; physical activity OR 3.52 95% CI 1.67, 7.40). CONCLUSION: Documentation of lifestyle risk factor statuses is strongly associated with having a recent periodic health review. If “annual physicals” continue to decline, primary care providers should final additional opportunities to address these key determinants of health.