Patient and practice characteristics predicting attendance and completion at a specialist weight management service in the UK: a cross-sectional study

Attendance, Weight Loss, and Participation in a Behavioural Diabetes Prevention Programme

BACKGROUND

Weight loss in diabetes prevention programmes has been shown to be associated with participants' age, socio-economic status, and ethnicity. However, little is known about how these differences relate to attendance and whether such differences can be mediated by other potentially modifiable factors. Differential effectiveness across these factors may exacerbate health inequalities.

METHOD

Prospective analysis of participant data collected by one provider of the standardised national NHS diabetes prevention programme in England. Mediation analysis was performed via a structural equation model to examine whether the number of attended sessions mediated the associations of age, socio-economic status, and ethnicity with follow-up weight. The group-level factor of number of attended sessions was examined using multiple linear regression as a benchmark; multilevel linear regression using three levels (venue, coach, and group); and fixed effects regression to account for venue-specific and coach-specific characteristics.

RESULTS

The associations of age, socio-economic status, and ethnicity with follow-up weight were all mediated by the number of attended sessions. Group size was associated with attendance in an inverted 'U' shape, and the number of days between referral and group start was negatively associated with attendance. Time of day, day of the week, and the number of past groups led by the coach were not associated with attendance.

CONCLUSION

Most of the differences in weight loss initially attributed to socio-demographic factors are mediated by the attendance of the diabetes prevention programme. Therefore, targeted efforts to improve uptake and adherence to such programmes may help alleviate inequalities.

A Qualitative Exploration of Patient and Staff Experiences of the Receipt and Delivery of Specialist Weight Management Services in the UK

BACKGROUND

Addressing the increasing prevalence of obesity is a global public health priority. Severe obesity (body mass index > 40) reduces life expectancy, due to its association with people developing complications (e.g. diabetes, cancer, cardiovascular disease), and greatly impairs quality of life. The National Health Service (NHS) in the UK provides specialist weight management services (SWMS) for people with severe obesity, but key uncertainties remain around patient access to and engagement with weight management services, as well as pathways beyond the service.

METHODS

In this multiple methods study, using online forum data and semi-structured interviews, stakeholders' experiences of delivering and receiving SWMS were explored. Using the web search engine Google with keywords and web address (URL) identifiers, relevant public online platforms were sourced with snowball sampling and search strings used to identify threads related to people's experiences of accessing SWMS (n = 57). Interviews were conducted with 24 participants (nine patients, 15 staff), and data from all sources were analysed thematically using the framework approach.

RESULTS

Six themes related to access to and engagement with SWMS emerged during data analysis: (1) making the first move, (2) uncertainty and confusion, (3) resource issues, (4) respect and understanding, (5) mode of delivery, and (6) desire for ongoing support.

CONCLUSION

There is a mixed and varied picture of SWMS provision across the UK. The service offered is based on local clinical decision making and available resources, resulting in a range of patient experiences and perspectives. Whilst service capacity issues and patient anxiety were seen as barriers to accessing care, peer support and positive clinical and group interactions (connectedness between individuals) were considered to increase engagement.

Determinants of completion and early dropout in an adult weight management service: a prospective observational study

BACKGROUND

High attrition rates in weight management interventions (WMIs) undermine their effectiveness but are poorly understood. This study aimed to identify determinants of completion and early dropout in National Health Service (NHS) WMIs.

METHODS

In this prospective observational study, 329 patients recruited at initial consultation appointments satisfied the eligibility criteria: age ≥18 years and body mass index (BMI) ≥30 kg/m2 . Multivariate logistic regression analyses were performed to identify the odds ratios (OR, given with 95% confidence interval) of completion and early dropout.

RESULTS

Intervention completion rate was 39.8% (131 of 329). Variables that increased the likelihood of completion included engagement in support sessions, OR10.6 (4.7-23.6, p < 0.001); male sex, OR2.5 (1.4-4.5, p = 0.002); osteoarthritis, OR1.9 (1.1-3.3, p = 0.014); and one or more missed intervention appointments marked as 'could not attend' (notified nonattendance), OR1.8 (1.1-2.9, p = 0.032). Odds of early dropout were higher for participants with anxiety and depression OR2.0 (1.0-4.0, p = 0.039). Dietetic 1:1 participants were less likely to drop out early compared with group programme participants, OR0.3 (0.2-0.7, p = 0.002), but were less likely to complete the full intervention, OR0.5 (0.3-0.9, p = 0.02). Age, BMI, social deprivation and travel distance were among the variables not associated with completion or early dropout.

CONCLUSIONS

This study provides further evidence of the importance of support for participants of WMIs and the need for services to consider how support networks can be incorporated. Patients with poorer mental health may be more likely to drop out early and consequently benefit less from WMIs. Future research should qualitatively explore why these factors contribute to attrition to improve WMI effectiveness.

Effectiveness of eHealth weight management interventions in overweight and obese adults from low socioeconomic groups: a systematic review

Background

Low socioeconomic status (SES) is associated with increased rates of overweight and obesity. Proponents of electronic health (eHealth) hypothesise that its inclusion in weight management interventions can improve efficacy by mitigating typical barriers associated with low SES.

Objectives

To establish the scope of eHealth weight management interventions for people with overweight and obesity from a low SES. Secondary objectives were to determine the efficacy of eHealth interventions in facilitating weight loss, physical activity and fitness improvements.

Methods

Four databases and grey literature were systematically searched to identify eligible studies published in English from inception to May 2021. Studies examining an eHealth intervention with low SES participants were included. Outcomes included temporal change in weight and BMI, anthropometry, physiological measures and physical activity levels. The number and heterogeneity of studies precluded any meta-analyses; thus, a narrative review was undertaken.

Results

Four experimental studies with low risk of bias were reviewed. There was variance in how SES was defined. Study aims and eHealth media also varied and included reducing/maintaining weight or increasing physical activity using interactive websites or voice responses, periodic communication and discourse via telephone, social media, text messaging or eNewsletters. Irrespectively, all studies reported short-term weight loss. eHealth interventions also increased short-term physical activity levels where it was assessed, but did not change anthropometry or physiological measures. None reported any effect on physical fitness.

Conclusions

This review revealed short-term effects of eHealth interventions on weight loss and increased physical activity levels for low SES participants. Evidence was limited to a small number of studies, with small to moderate sample sizes. Inter-study comparison is challenging because of considerable variability. Future work should prioritise how to utilise eHealth in the longer term either as a supportive public health measure or by determining its long-term efficacy in engendering volitional health behaviour changes.

Systematic review registration

PROSPERO CRD42021243973

Supplementary Information

The online version contains supplementary material available at 10.1186/s13643-023-02207-3.

Does recruiting patients to diabetes prevention programmes via primary care reinforce existing inequalities in care provision between general practices? A retrospective observational study

BACKGROUND

Primary care plays a crucial role in identifying patients' needs and referring at-risk individuals to preventive services. However, well-established variations in care delivery may be replicated in this prevention activity.

OBJECTIVE

To examine whether recruiting patients to the English NHS Diabetes Prevention Programme via primary care reinforces existing inequalities in care provision between practices, in terms of clinical quality, accessibility and resources.

METHODS

We generated annual practice-level counts of referrals across the first 4 years of the programme (June 2016 to March 2020). These were linked to 15 indicators of practice clinical quality, access and resources measured during 2018/19. We used random effects Poisson regressions to examine associations between referrals and these indicators, controlling for practice and population characteristics, for 6871 practices in England.

RESULTS

On average, practices made 3.72 referrals per 1000 population annually and rates varied substantially between practices. Referral rates were positively associated with the quality of clinical care provided. A 1 SD higher level of achievement on Quality and Outcomes Framework diabetes indicators was associated with an 11% (95% CI: 8% to 14%) higher referral rate. This positive association was consistent across all five clinical quality indicators. There was no association between referral rates and accessibility, overall payments or staffing. Associations between referrals and receiving different supplementary payments over the core contract were mixed, with 8%-11% lower referral rates for some payments but not for others.

CONCLUSION

Recruiting patients to diabetes prevention programmes via primary care reinforces existing inequalities between general practices in the clinical quality of care they provide. This leaves patients registered with practices providing lower quality clinical care even more disadvantaged. Providing additional support to lower quality practices or using alternative recruitment methods may be necessary to avoid differential engagement in prevention programmes from widening these variations and potential health inequalities further.

Can We Deliver Person-Centred Obesity Care Across the Globe?

PURPOSE OF REVIEW

This article discusses what person-centred care is; why it is critically important in providing effective care of a chronic, complex disease like obesity; and what can be learnt from international best practice to inform global implementation.

RECENT FINDINGS

There are four key principles to providing person-centred obesity care: providing care that is coordinated, personalised, enabling and delivered with dignity, compassion and respect. The Canadian 5AsT framework provides a co-developed person-centred obesity care approach that addresses complexity and is being tested internationally. Embedding person-centred obesity care across the globe will require a complex system approach to provide a framework for healthcare system redesign, advances in people-driven discovery and advocacy for policy change. Additional training, tools and resources are required to support local implementation, delivery and evaluation. Delivering high-quality, effective person-centred care across the globe will be critical in addressing the current obesity epidemic.

Encouraging appropriate gestational weight gain in high-risk gravida: A randomized controlled trial

Trial Design

Excessive gestational weight gain (GWG) can increase pregnancy morbidity and is particularly problematic for women with pregestational obesity. A lifestyle modification intervention was introduced to gravida with obesity to decrease excessive GWG as compared to usual care (UC).

Methods

A randomized controlled trial was conducted to improve healthy lifestyle behaviors to manage appropriate GWG. Consenting participants with prepregnancy obesity and singletons ≤17 weeks were randomized to (1) Usual Care (UC): usual written educational materials and counseling by obstetric provider or (2) Enhanced Care (EC): UC plus (a) personalized letter from physician detailing appropriate GWG; (b) access to individualized GWG chart; (c) ongoing counseling with registered dietitian/nutritionist (RDN). The primary outcome was proportion with GWG ≤9.1 kg, as this is upper limit recommended by Institute of Medicine (IOM). Total GWG and GWG as less than/within/greater than IOM recommendations (in aggregate and stratified by obesity class), and pregnancy/neonatal outcomes were evaluated as secondary outcomes.

Results

Analyses included 105 participants in EC and 109 in UC arms. The groups had similar demographics: 46% with class I obesity, 26% class II, and 28% class III. There were no group differences for any GWG, pregnancy, or neonatal outcomes when analyzed in aggregate. As compared to those randomized to the EC arm, participants in UC arm with class I obesity gained 1.4 kg less and those with class II obesity were significantly more likely to gain within IOM guidelines (14.8% vs. 40.0%, adjusted p = 0.04). Participants with class III obesity randomized to EC arm were more likely to gain within IOM guidelines as compared to participants randomized to UC arm (29.0% vs. 6.7%, adjusted p = 0.02).

Conclusion

There were no differences in GWG observed between groups when analyzing participants in aggregate. However, a physician's letter detailing appropriate GWG, patient portal access to a personalized GWG chart, and RDN consultation were helpful for encouraging GWG within IOM guidelines for women with prepregnancy class III obesity. Women with class I or II obesity had better GWG outcomes without these additional interventions.

Predictors of weight discussion in primary care consultations: A multilevel modeling approach

OBJECTIVE

To understand how primary care weight-related communication processes are influenced by individual differences in primary care practitioner (PCP) and patient characteristics and communication use.

METHODS

Two multilevel logistic regression models were calculated to predict the occurrence of 1) weight-related discussion and 2) weight-related consultation outcomes. Coded communication data (Roter Interaction Analysis System) from 218 video-recorded consultations between PCPs and patients with overweight and obesity in Scottish primary care practices were combined with their demographic data to develop the multilevel models.

RESULTS

Weight-related discussions were more likely to occur when a greater proportion of PCP's total communication was partnership building and activating communication. More discrete weight discussions during a consultation predicted weight-related consultation outcomes. Patient BMI positively predicted both weight-related discussion and consultation outcomes.

CONCLUSION

This work demonstrates that multilevel modeling is a viable approach to investigating coded primary care weight-related communication data and that it can provide insight into the impact that various patient and PCP factors have on these communication processes.

PRACTICE IMPLICATIONS

Through the increased use of partnership building and activating communications, and by engaging in shorter, but more frequent, discussions about patient weight, PCPs may better facilitate weight-related discussion and weight-related consultation outcomes for their patients.

The impact of participant mental health on attendance and engagement in a trial of behavioural weight management programmes: secondary analysis of the WRAP randomised controlled trial

Background

Low attendance and engagement in behavioural weight management trials are common. Mental health may play an important role, however previous research exploring this association is limited with inconsistent findings. We aimed to investigate whether mental health was associated with attendance and engagement in a trial of behavioural weight management programmes.

Methods

This is a secondary data analysis of the Weight loss referrals for adults in primary care (WRAP) trial, which randomised 1267 adults with overweight or obesity to brief intervention, WW (formerly Weight Watchers) for 12-weeks, or WW for 52-weeks. We used regression analyses to assess the association of baseline mental health (depression and anxiety (by Hospital Anxiety and Depression Scale), quality of life (by EQ5D), satisfaction with life (by Satisfaction with Life Questionnaire)) with programme attendance and engagement in WW groups, and trial attendance in all randomised groups.

Results

Every one unit of baseline depression score was associated with a 1% relative reduction in rate of WW session attendance in the first 12 weeks (Incidence rate ratio [IRR] 0.99; 95% CI 0.98, 0.999). Higher baseline anxiety was associated with 4% lower odds to report high engagement with WW digital tools (Odds ratio [OR] 0.96; 95% CI 0.94, 0.99). Every one unit of global quality of life was associated with 69% lower odds of reporting high engagement with the WW mobile app (OR 0.31; 95% CI 0.15, 0.64). Greater symptoms of depression and anxiety and lower satisfaction with life at baseline were consistently associated with lower odds of attending study visits at 3-, 12-, 24-, and 60-months.

Conclusions

Participants were less likely to attend programme sessions, engage with resources, and attend study assessments when reporting poorer baseline mental health. Differences in attendance and engagement were small, however changes may still have a meaningful effect on programme effectiveness and trial completion. Future research should investigate strategies to maximise attendance and engagement in those reporting poorer mental health.

Trial registration

The original trial (ISRCTN82857232) and five year follow up (ISRCTN64986150) were prospectively registered with Current Controlled Trials on 15/10/2012 and 01/02/2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01216-6.

Factors Impacting Physician Referral To and Patient Attendance at Weight Management Programs Within a Large Integrated Health System

BACKGROUND

Identifying which patients receive referrals to and which ones attend weight management programs can provide insights into how physicians manage obesity.

OBJECTIVE

To describe patient factors associated with referrals, which primarily reflect physician priorities, and attendance, which reflects patient priorities. We also examine the influence of the individual physician by comparing adjusted rates of referral and attendance across physicians.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Adults with a body mass index (BMI) ≥ 30 kg/m² who had a primary care visit between 2015 and 2018 at a large integrated health system MAIN MEASURES: Referrals and visits to programs were collected from the EHR in 2019 and analyzed in 2019-2020. Multilevel logistic regression models were used to identify the association between patient characteristics and (1) receiving a referral, and (2) attending a visit after a referral. We compared physicians' adjusted probabilities of referring patients and of their patients attending a visit.

KEY RESULTS

Our study included 160,163 adults, with a median BMI of 35 kg/m². Seventeen percent of patients received ≥ 1 referral and 29% of those attended a visit. The adjusted odds of referral increased 57% for patients with a BMI 35-39 (versus 30-34) and 32% for each comorbidity (p < 0.01). Attending a visit was less strongly associated with BMI (aOR 1.18 for 35-39 versus 30-34, 95% CI 1.09-1.27) and not at all with comorbidity. For the physician-level analysis, the adjusted probability of referral had a much wider range (0 to 83%; mean = 19%) than did the adjusted probability of attendance (range 27 to 34%).

CONCLUSIONS

Few patients attended a weight management program. Physicians vary greatly in their probability of referring patients to programs but not in their patients' probability of attending.

Barriers and facilitators to uptake and retention of inner-city ethnically diverse women in a postnatal weight management intervention: a mixed-methods process evaluation within a feasibility trial in England

OBJECTIVES

To understand the barriers and facilitators to uptake and retention of postnatal women randomised to a commercial group weight management intervention using the COM-B (capability, opportunity, motivation and behaviour) behaviour change model.

DESIGN

Concurrent mixed-methods (qualitative dominant) process evaluation nested within a feasibility randomised controlled trial, comprising questionnaires and interviews at 6 and 12 months postbirth.

SETTING

One National Health Service maternity unit in an inner city area in the south of England.

PARTICIPANTS

98 postnatal women with body mass indices>25 kg/m² (overweight/obese) at pregnancy commencement.

INTERVENTION

Twelve-week Slimming World (SW) commercial group weight management programme, commencing anytime from 8 to 16 weeks postnatally.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data regarding uptake and retention from questionnaires and interviews conducted 6 and 12 months postbirth analysed thematically and mapped to the COM-B model.

RESULTS

Barriers to SW uptake mostly concerned opportunity issues (eg, lack of time or childcare support) though some women also lacked motivation, not feeling that weight reduction was a priority, and a few cited capability issues such as lacking confidence. Weight loss aspirations were also a key factor explaining retention, as were social opportunity issues, particularly in relation to factors such as the extent of group identity and relationship with the group consultant; and physical opportunity such as perceived support from and fit with family lifestyle. In addition, barriers relating to beliefs and expectations about the SW programme were identified, including concerns regarding compatibility with breastfeeding and importance of exercise. Women's understanding of the SW approach, and capability to implement into their lifestyles, appeared related to level of attendance (dose-response effect).

CONCLUSIONS

Uptake and retention in commercial weight management programmes may be enhanced by applying behaviour change techniques to address the barriers impacting on women's perceived capability, motivation and opportunity to participate.

TRIAL REGISTRATION NUMBER

ISRCTN39186148.

Weight assessment and the provision of weight management advice in primary care: a cross-sectional survey of self-reported practice among general practitioners and practice nurses in the United Kingdom

Background

Although primary care settings provide a large-scale and high-reach opportunity for weight management and obesity prevention, the proportion of adults in the United Kingdom (UK) who report receiving weight management advice is limited. This study examines the self-reported frequency of assessing weight and providing weight management advice by General Practitioners (GPs) and Practice Nurses (PNs) working in primary care in the UK, and differences by practitioner characteristics.

Methods

Cross-sectional survey with GPs and PNs in the UK (n = 2020), conducted January–March 2017. A mock consultation exercise assessed what factors led to calculating a patient’s Body Mass Index (BMI) and whether weight management advice was given after determining the patient had an obese BMI. For all patients, practitioners were asked how often they calculated BMI, how often they gave weight management advice to patients with an obese BMI, and how often they utilised different advice or referral options (each: Always/Often vs. Less often/Never). Binary logistic regressions examined whether frequency of assessing weight and providing advice was associated with practitioner characteristics.

Results

In the mock consultation, physical cues (40%) were most likely to prompt calculation of BMI, and half of practitioners (56%) provided weight management advice after determining the patient had an obese BMI, with GPs less likely to do so than PNs (Odds Ratio [OR] = 0.59, 95% CI: 0.47–0.75). Half of practitioners (58%) said they calculated the BMI of all patients Always/Often, with GPs less likely to do so than PNs (OR = 0.27, 95% CI: 0.21–0.34). Three quarters (78%) said they provided weight management advice to patients with an obese BMI Always/Often, with GPs less likely to do so than PNs (OR = 0.63, 95% CI: 0.47–0.85). Weight management advice was provided more frequently than referrals, particularly suggesting increased physical activity (93%) and diet modification (89%).

Conclusions

Consistent with previous research, the findings suggest that opportunities to provide weight management advice in primary care, including to patients with an obese BMI, are potentially missed. Future research should test alternative mechanisms to increase weight assessment and advice provision, examine the effectiveness of advice frequently given, and seek solutions to reported barriers for providing weight management advice.

What works and why in the identification and referral of adults with comorbid obesity in primary care: A realist review

Primary care practitioners (PCPs) are well placed to identify individuals with obesity and weight-related comorbidities and to refer them to weight management services (WMS), but this does not often happen in practice. In this realist review, we searched six databases for intervention studies targeted at PCPs to improve the identification and referral of adults with comorbid obesity. Realist analysis was used to identify context-mechanism-outcome (CMO) configurations across 30 included papers (reporting on 27 studies). Most studies used multiple intervention strategies, categorised into: (a) training, (b) tools to improve identification, (c) tools to improve ease of referral, (d) audit/feedback, (e) working in networks/quality circles, and (f) other. The realist synthesis identified 12 mechanisms through which interventions work to improve identification and referral, including increasing knowledge about obesity and awareness of and confidence in WMS among practitioners, improved communication and trust between practitioners and WMS, and higher priority given to weight management among primary care teams. The theory of "candidacy" (a person's eligibility for medical attention and intervention) provided a robust explanatory framework but required refinement: (a) to take account of the different services (primary care and weight management) that patients must navigate to access support; and (b) to acknowledge the importance of wider contextual factors.

Predictors for continued participation of employees in structured outpatient obesity intervention programmes

Background

Overweight, obesity and the conditions resulting from them have become one of the major challenges for health systems all over the world. High dropout rates are particularly common among the participants in outpatient obesity intervention programmes (OIP). Limited research has examined retention in OIP.

Methods

Based on the data of a 24-month Bundeswehr outpatient OIP with a total of 630 participants, predisposing factors (n = 30) for continued participation beyond an early stage (0–3 months) and beyond a later stage (0–6 months) were analysed by means of a logistic regression analysis. In order to correct for multiple-comparison, the p-value was adjusted (p* < 0.0017).

Results

Three hundred out of 630 participants continued to participate beyond an early stage and 205 beyond a later stage. Besides an age between 40 and 50 at the beginning of the outpatient OIP, it was possible to show that knowledge of one’s blood pressure and a positive lifestyle prior to participation in the programme (higher level of sporting activity) were predisposing factors for early dropout (>3 months) in the intervention programme.

Discussion

The possible predisposing factors examined accounted for about 35% of the variance in a rough estimate. In order to improve long-term participation in workplace outpatient OIP, the study focused on how the motivation of older people and employees with an unfavourable cardiovascular risk profile could be improved.

A predictive model for non-completion of an intensive specialist obesity service in a public hospital: a case-control study

Background

Despite the growing evidence base supporting intensive lifestyle and medical treatments for severe obesity, patient engagement in specialist obesity services is difficult to achieve and poorly understood. To address this knowledge gap, we aimed to develop a model for predicting non-completion of a specialist multidisciplinary service for clinically severe obesity, termed the Metabolic Rehabilitation Programme (MRP).

Method

Using a case-control study design in a public hospital setting, we extracted data from medical records for all eligible patients with a body mass index (BMI) of ≥35 kg/m² with either type 2 diabetes or fatty liver disease referred to the MRP from 2010 through 2015. Non-completion status (case definition) was coded for patients whom started but dropped-out of the MRP within 12 months. Using multivariable logistic regression, we tested the following baseline predictors hypothesised in previous research: age, gender, BMI, waist circumference, residential distance from the clinic, blood pressure, obstructive sleep apnoea (OSA), current continuous positive airway pressure (CPAP) therapy, current depression/anxiety, diabetes status, and medications. We used receiver operating characteristics and area under the curve to test the performance of models.

Results

Out of the 219 eligible patient records, 78 (35.6%) non-completion cases were identified. Significant differences between non-completers versus completers were: age (47.1 versus 54.5 years, p < 0.001); residential distance from the clinic (21.8 versus 17.1 km, p = 0.018); obstructive sleep apnoea (OSA) (42.9% versus 56.7%, p = 0.050) and CPAP therapy (11.7% versus 28.4%, p = 0.005). The probability of non-completion could be independently associated with age, residential distance, and either OSA or CPAP. There was no statistically significant difference in performance between the alternate models (69.5% versus 66.4%, p = 0.57).

Conclusions

Non-completion of intensive specialist obesity management services is most common among younger patients, with fewer complex care needs, and those living further away from the clinic. Clinicians should be aware of these potential risk factors for dropping out early when managing outpatients with severe obesity, whereas policy makers might consider strategies for increasing access to specialist obesity management services.

Why do general practitioners not refer patients to behaviour-change programmes after preventive health checks? A mixed-method study

Background

This study was embedded in the Check-In randomised controlled trial that investigated the effectiveness of general practice-based preventive health checks on adverse health behaviour and early detection of non-communicable diseases offered to individuals with low socioeconomic positions. Despite successful recruitment of patients, the intervention had no effect. One reason for the lack of effectiveness could be low rates of referral to behaviour-change programmes in the municipality, resulting in a low dose of the intervention delivered. The aim of this study is to examine the referral pattern of the general practitioners and potential barriers to referring eligible patients to these behaviour-change programmes.

Methods

A mixed-method design was used, including patients’ questionnaires, recording sheet from the health checks and semi-structured qualitative interviews with general practitioners. All data used in the study were collected during the time of the intervention. Logistic regressions were used to estimate odds ratios for being eligible and for receiving referrals. The qualitative empirical material was analysed thematically. Emerging themes were grouped, discussed and the material was re-read. The themes were reviewed alongside the analysis of the quantitative material to refine and discuss the themes.

Results

Of the 364 patients, who attended the health check, 165 (45%) were marked as eligible for a referral to behaviour-change programme by their general practitioner and of these, 90 (55%) received referrals. Daily smoking (OR = 3.22; 95% CI:2.01–5.17), high-risk alcohol consumption (OR = 2.66; 95% CI:1.38–5.12), obesity (OR = 2.89; 95% CI:1.61–5.16) and poor lung function (OR = 2.05; 95% CI:1.14–3.70) were all significantly associated with being eligible, but not with receiving referral. Four themes emerged as the main barriers to referring patients to behaviour-change programmes: 1) general practitioners’ responsibility and ownership for their patients, 2) balancing information and accepting a rejection, 3) assessment of the right time for behavioural change and 4) general practitioners’ attitudes towards behaviour-change programmes in the municipality.

Conclusion

We identified important barriers among the general practitioners which influenced whether the patients received referrals to behaviour-change programmes in the municipality and thereby influenced the dose of intervention delivered in Check-In. The findings suggest that an effort is needed to assist the collaboration between general practices and the municipalities’ primary preventive services.

Trial registration

Clinical Trials NCT01979107; October 25, 2013.

Determining patient attendance, access to interventions and clinical outcomes in a publicly funded obesity programme: Results from the Canberra Obesity Management Service

Multi-disciplinary specialist services have a crucial role in the management of patients with obesity. As demand for these services increases, so too does the need to monitor individual service performance and compare outcomes across multiple sites. This paper reports on results from the publicly funded Canberra Obesity Management Service. A descriptive observational study was conducted on new patients who attended an initial medical review from July 2016 to June 2017. Baseline characteristics, comorbidities, attendance, service utilization and outcomes were collated until June 2018. Of the 162 patients identified, 64% continued to attend beyond initial medical review. Dietetics was the most commonly accessed allied health service, followed by exercise physiology and psychology. Very low-energy diet was the most commonly trialled intensive intervention, followed by pharmacotherapy and bariatric surgery. Mean baseline weight for those who continued beyond initial medical review was 142.0 kg (SD 26.6 kg), with a mean weight change of -6.2 kg (SD 10.2 kg) and a mean change in percentage body weight of -5% (SD 7%). Clinically significant weight loss was achieved in 36% of these patients, with a further 47% achieving weight stabilization. Mean Depression, Anxiety and Stress Scale scores reduced from 8-6-8 to 7-5-5, and mean Epworth Sleepiness Scale scores decreased from 8/24 to 6/24. Polysomnography referrals were made for 37% of all new patients, 87% of whom were diagnosed with varying degrees of obstructive sleep apnoea. We present these findings in the hope that they may serve as an example for data collection, individual service monitoring and comparison across multiple obesity services.

Discussing Weight Management With Type 2 Diabetes Patients in Primary Care Using the Small Talk Big Difference Intervention: Protocol for a Randomized Controlled Trial

Background

Guidelines for the management of type 2 diabetes universally recommend that adults with type 2 diabetes and obesity be offered individualized interventions to encourage weight loss. Yet despite the existing recommendations, provision of weight management services is currently patchy around the United Kingdom and where services are available, high attrition rates are often reported. In addition, individuals often fail to take up services, that is, after discussion with a general practitioner or practice nurse, individuals are referred to the service but do not attend for an appointment. Qualitative research has identified that the initial discussion raising the issue of weight, motivating the patient, and referring to services is crucial to a successful outcome from weight management.

Objective

Our aim was to evaluate the effectiveness of an Internet-based training program and practice implementation toolkit with or without face-to-face training for primary care staff. The primary outcome is the change in referral rate of patients with type 2 diabetes to National Health Service adult weight management programs, 3 months pre- and postintervention.

Methods

We used the Behavior Change Wheel to develop an intervention for staff in primary care consisting of a 1-hour Internet-based eLearning package covering the links between obesity, type 2 diabetes, and the benefits of weight management, the treatment of diabetes in patients with obesity, specific training in raising the issue of weight, local services and referral pathways, overview of weight management components/ evidence base, and the role of the referrer. The package also includes a patient pamphlet, a discussion tool, a practice implementation checklist, and an optional 2.5-hour face-to-face training session. We have randomly assigned 100 practices in a 1:1 ratio to either have immediate access to all the resources or have access delayed for 4 months. An intention-to-treat statistical analysis will be performed.

Results

Recruitment to the study is now complete. We will finalize follow-up in 2018 and publish in early 2019.

Conclusions

This protocol describes the development and randomized evaluation of the effectiveness of an intervention to improve referral and uptake rates of weight management programs for adults with type 2 diabetes. At a time when many new dietary and pharmacological weight management interventions are showing large clinical benefits for people with type 2 diabetes, it is vital that primary care practitioners are willing, skilled, and able to discuss weight and make appropriate referrals to services.

Trial Registration

ClinicalTrials.gov NCT03360058; https://clinicaltrials.gov/ct2/show/NCT03360058 (Archived by WebCite at http://www.webcitation.org/74HI8ULfn)

International Registered Report Identifier (IRRID)

DERR1-10.2196/12162

Clinical Obesity Services in Public Hospitals in Australia: a position statement based on expert consensus

We aimed to describe the current state of specialist obesity services for adults with clinically severe obesity in public hospitals in Australia, and to analyse the gap in resources based on expert consensus. We conducted two surveys to collect information about current and required specialist obesity services and resources using open-ended questionnaires. Organizational level data were sought from clinician expert representatives of specialist obesity services across Australia in 2017. Fifteen of 16 representatives of current services in New South Wales (n = 8), Queensland (n = 1), Victoria (n = 2), South Australia (n = 3), and the Australian Capital Territory (n = 1) provided data. The composition of services varied substantially between hospitals, and patient access to services and effective treatments were limited by strict entry criteria (e.g. body mass index 40 kg/m² or higher with specific complication/s), prolonged wait times, geographical location (major cities only) and out-of-pocket costs. Of these services, 47% had a multidisciplinary team (MDT), 53% had an exercise physiologist/physiotherapist, 53% had a bariatric surgeon and 33% had pharmacotherapy resources. Key gaps included staffing components of the MDT (psychologist, exercise physiologist/physiotherapist) and access to publicly funded weight loss pharmacotherapy and bariatric surgery. There was consensus on the need for significant improvements in staff, physical infrastructure, access to services, education/training in obesity medicine and targeted research funding. Based on the small number of existing, often under-resourced specialist obesity services that are located only in a few major cities, the vast majority of Australians with clinically severe obesity cannot access the specialist evidence based treatments needed.