A System-Level Approach to Overweight and Obesity in the Veterans Health Administration

Why may patients with spinal cord injury be overlooked for obesity screening in the Veterans Health Administration? Qualitative research of the perspectives of patients and healthcare providers

PURPOSE

We sought to describe factors influencing reduced rates of obesity screening for patients with spinal cord injury (SCI) in the United States Veterans Health Administration (VA) and to foster potential solutions.

MATERIALS AND METHODS

Semi-structured interviews with healthcare providers and patients with SCI who were recruited nationally from diverse VAs. We performed rapid qualitative analysis using content analysis of interview data.

RESULTS

There were 36 providers and 37 patients. We identified provider, patient, and system level barriers to obesity screening for individuals with SCI. Overarching barriers involved provider and patient perceptions that obesity screening is a low priority compared to other health conditions, and body mass index is of low utility. Other obesity screening barriers were related to measuring weight (i.e., insufficient equipment, unknown wheelchair weight, staffing shortages, measurement errors, reduced access to annual screening, insufficient time, patient preference not to be weighed) and measuring height (i.e., insufficient guidance and equipment to this population, measurement errors).

CONCLUSIONS

Barriers to obesity screenings exist for patients with SCI receiving care in VA. Healthcare provider and patient interviews suggest possible solutions, including standardizing height and weight measurement processes, ensuring equipment availability in clinics, clarifying guidelines, and offering support to providers and patients.IMPLICATIONS FOR REHABILITATIONIndividuals with spinal cord injury (SCI) have higher rates of obesity, but are often overlooked for annual obesity screening, even in clinic settings designed to care for individuals with SCI.Results may help tailor guidelines/education for healthcare and rehabilitation providers offering them guidance for improving obesity screening for individuals with SCI by standardizing weight and height measurement and documentation. To facilitate this, findings highlight the need for resources, such as ensuring clinics have necessary equipment, and increasing patient access to support and equipment.Improving the provision of obesity screening for individuals with SCI is necessary to improve health outcomes and patient satisfaction with care.

Facility-level program components leading to population impact: a coincidence analysis of obesity treatment options within the Veterans Health Administration

Obesity is a well-established risk factor for increased morbidity and mortality. Comprehensive lifestyle interventions, pharmacotherapy, and bariatric surgery are three effective treatment approaches for obesity. The Veterans Health Administration (VHA) offers all three domains but in different configurations across medical facilities. Study aim was to explore the relationship between configurations of three types of obesity treatments, context, and population impact across VHA using coincidence analysis. This was a cross-sectional analysis of survey data describing weight management treatment components linked with administrative data to compute population impact for each facility. Coincidence analysis was used to identify combinations of treatment components that led to higher population impact. Facilities with higher impact were in the top two quintiles for (1) reach to eligible patients and (2) weight outcomes. Sixty-nine facilities were included in the analyses. The final model explained 88% (29/33) of the higher-impact facilities with 91% consistency (29/32) and was comprised of five distinct pathways. Each of the five pathways depended on facility complexity-level plus factors from one or more of the three domains of weight management: comprehensive lifestyle interventions, pharmacotherapy, and/or bariatric surgery. Three pathways include components from multiple treatment domains. Combinations of conditions formed "recipes" that lead to higher population impact. Our coincidence analyses highlighted both the importance of local context and how combinations of specific conditions consistently and uniquely distinguished higher impact facilities from lower impact facilities for weight management.

A Qualitative Study of the System-level Barriers to Bariatric Surgery Within the Veterans Health Administration

OBJECTIVE

To characterize system-level barriers to bariatric surgery from the perspectives of Veterans with severe obesity and obesity care providers.

SUMMARY OF BACKGROUND DATA

Bariatric surgery is the most effective weight loss option for Veterans with severe obesity, but fewer than 0.1% of Veterans with severe obesity undergo it. Addressing low utilization of bariatric surgery and weight management services is a priority for the veterans health administration.

METHODS

We conducted semi-structured interviews with Veterans with severe obesity who were referred for or underwent bariatric surgery, and providers who delivered care to veterans with severe obesity, including bariatric surgeons, primary care providers, registered dietitians, and health psychologists. We asked study participants to describe their experiences with the bariatric surgery delivery process in the VA system. All interviews were audio-recorded and transcribed. Four coders iteratively developed a codebook and used conventional content analysis to identify relevant systems or "contextual" barriers within Andersen Behavioral Model of Health Services Use.

RESULTS

Seventy-three semi-structured interviews with veterans (n = 33) and providers (n = 40) throughout the veterans health administration system were completed. More than three-fourths of Veterans were male, whereas nearly three-fourths of the providers were female. Eight themes were mapped onto Andersen model as barriers to bariatric surgery: poor care coordination, lack of bariatric surgery guidelines, limited primary care providers and referring provider knowledge about bariatric surgery, long travel distances, delayed referrals, limited access to healthy foods, difficulties meetings preoperative requirements, and lack of provider availability and/or time.

CONCLUSIONS

Addressing system-level barriers by improving coordination of care and standardizing some aspects of bariatric surgery care may improve access to evidence-based severe obesity care within VA.

Facility-level conditions leading to higher reach: a configurational analysis of national VA weight management programming

Background

While the Veterans Health Administration (VHA) MOVE! weight management program is effective in helping patients lose weight and is available at every VHA medical center across the United States, reaching patients to engage them in treatment remains a challenge. Facility-based MOVE! programs vary in structures, processes of programming, and levels of reach, with no single factor explaining variation in reach. Configurational analysis, based on Boolean algebra and set theory, represents a mathematical approach to data analysis well-suited for discerning how conditions interact and identifying multiple pathways leading to the same outcome. We applied configurational analysis to identify facility-level obesity treatment program arrangements that directly linked to higher reach.

Methods

A national survey was fielded in March 2017 to elicit information about more than 75 different components of obesity treatment programming in all VHA medical centers. This survey data was linked to reach scores available through administrative data. Reach scores were calculated by dividing the total number of Veterans who are candidates for obesity treatment by the number of “new” MOVE! visits in 2017 for each program and then multiplied by 1000. Programs with the top 40 % highest reach scores (n = 51) were compared to those in the lowest 40 % (n = 51). Configurational analysis was applied to identify specific combinations of conditions linked to reach rates.

Results

One hundred twenty-seven MOVE! program representatives responded to the survey and had complete reach data. The final solution consisted of 5 distinct pathways comprising combinations of program components related to pharmacotherapy, bariatric surgery, and comprehensive lifestyle intervention; 3 of the 5 pathways depended on the size/complexity of medical center. The 5 pathways explained 78 % (40/51) of the facilities in the higher-reach group with 85 % consistency (40/47).

Conclusions

Specific combinations of facility-level conditions identified through configurational analysis uniquely distinguished facilities with higher reach from those with lower reach. Solutions demonstrated the importance of how local context plus specific program components linked together to account for a key implementation outcome. These findings will guide system recommendations about optimal program structures to maximize reach to patients who would benefit from obesity treatment such as the MOVE! program.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06774-w.

Protocol and short-term results for a feasibility randomized controlled trial of a video intervention for Veterans with obesity: The TOTAL (Teaching Obesity Treatment Options to Adult Learners) pilot study

Introduction

All three evidence-based treatment options for adults with severe obesity – behavioral weight management, weight management medications (WMM), and bariatric surgery – are underutilized in the Veterans Health Administration (VHA) system. Our objective in this study was to develop and pilot-test the TOTAL (Teaching Obesity Treatment Options to Adult Learners) intervention, which seeks to increase Veteran participation in obesity treatment.

Methods

In this single-site, parallel, pilot RCT, Veterans with severe obesity with an upcoming behavioral weight management visit were sent a recruitment letter after meeting inclusion/exclusion criteria via electronic health record screening. Eligible Veterans were randomized to TOTAL or usual care. TOTAL consisted of an 18-min video highlighting obesity health risks and treatment outcomes, eligibility criteria, and pros/cons of all three evidence-based obesity treatments. The primary outcomes were trial design feasibility (recruitment and retention rates) and acceptability to Veterans, which was assessed via semi-structured interviews with participants one week after randomization to TOTAL. Secondary outcomes included attitudes and self-efficacy to initiate treatment one week post-randomization and BMI change six months post-randomization (assessed via Cohen's d).

Results

Forty-two Veterans were randomized (recruitment rate = 47.2%), and 40/42 completed one-week assessments (retention rate = 95.2%). The mean participant age was 59.2 ± 11.9 years. Female and non-White participants comprised 14.3% and 11.9% of the cohort, respectively. Semi-structured interviews with all 20 participants who received TOTAL suggested that the delivery logistics and content of TOTAL were acceptable to Veterans. Attitudes toward behavioral weight management and bariatric surgery and weight loss improved in TOTAL vs. usual care patients (Cohen's d ranging from 0.3 to 0.6).

Conclusions

TOTAL was feasible to implement, acceptable to Veterans, and has the potential to increase obesity treatment participation in VHA. An adequately powered RCT is warranted to assess its impact on population-level weight loss.

Trial registration

ClinicalTrials.gov NCT03856320.

Patient Characteristics Associated with Receipt of Prescription Weight-Management Medications Among Veterans Participating in MOVE!

OBJECTIVE

Weight-management medications (WMM) are recommended for the treatment of obesity. This study examined characteristics associated with initial receipt of WMM among eligible veterans in the first year following enrollment in the Veterans Health Administration (VHA) MOVE! behavioral weight-management program.

METHODS

We conducted a retrospective cohort study of VHA patients with obesity or overweight and obesity-related comorbidities who enrolled in MOVE! from October 2013 to September 2016 (N = 153,939). Multivariable logistic regression models estimated predictors of having a filled prescription for WMM and for orlistat.

RESULTS

A total of 1.1% of these veterans received WMM. The most common WMM included orlistat (70.4%), phentermine/topiramate (11.2%), and bupropion/naltrexone (9.7%). Female sex, higher BMI, obstructive sleep apnea, osteoarthritis, depression, lower back pain, and alcohol abuse were associated with greater odds of use of WMM, whereas age over 65 years, Hispanic ethnicity, and required co-payments were associated with lower odds. Among patients receiving WMM, older age, black race, female sex, higher BMI, cardiovascular disease, lower back pain, and congestive heart failure were associated with use of orlistat versus any other WMM.

CONCLUSIONS

Of patients engaged in MOVE! in the VHA, 1.1% received WMM. WMM are underutilized among veterans. Additional research is needed to understand barriers to incorporating WMM into comprehensive obesity treatment plans.

Geographic Variation in Obesity, Behavioral Treatment, and Bariatric Surgery for Veterans

OBJECTIVE

This study aims to describe geographic variation in veterans' prevalence of obesity, participation in Veterans Health Administration's behavioral weight management program (MOVE!), and receipt of bariatric surgery in fiscal year (FY) 2016.

METHODS

In this retrospective cohort study of veterans with obesity who received Veterans Health Administration care in FY2016, electronic health record data were obtained on weight, height, outpatient visits to the MOVE! program, and bariatric surgeries. For each Veterans Integrated Service Network (VISN) region, the prevalence rate of veterans with obesity (BMI ≥ 30 kg/m² ), MOVE! participation rates, and bariatric surgery rates are presented.

RESULTS

The prevalence of obesity in veterans ranged from 30.5% to 40.5% across VISNs in FY2016. MOVE! participation among veterans with obesity was low (2.8%-6.9%) across all VISNs, but veterans with class II and III obesity (BMI ≥ 35) had higher MOVE! participation rates (4.3%-10.8%) than veterans with class I obesity. There was 20-fold variation across VISNs in receipt of bariatric surgery among veterans with BMI ≥ 35, ranging from 0.01% to 0.2%. Among veterans with BMI ≥ 35 participating in MOVE!, there was 46-fold variation in bariatric surgery provision, ranging from 0.07% to 3.27%.

CONCLUSIONS

Despite veterans' high prevalence of obesity, behavioral and surgical weight management participation is low and varies across regions.

Pilot randomized trial of a telephone-delivered physical activity and weight management intervention for individuals with lower extremity amputation

BACKGROUND

Obesity and inactivity are common and burdensome for people with lower extremity amputation (LEA). The extent to which home-based physical activity/weight management programs are effective and safe for people with LEA is unknown. Translating effective interventions for understudied disability groups is needed.

OBJECTIVE

To test the feasibility, acceptability, and safety of a weight management and physical activity intervention and obtain preliminary efficacy estimates for changes in weight, body composition, and physical functioning.

METHODS

Eligibility criteria included: LEA ≥1 year prior, 18-69 years of age, overweight or obese and living in the Seattle area. The intervention arm received self-monitoring tools (e.g., pedometer, scale) and written materials, a single exercise counseling home visit by a physical therapist, and up to 11 telephone calls from a health coach over 20 weeks that involved motivational interviewing to set specific, attainable, and measurable goals. The self-directed control group received the same tools and materials but no home visit or coaching calls.

RESULTS

Nineteen individuals consented to participate, 15 were randomized (mean age = 56, 73% male, 80% transtibial amputation) and 11 completed 20-week follow-up assessments. The intervention was acceptable and safe. Coached participants had greater decreases in waist circumference (mean difference between groups over 20 weeks, baseline values carried forward: -4.3 cm, 95% CI -8.2, -0.4, p = 0.03) and fat mass (-2.1 kg, 95% CI -3.8, -0.4, p = 0.02).

CONCLUSIONS

The home-based intervention was promising in terms of efficacy, safety and acceptability. Inclusion of multiple trial centers and increased use of technology may facilitate recruitment and retention.

Military Sexual Trauma and Obesity Among Women Veterans

BACKGROUND/OBJECTIVE

Posttraumatic stress disorder (PTSD), the experience of military sexual trauma (MST) that may contribute to PTSD, and obesity are three issues that complicate care for our population of new veterans. Our aim was to analyze the association of MST and diagnosed PTSD with obesity among female veterans.

MATERIALS AND METHODS

Women 20-103 years old using the Veterans Health Administration (VA) in fiscal year 2014 (October 2013-September 2014) with diagnosis and body-mass data were identified in administrative databases (213,985 of 404,183 women). MST was defined by use of an MST clinic or positive MST screen, PTSD by International Classification of Diseases, Ninth Revision (ICD-9) diagnosis code (309.81), and weight categories from body-mass index.

RESULTS

The unadjusted chi-square of MST by obesity showed a modest association: 52% MST-affected versus 46% non-MST women were obese. MST status was associated with PTSD (50% MST vs. 15% non-MST women). A multivariable model of obesity adjusting for clinical and demographic covariates estimated a 9% increased risk of obesity from MST (adjusted risk ratio [RR] = 1.09). Younger age, African American race, and chronic disease such as hypertension and dyslipidemia correlated with obesity. Adding PTSD to the model did not affect the association with MST: RR (MST) = 1.09, RR (PTSD) = 1.00 (not significant).

CONCLUSIONS

This study showed association of MST with obesity in female veterans, independent of PTSD. Weight-gain in patients with trauma may add psychological or medical risk to the burden of disease shouldered by female veterans with MST. Primary care clinicians may need to consider integrating mental health into care of patients with suspected history of trauma especially sexual trauma.

Examining the Dose-Response Relationship in the Veterans Health Administration's MOVE!® Weight Management Program: A Nationwide Observational Study

BACKGROUND

For more than a decade, the Veterans Health Administration (VHA) has offered MOVE!, a comprehensive lifestyle intervention for weight management. However, there is limited knowledge to inform resource allocation decisions at the health system level-for example, the choice between reaching new veterans with weight management treatment, re-engaging veterans who have stopped attending, and/or increasing contact with current MOVE!

OBJECTIVE

To inform VHA policy and planning, this VHA-wide study examines the relationship between MOVE! participation and weight outcomes.

DESIGN

A longitudinal observational study of veterans across VHA who participated in MOVE!.

PARTICIPANTS

Veterans who initiated their most recent episode of MOVE! care between 2004 and 2014.

MAIN MEASURES

Weight measurements were abstracted from VHA electronic health records. The primary outcome was the proportion of veterans with clinically relevant weight loss. The predictor of interest was number of MOVE! contacts during the 12 months following MOVE! initiation.

KEY RESULTS

The cohort consisted of 237,577 veterans (87.4% male; mean age 54.4 years), who had 5.3 contacts on average in the 12 months following initiation. Veterans with 2-5 contacts had the same odds of achieving clinically relevant weight loss as veterans with only one contact (adjusted OR: 1.00, 95% CI: 0.98-1.03). Veterans with 6-9, 10-13, 14-17, and 18 or more contacts had significantly higher odds of clinically relevant weight loss (adjusted OR: 1.17, 95% CI: 1.13-1.20; adjusted OR: 1.53, 95% CI: 1.47-1.59; adjusted OR: 1.84, 95% CI: 1.74-1.94; adjusted OR: 2.21, 95% CI: 2.12-2.31, respectively).

CONCLUSIONS

Veterans with ≥6 MOVE! contacts in the year following treatment initiation were significantly more likely to achieve clinically relevant weight loss than those with one contact, with greater participation further increasing the odds of clinically relevant weight loss. While further characterization of weight loss predictors is needed, the VHA should provide policy guidance that supports increasing participation among veterans who have initiated MOVE!.