LOFIT: Lifestyle front Office For Integrating lifestyle medicine in the Treatment of patients: a novel care-model towards community-based options for lifestyle change

Non-communicable diseases (NCDs), including cardiovascular disease (CVD) and osteoarthritis, are important contributors to (premature) death rates and a potent driver of direct and indirect costs in the Netherlands. Lifestyle medicine intends to support patients with healthcare problems to cure or reduce disease burden, complications and the intake of medicine. However, implementation of lifestyle medicine is hampered by time constraints and competing priorities of treating physicians. Therefore, to optimize patient-centered lifestyle care this LOFIT project will develop and evaluate the (cost-) effectiveness of a ‘lifestyle front office’ (LFO), and integrate this office in secondary/tertiary care for patients with NCDs. In a LFO dedicated LifeStyle Brookers (LSBs) build in dialogue with the patient motivation for lifestyle change and refer patients to local community-based lifestyle change initiatives (f.i. neighborhood lifestyle coaches, etc.), while always maintaining a feedback loop with the treating physician. In LOFIT, building strongly on results collated in and learned from PIE=M, we will develop and evaluate a LFO at two university medical centers (Amsterdam UMC and UMC Groningen) in collaboration with stakeholders, through active involvement in the project team and through pre-intervention qualitative research (i.e. interviews). We will test this LFO novel care path firstly among patients with cardiovascular disease (CVD) and (hip and knee) osteoarthritis in need of lifestyle change, but a LFO will have the potential for implementation for other categories of patients with NCDs. In two consecutive workpackages (WP) we will develop and evaluate a LFO. WP1: To develop a LFO, the following tasks will be carried out: • Task 1.1 and 1.2: Qualitative research among patients with different NCDs (Task 1.1) and relevant health care professionals, heads of departments, hospital management, health care insurance companies and providers of community initiatives (Task 1.2) to provide a scientific foundation for effective implementation and integration of a LFO. The aim is to identify experiences with current hospital care, views and preferences regarding a LFO, understand current lifestyle referral and treatment procedures (if any), collate current available community-based lifestyle interventions, and to investigate barriers, facilitators and strategies for the implementation of a LFO. • Task 1.3: Develop a LFO based on results of Task 1.1-1.2 following a practical tool for planning complex behavior modification interventions (i.e. MAP-IT). • Task 1.4: Develop a decision aid to help LSBs to refer patients to appropriate already existing community lifestyle change options, based on results of Task 1.1-1.2. The decision aid will be pre-tested among a select group of patients, before application in a LFO. • Task 1.5: Set up a training and quality monitoring system for LSBs, that contains: a 3-day motivational interviewing (MI) training by a certified MI trainer; regular feedback on audio-recorded conversations; peer intervision meetings; and, an online community platform, integrating support tools. • Task 1.6: Develop an implementation plan for a LFO by mapping implementation strategies to each of the implementation barriers in Task 1.2. • Task 1.7: Integrate a LFO in usual care, by setting up a low-effort and time-efficient electronic referral system to the LFO and a feedback loop to inform the referring physician on the progress of the patient, based on results in Task 1.2. WP2: To evaluate the (cost-) effectiveness of a LFO, the following task will be carried out: • Task 2.1: Determine the effectiveness of a LFO for patients with a) cardiovascular disease or ostheoarthritis in two in parallel conducted randomized controlled trials (RCTs). Primary outcome is the adapted-Fuster-BEWAT. This is a composite health risk and lifestyle score, consisting of six components: resting blood pressure (BP), objectively measured physical activity, objectively measured sitting time, body mass index (BMI), fruit and vegetable consumption, and smoking. Secondary outcomes include: anthropometric, behavioral, psychological, biomarkers, and patient reported outcome measures (PROMs). Cost-effectiveness will be assessed from both a societal and healthcare perspective and an extensive quantitative and qualitative process evaluation following the UK MRC guidelines will be conducted. A key novel aspect of LOFIT care path is the integration of lifestyle medicine related care through a LFO into routine clinical care, which facilitates the need to provide high quality lifestyle change care, making use in a cafeteria-like fashion of already existing community-based initiatives and incorporating patient-preferences. This study will have practical implications for the organization of healthcare as a whole. A favorable study outcome will benefit physicians and the patients for whom they care, but will also benefit society at a macro-economic level.