The epidemiology of weight counseling for adults in the United States: a case of positive deviance

Investigating innovations in outpatient services: a mixed-methods rapid evaluation

Background

Within outpatient services, a broad range of innovations are being pursued to better manage care and reduce unnecessary appointments. One of the least-studied innovations is Patient-Initiated Follow-Up, which allows patients to book appointments if and when they need them, rather than follow a standard schedule.

Objectives

To use routine national hospital data to identify innovations in outpatient services implemented, in recent years, within the National Health Service in England. To carry out a rapid mixed-methods evaluation of the implementation and impact of Patient-Initiated Follow-Up.

Methods

The project was carried out in four sequential workstreams: (1) a rapid scoping review of outpatient innovations; (2) the application of indicator saturation methodology for scanning national patient-level data to identify potentially successful local interventions; (3) interviews with hospitals identified in workstream 2; and (4) a rapid mixed-methods evaluation of Patient-Initiated Follow-Up. The evaluation of Patient-Initiated Follow-Up comprised an evidence review, interviews with 36 clinical and operational staff at 5 National Health Service acute trusts, a workshop with staff from 13 National Health Service acute trusts, interviews with four patients, analysis of national and local data, and development of an evaluation guide.

Results

Using indicator saturation, we identified nine services with notable changes in follow-up to first attendance ratios. Of three sites interviewed, two queried the data findings and one attributed the change to a clinical assessment service. Models of Patient-Initiated Follow-Up varied widely between hospital and clinical specialty, with a significant degree of variation in the approach to patient selection, patient monitoring and discharge. The success of implementation was dependent on several factors, for example, clinical condition, staff capacity and information technology systems. From the analysis of national data, we found evidence of an association between greater use of Patient-Initiated Follow-Up and a lower frequency of outpatient attendance within 15 out of 29 specialties and higher frequency of outpatient attendance within 7 specialties. Four specialties had less frequent emergency department visits associated with increasing Patient-Initiated Follow-Up rates. Patient-Initiated Follow-Up was viewed by staff and the few patients we interviewed as a positive intervention, although there was varied impact on individual staff roles and workload. It is important that sites and services undertake their own evaluations of Patient-Initiated Follow-Up. To this end we have developed an evaluation guide to support trusts with data collection and methods.

Limitations

The Patient-Initiated Follow-Up evaluation was affected by a lack of patient-level data showing who is on a Patient-Initiated Follow-Up pathway. Engagement with local services was also challenging, given the pressures facing sites and staff. Patient recruitment was low, which affected the ability to understand experiences of patients directly.

Conclusions

The study provides useful insights into the evolving national outpatient transformation policy and for local practice. Patient-Initiated Follow-Up is often perceived as a positive intervention for staff and patients, but the impact on individual outcomes, health inequalities, wider patient experience, workload and capacity is still uncertain.

Future research

Further research should include patient-level analysis to determine clinical outcomes for individual patients on Patient-Initiated Follow-Up and health inequalities, and more extensive investigation of patient experiences.

Study registration

This study is registered with the Research Registry (UIN: researchregistry8864).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/138/17) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 38. See the NIHR Funding and Awards website for further award information.

Missed diagnosis-a major barrier to patient access to obesity healthcare in the primary care setting

OBJECTIVE

To investigate whether individuals with an elevated BMI measurement, for whom a diagnosis of overweight or obesity (OW/OB) is not recorded, are less likely to be offered clinical care for obesity compared to those with a recorded diagnosis.

SUBJECTS

A retrospective cohort study using the electronic medical record database of Maccabi Healthcare Services (MHS) in Israel. Included were 200,000 adults with BMI ≥ 25 kg/m2 measurement recorded during a primary care visit between 2014 and 2020, and no prior diagnosis of OW/OB or related co-morbidities.

METHODS

The relationships between a recorded diagnosis of OW/OB and two composite outcomes: 1. A composite of referrals to screening tests for metabolic complications; 2. A composite of weight loss intervention and follow up, were analyzed using multivariate logistic regression models.

RESULTS

In only 18% of individuals, a diagnosis of OW/OB was recorded. After adjusting for multiple potential confounding factors, individuals who received a recorded diagnosis were 18% more likely to be offered an evaluation for obesity-related metabolic complication, (OR 1.18, 95% CI 1.15-1.21, p < 0.001), and almost twice as likely to be offered intervention and follow up for their excess body weight (OR 1.84, 95% CI 1.76-1.94, p < 0.001) compared to individuals with missed diagnosis. These results persisted after adjusting for inter-physician variability. In addition, male sex, older age, and Arab sector were all associated with lower rates of weight loss intervention and follow up, while young individuals were less likely to be screened for metabolic complications.

CONCLUSION

Beyond BMI measurement, a recorded diagnosis of OW/OB is associated with statistically and clinically significant higher rates of performance of obesity care and intervention. Undiagnosed OW/OB presents a significant clinical opportunity, as recording a diagnosis of OW/OB would predict improved patient access to obesity healthcare and improved clinical outcomes.

The use of positive deviance approach to improve health service delivery and quality of care: a scoping review

BACKGROUND

Quality has been a persistent challenge in the healthcare system, particularly in resource-limited settings. As a result, the utilization of innovative approaches is required to help countries in their efforts to enhance the quality of healthcare. The positive deviance (PD) approach is an innovative approach that can be utilized to improve healthcare quality. The approach assumes that solutions to problems are already available within the community and identifying and sharing those solutions can help others to resolve existing issues. Therefore, this scoping review aimed to synthesize the evidence regarding the use of the PD approach in healthcare system service delivery and quality improvement programs.

METHODS

Articles were retrieved from six international databases. The last date for article search was June 02, 2023, and no date restriction was applied. All articles were assessed for inclusion through a title and/or abstract read. Then, articles that passed the title and abstract review were screened by reading their full texts. In case of duplication, only the full-text published articles were retained. A descriptive mapping and evidence synthesis was done to present data with the guide of the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews checklist and the results are presented in text, table, and figure formats.

RESULTS

A total of 125 articles were included in this scoping review. More than half, 66 (52.8%), of the articles were from the United States, 11(8.8%) from multinational studies, 10 (8%) from Canada, 8 (6.4%) from the United Kingdom and the remaining, 30 (24%) are from other nations around the world. The scoping review indicates that several types of study designs can be applied in utilizing the PD approach for healthcare service and quality improvement programs. However, although validated performance measures are utilized to identify positive deviants (PDs) in many of the articles, some of the selection criteria utilized by authors lack clarity and are subject to potential bias. In addition, several limitations have been mentioned in the articles including issues in operationalizing PD, focus on leaders and senior managers and limited staff involvement, bias, lack of comparison, limited setting, and issues in generalizability/transferability of results from prospects perspective. Nevertheless, the limitations identified are potentially manageable and can be contextually resolved depending on the nature of the study. Furthermore, PD has been successfully employed in healthcare service and quality improvement programs including in increasing surgical care quality, hand hygiene practice, and reducing healthcare-associated infections.

CONCLUSION

The scoping review findings have indicated that healthcare systems have been able to enhance quality, reduce errors, and improve patient outcomes by identifying lessons from those who exhibit exceptional practices and implementing successful strategies in their practice. All the outcomes of PD-based research, however, are dependent on the first step of identifying true PDs. Hence, it is critical that PDs are identified using objective and validated measures of performance as failure to identify true PDs can subsequently lead to failure in identifying best practices for learning and dissemination to other contextually similar settings.

A systematic review of the use of positive deviance approaches in primary care

BACKGROUND

The Positive Deviance (PD) approach focuses on identifying and learning from those who demonstrate exceptional performance despite facing similar resource constraints to others. Recently, it has been embraced to improve the quality of patient care in a variety of healthcare domains. PD may offer one means of enacting effective quality improvement in primary care.

OBJECTIVE(S)

This review aimed to synthesize the extant research on applications of the PD approach in primary care.

METHODS

Seven electronic databases were searched; MEDLINE, CINAHL, Embase, PsycINFO, Academic Search Complete, Psychology and Behavioral Sciences Collection, and Web of Science. Studies reporting original data on applications of the PD approach, as described by the PD framework, in primary care were included, and data extracted. Thematic analysis was used to classify positively deviant factors and to develop a conceptual framework. Methodological quality was appraised using the Quality Assessment with Diverse Studies (QuADS).

RESULTS

In total, 27 studies were included in the review. Studies most frequently addressed Stages 1 and 2 of the PD framework, and targeted 5 core features of primary care; effectiveness, chronic disease management, preventative care, prescribing behaviour, and health promotion. In total, 268 factors characteristic of exceptional care were identified and synthesized into a framework of 37 themes across 7 system levels.

CONCLUSION

Several useful factors associated with exceptional care were described in the literature. The proposed framework has implications for understanding and disseminating best care practice in primary care. Further refinement of the framework is required before its widespread recommendation.

Positive deviance in health and medical research on individual level outcomes - a review of methodology

BACKGROUND

Positive deviance as a methodology is increasing in application yet there is high variability in how this approach is applied in health services research.

METHODS

We conducted a scoping review of the literature for positive deviance applied to health outcomes informed by PRISMA-ScR. We searched the literature from 1945 to 2020, including articles on positive deviance or positive outliers, and restricted to examining individual rather than organizational outcomes. We analyzed the methodology applied including the process of identifying deviants, the use of control groups, and the degree of community engagement.

RESULTS

Our initial search identified 1140 manuscripts; we included 104 papers describing 98 studies, 11 topical and one miscellaneous category. Most studies used objective measures of health or survey-based responses to identify deviants from a sub-set of the population at risk. The use of controls was less common in some topics (hospital infections), whereas controls were universally applied in other topics (malnutrition). The degree of community engagement varied widely.

CONCLUSIONS

Positive deviance would benefit from improvements in reporting and standardized approaches to defining deviance. Studies could be improved through clarified definitions of deviance/risk, explicit descriptions of community engagement, and more consistent use of controls.

Retrospective descriptive analysis of a managed care population with obesity

OBJECTIVES

To reveal the extent of obesity in a single healthcare system and provide a blueprint for other health systems to perform similar analyses, this study describes characteristics and weight change patterns of patients classified with overweight and obesity at a large integrated delivery network (IDN) in the South-Central United States.

METHODS

A descriptive, observational, retrospective study was conducted using electronic medical records and claims data. Patients were ≥18 years old, body mass index (BMI) ≥27 kg/m², and continuously enrolled in the IDN plan for ≥6 months before and ≥12 months after the index date. Demographics, comorbidities, BMI, and weight were collected. Weight changes were assessed annually, and anti-obesity medications (AOM) use was also captured.

RESULTS

A total of 36,430 eligible patients were identified. A subset of 22,712 patients was continuously enrolled for the entire study period (mean age: 57.2) and were primarily white (83.3%) and commercially insured (54.3%). Most patients were categorized as overweight (40.1%) or obesity class I (32.5%) at baseline. At years 1 and 4 post-index, patients who maintained index weight (±3%) was 56.2% and 37.0%, respectively, whereas weight gain (≥3% increase) was 23.7% and 33.3%, respectively. AOM use (1.1%) primarily consisted of phentermine-hydrochloride (n = 114, 0.5%) and orlistat (n = 115, 0.5%).

CONCLUSIONS

An increasing proportion of patients gained weight over time, combined with low AOM use, emphasizing the need for weight-loss interventions in this population. Findings from this study provide a foundation for health systems to perform similar analyses.

Impact of an Expansion of a Clinical Nutrition Curriculum on Pre-Clerkship Medical Students' Perception of Their Knowledge and Skills Related to Performing a Nutritional Assessment

Learning how to provide nutritional counseling to patients should start early in undergraduate medical education to improve the knowledge, comfort, and confidence of physicians. Two nutrition workshops were developed for first-year medical students. The first workshop, co-led by physicians and registered dieticians, focused on obtaining nutrition assessments. The second workshop focused on the appropriate dietary counseling of patients with chronic kidney disease and cardiovascular risk. We surveyed students before workshop 1, after workshop 1, and after workshop 2 to assess their perceptions of the value of physician nutrition knowledge and counseling skills as well as their own comfort in the area of nutritional knowledge, assessment, and counseling. We found a significant improvement in their self-assessed level of knowledge regarding counseling patients, in their comfort in completing a nutritional assessment, and in their confidence in advising a patient about nutrition by the end of the first workshop. By the time of the second workshop five months later, students continued to report a high level of knowledge, comfort, and confidence. The implementation of clinical nutrition workshops with a focus on assessment, management, and counseling was found to be effective in increasing student's self-assessed level of knowledge as well as their confidence and comfort in advising patients on nutrition. Our findings further support the previous assertion that clinical nutrition education can be successfully integrated into the pre-clerkship medical school curriculum.

Teaching Medical Students to Help Patients Manage Their Weight: Outcomes of an Eight-School Randomized Controlled Trial

BACKGROUND

Given the rising rates of obesity there is a pressing need for medical schools to better prepare students for intervening with patients who have overweight or obesity and for prevention efforts.

OBJECTIVE

To assess the effect of a multi-modal weight management curriculum on counseling skills for health behavior change.

DESIGN

A pair-matched, group-randomized controlled trial (2015-2020) included students enrolled in eight U.S. medical schools randomized to receive either multi-modal weight management education (MME) or traditional weight management education (TE).

SETTING/PARTICIPANTS

Students from the class of 2020 (N=1305) were asked to participate in an objective structured clinical examination (OSCE) focused on weight management counseling and complete pre and post surveys. A total of 70.1% of eligible students (N=915) completed the OSCE and 69.3% (N=904) completed both surveys.

INTERVENTIONS

The MME implemented over three years included a web-based course, a role-play classroom exercise, a web-patient encounter with feedback, and an enhanced clerkship experience with preceptors trained in weight management counseling (WMC). Counseling focused on the 5As (Ask, Advise, Assess, Assist, Arrange) and patient-centeredness.

MEASUREMENTS

The outcome was student 5As WMC skills assessed using an objective measure, an OSCE, scored using a behavior checklist, and a subjective measure, student self-reported skills for performing the 5As.

RESULTS

Among MME students who completed two of three WMC components compared to those who completed none, exposure was significantly associated with higher OSCE scores and self-reported 5A skills.

LIMITATIONS

Variability in medical schools requiring participation in the WMC curriculum.

CONCLUSIONS

This trial revealed that medical students struggle with delivering weight management counseling to their patients who have overweight or obesity. Medical schools, though restrained in adding curricula, should incorporate should incorporate multiple WMC curricula components early in medical student education to provide knowledge and build confidence for supporting patients in developing individualized plans for weight management.

NIH TRIAL REGISTRY NUMBER

R01-194787.

Weight management counseling experiences of first year medical students before starting medical school and their self-perceived impact on treating patients with obesity

Physicians can play a vital role in counseling patients on overweight and obesity. This secondary analysis examined whether experiences in patient care specific to weight management before starting medical school were associated with students' intentions and confidence to provide weight management counseling (WMC) to patients who have overweight or obesity, and perceived impact as future physicians on patients' motivation to manage weight. First-year medical students (n = 1305) in the entering class of 2020 at eight medical schools nationwide completed questions relating to their prior experiences in patient care and WMC using the 5As. Also assessed were their intentions to treat patients with overweight or obesity, and confidence in counseling patients to help manage their weight. Over half the students (58.3%) who completed the survey had prior experience in patient care and nearly half (47.4%) began medical school with prior WMC experiences. Prior experiences correlated positively with higher confidence in performing WMC and students' intentions to treat patients with overweight or obesity. Given the relatively high rates of exposure to some type of weight management or lifestyle counseling among students before enrolling in medical school, the curriculum could build on established student interest and experience by offering treatment strategies including counseling for patients with overweight and obesity. By making prior experiences advantageous for admission, medical schools could gravitate towards admitting students who have brief but valuable insights about weight management in health care, thus increasing the possibility of filling important gaps.

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.

A web-based intervention to increase weight loss treatment initiation: results of a cluster randomized feasibility and acceptability trial

Evidence-based behavioral weight loss treatment is under-utilized. To increase initiation of treatment, we developed a single-session, online, primary care-based intervention ("mobilization tool"). We evaluated the mobilization tool's acceptability for primary care patients with obesity, trial design feasibility, and signal of an effect of the tool on treatment initiation. In this cluster randomized feasibility trial, primary care providers (PCPs) were randomized to a mobilization tool or comparator tool arm. Patients with obesity and a scheduled appointment with a randomized PCP were assigned to complete the mobilization or comparator tool prior to their appointment. The online mobilization tool asks patients to answer questions about a variety of weight-related topics and then provides automated, tailored feedback that addresses psychosocial determinants of weight loss treatment initiation. The comparator tool provided a nontailored description of treatments. All participants were offered free enrollment in behavioral weight loss treatments. Six PCPs were randomized. Sixty patients (57% female; 66% white; aged 55 ± 13 years) participated in this study of 296 contacted for eligibility evaluation (20.2%). Six-month follow-up assessments were completed by 65% (22/34) of the mobilization and 73% (19/26) of comparator tool participants. Participants completing the acceptability survey reported that the mobilization tool was usable, enjoyable, informative, and useful. Weight loss treatment was initiated by 59% (n = 19) of mobilization and 33% (n = 8) of comparator tool participants. The mobilization tool shows promise for increasing treatment initiation among primary care patients, which may increase population weight loss. Trial Registration: Clinicaltrials.gov identifier: NCT02708121.

Provider Advice and Patient Perceptions on Weight Across Five Health Systems

INTRODUCTION

To improve the management of overweight and obesity in the primary care setting, an analysis of patient perceptions of weight status and predictors of weight loss attempts for those with overweight and obesity is needed.

METHODS

Primary care patients (n=949) across 5 health systems in the Mid-Atlantic region of the U.S. were surveyed in 2015; data analysis was performed in 2018. Survey data was combined with data via the electronic health record to understand patients' perceptions of weight, factors associated with weight loss efforts, and provider counseling practices.

RESULTS

Most participants with overweight or obesity perceived themselves as weighing too much and reported trying to lose weight. Furthermore, most participants with obesity reported receiving advice to lose weight by a provider in the past 12 months. However, less than half of patients with overweight reported receiving advice to lose weight, maintain weight, or develop healthy eating and physical activity patterns from a health professional in the past 12 months. Among participants with overweight and obesity, multivariable logistic regression analysis demonstrated that the perception of being overweight and receiving healthcare advice to lose weight had the highest odds of reporting attempted weight loss (OR=5.5, 95% CI=2.7, 11.2 and OR=3.9, 95% CI=1.9, 7.9, respectively).

CONCLUSIONS

The findings emphasize the importance of provider attention to weight management counseling and identifies patients with overweight as needing increased attention by providers.

Characteristics of adults with overweight and obesity who have not attempted weight loss in the prior 12 months

OBJECTIVE

To determine weight-related characteristics of adults with overweight or obesity who had not attempted weight loss in the prior 12 months.

METHODS

Adults from the obesity cohort of the PORTAL clinical data research network were randomly selected to complete a survey in 2015. It included topics of experiences with health care providers, weight history, and health-promoting behaviors.

RESULTS

A total of 2811 adults completed the survey, of whom 24% reported not attempting weight loss in the previous 12 months. Controlling for sociodemographic characteristics and body mass index, respondents who reported that their health care provider never talked about weight were more likely to not attempt weight loss in the previous 12 months compared with respondents who reported providers frequently brought up weight (OR: 0.45; 95% CI: 0.24, 0.66). Respondents who perceived themselves as normal weight or underweight were 4.22 times more likely (95% CI: 3.53, 5.05) to not attempt weight loss compared with respondents who perceived themselves as overweight. Respondents who reported that they never tried to lose at least 10 lbs, ate 0-2 servings of fruits and vegetables daily, or engaged in 0-29 min of physical activity weekly were less likely to attempt weight loss.

CONCLUSIONS

Receiving advice on weight loss from health care providers to improve awareness of overweight and obesity status may be important factors for a person's weight management. Provider discussions about weight may be a strategy to motivate weight loss attempts.

General Public's Information-Seeking Patterns of Topics Related to Obesity: Google Trends Analysis

BACKGROUND

Obesity is a major public health challenge, and recent literature sheds light on the concept of "normalization" of obesity.

OBJECTIVE

We aimed to study the worldwide pattern of web-based information seeking by public on obesity and on its related terms and topics using Google Trends.

METHODS

We compared the relative frequency of obesity-related search terms and topics between 2004 and 2019 on Google Trends. The mean relative interest scores for these terms over the 4-year quartiles were compared.

RESULTS

The mean relative interest score of the search term "obesity" consistently decreased with time in all four quartiles (2004-2019), whereas the relative interest scores of the search topics "weight loss" and "abdominal obesity" increased. The topic "weight loss" was popular during the month of January, and its median relative interest score for January was higher than that for other months for the entire study period (P<.001). The relative interest score for the search term "obese" decreased over time, whereas those scores for the terms "body positivity" and "self-love" increased after 2013.

CONCLUSIONS

Despite a worldwide increase in the prevalence of obesity, its popularity as an internet search term diminished over time. The reason for peaks in months should be explored and applied to the awareness campaigns for better effectiveness. These patterns suggest normalization of obesity in society and a rise of public curiosity about image-related obesity rather than its medical implications and harm.

A Toolbox Approach to Obesity Treatment in Urban Safety-Net Primary Care Clinics: a Pragmatic Clinical Trial

BACKGROUND

There is a need for new strategies to improve the success of obesity treatment within the primary care setting.

OBJECTIVE

To determine if patients offered low out-of-pocket cost weight management tools achieved more weight loss compared to usual care.

DESIGN

Twelve-month pragmatic clinical weight loss trial with a registry-based comparator group performed in primary care clinics of an urban safety-net hospital.

PARTICIPANTS

From a large clinical registry, we randomly selected 428 patients to have the opportunity to receive the intervention.

INTERVENTIONS

Medical weight management tools-partial meal replacements, recreation center vouchers, pharmacotherapy, commercial weight loss program vouchers, and a group behavioral weight loss program-for $5 or $10 monthly. Patients chose their tools, could switch tools, and could add a second tool at 6 months.

MAIN MEASURES

The primary outcome was the proportion of intervention-eligible patients who achieved ≥ 5% weight loss. The main secondary outcome was the proportion of on-treatment patients who achieved ≥ 5% weight loss.

KEY RESULTS

Overall, 71.3% (305 of 428) had available weight measurement data/PCP visit data to observe the primary outcome. At 12 months, 23.3% (71 of 305) of intervention-eligible participants and 15.7% (415 of 2640) of registry-based comparators had achieved 5% weight loss (p < 0.001). Of the on-treatment participants, 34.5% (39 of 113) achieved 5% weight loss. Mean percentage weight loss was - 3.15% ± 6.41% for on-treatment participants and - 0.30% ± 6.10% for comparators (p < 0.001). The initially preferred tools were meal replacements, pharmacotherapy, and recreation center passes.

CONCLUSIONS

Access to a variety of low out-of-pocket cost weight management tools within primary care resulted in ≥ 5% body weight loss in approximately one quarter of low-income patients with obesity.

TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT01922934.

Nutrition and physical activity counselling by general practitioners in Lithuania, 2000-2014

BACKGROUND

Primary health care plays a crucial role in providing recommendations on a healthy diet and physical activity to assist patients in weight management. The study aimed to evaluate health behaviour counselling provided by general practitioners (GPs) for adults with overweight and obesity in Lithuania between 2000 and 2014.

METHODS

Eight biennial postal surveys to independent nationally representative random samples of Lithuanians aged 20-64 were conducted. Response rates varied from 41.1 to 74%, with a decreasing trend over time. The data of 5867 participants who visited a GP at least once during the last year and had BMI of ≥25.0 kg/m² were analysed. Respondents were asked about GP advice on nutrition and physical activity and changes in their health behaviour during the last year.

RESULTS

The proportion of persons with overweight who reported GP advice on nutrition increased from 23.6% in 2000 to 37.5% in 2010 and advice on physical activity from 11.9 to 17.2% respectively; however, later both proportions decreased slightly. The likelihood of reporting was higher in respondents with higher BMI, more chronic conditions and frequent contact with a GP. Respondents who were living in cities, older and highly educated women were all more likely to report being advised on physical activity. Men and women who received advice from a GP more often reported changes in health behaviour as compared with non-advised individuals.

CONCLUSIONS

Despite increasing trends, the rate of GP advice on nutrition and physical activity reported by patients with overweight and obesity remains low in Lithuania. GP advice appears to have a significant impact on attempts by patients to change behaviour related to weight control. Therefore, there is an obvious need to make additional efforts to increase the frequency of GP counselling and to identify and address barriers to advising patients with overweight.

A Patient-Centered PaTH to Address Diabetes: Protocol for a Study on the Impact of Obesity Counseling

BACKGROUND

Overweight and obesity are America's number one health concern. The prevalence of obesity in the United States is greater than 36%, a rate that has doubled since 1970. As the second most preventable cause of death, obesity is a risk factor for diabetes, cardiovascular disease, stroke, and cancer, all major causes of death. Primary care clinics may be an ideal setting for weight control interventions to help manage and prevent diabetes. For this reason, the Centers for Medicare and Medicaid Services (CMS) implemented a health care procedure coding system code for intensive behavioral therapy (IBT) for obesity within primary care in 2012 to facilitate payment for addressing obesity, which was followed by broader coverage by most insurers for IBT for adults in 2013. However, the impact of this coverage on patient-centered outcomes is largely unknown.

OBJECTIVE

The overarching goal of this study is to understand the comparative effectiveness of obesity counseling as covered by CMS and other insurers in improving weight loss for adults either with or at increased risk for type 2 diabetes.

METHODS

This study leverages the novel infrastructure of the Patient-Centered Outcomes Research Institute-funded PaTH Clinical Data Research Network. The PaTH network is comprised of Geisinger Health System, Johns Hopkins University, Johns Hopkins Health System, Lewis Katz School of Medicine at Temple University, Temple Health System, Penn State College of Medicine, Penn State Milton S Hershey Medical Center, University of Pittsburgh, UPMC and UPMC Health Plan, and the University of Utah. Electronic health record (EHR) data will originate from the 6 PaTH health systems. Specifically, we will (1) evaluate the impact of broader preventive service coverage for obesity screening and counseling on weight loss, diabetes incidence, and diabetes outcomes in patients with diabetes or at increased risk for diabetes (defined by body mass index [BMI] ≥25). We will determine how the annual probability of receiving obesity and/or nutritional counseling changed pre- and postpolicy across all insurers in a cohort of patients with diabetes and at high risk for diabetes. We will (2) compare patient weight loss and diabetes-related outcomes among those who receive obesity screening and counseling with those who do not, following implementation of preventive service coverage. We will examine postpolicy impact of obesity screening and counseling in a cohort of patients with diabetes and at increased risk for diabetes. Specific outcomes to be examined include weight loss, diabetes incidence, and diabetes outcomes. Exploratory outcomes will include patient-reported outcomes. Furthermore, we will determine patient characteristics, including demographics, and practice characteristics, including provider type.

RESULTS

Our PCORI-funded study is underway. To date, we have obtained our second data extraction from the PaTH CDRN and are performing data editing and cleaning. Next steps include analysis of early policy change.

CONCLUSIONS

Given patients who are overweight are at highest risk for diabetes, improved weight management services could prevent diabetes and its negative health outcomes. Comparing weight and diabetes outcomes in 3 states using EHRs and claims data before and after this policy was implemented using the PaTH Network will allow important insight into policy effectiveness.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/12054.

Practical Strategies for Engaging Individuals With Obesity in Primary Care

Although widely recognized as a chronic disease that requires long-term, structured, and multidisciplinary management, obesity remains largely underdiagnosed and undertreated. The prevalence of obesity continues to increase dramatically, with the highest rates seen in the United States. Despite the availability of several clinical practice guidelines, published studies suggest that health care professionals (HCPs) infrequently and inconsistently follow guideline recommendations. Barriers to HCP participation in obesity management are likely to inhibit obesity counseling in primary care. Improving HCP obesity-related practices and counseling is important. This article discusses current practices, barriers to effective obesity management, and recommendations to improve HCP obesity management and counseling, based on findings from a PubMed search and clinical experience. The aim of the article is to share best-practice strategies for engaging patients.

How is success achieved by individuals innovating for patient safety and quality in the NHS?

Background

Innovation in healthcare is said to be notoriously difficult to achieve and sustain yet simultaneously the health service is under intense pressure to innovate given the ever increasing demands placed upon it. Whilst many studies have looked at diffusion of innovation from an organisational perspective, few have sought to understand how individuals working in healthcare innovate successfully. We took a positive deviance approach to understand how innovations are achieved by individuals working in the NHS.

Method

We conducted in depth interviews in 2015 with 15 individuals who had received a national award for being a successful UK innovator in healthcare. We invited only those people who were currently (or had recently) worked in the NHS and whose innovation focused on improving patient safety or quality. Thematic analysis was used.

Findings

Four themes emerged from the data: personal determination, the ability to broker relationships and make connections, the ways in which innovators were able to navigate organisational culture to their advantage and their ability to use evidence to influence others. Determination, focus and persistence were important personal characteristics of innovators as were skills in being able to challenge the status quo. Innovators were able to connect sometimes disparate teams and people, being the broker between them in negotiating collaborative working. The culture of the organisation these participants resided in was important with some being able to use this (and the current patient safety agenda) to their advantage. Gathering robust data to demonstrate their innovation had a positive impact and was seen as essential to its progression.

Conclusions

This paper reveals a number of factors which are important to the success of innovators in healthcare. We have uncovered that innovators have particular personal traits which encourage a propensity towards change and action. Yet, for fruitful innovation to take place, it is important for relational networks and organisational culture to be receptive to change.

Preliminary examination of metabolic syndrome response to motivational interviewing for weight loss as compared to an attentional control and usual care in primary care for individuals with and without binge-eating disorder

Motivational interviewing (MI) treatment for weight loss is being studied in primary care. The effect of such interventions on metabolic syndrome or binge eating disorder (BED), both highly related to excess weight, has not been examined in primary care. This study conducted secondary analyses from a randomized controlled trial to test the impact of MI for weight loss in primary care on metabolic syndrome. 74 adult participants with overweight/obesity recruited through primary care were randomized to 12weeks of either MI, an attentional control, or usual care. Participants completed measurements for metabolic syndrome at pre- and post-treatment. There were no statistically significant differences in metabolic syndrome rates at pre-, X²(2)=0.16, p=0.921, or post-, X²(2)=0.852, p=0.653 treatment. The rates in metabolic syndrome, however, decreased for MI (10.2%) and attentional control (13.8%) participants, but not for usual care. At baseline, metabolic syndrome rates did not differ significantly between participants with BED or without BED across treatments. At post-treatment, participants with BED were significantly more likely to meet criteria for metabolic syndrome than participants without BED, X²(1)=5.145, p=0.023, phi=0.273. Across treatments, metabolic syndrome remitted for almost a quarter of participants without BED (23.1%) but for 0% of those with BED. These preliminary results are based on a small sample and should be interpreted with caution, but they are the first to suggest that relatively low intensity MI weight loss interventions in primary care may decrease metabolic syndrome rates but not for individuals with BED.

Provider Advice About Weight Loss in a Primary Care Sample of Obese and Overweight Patients

Objective: Primary care providers play an important role in obesity prevention and reduction by advising patients about weight loss strategies. This study examined receipt of provider advice to lose weight among primary care patients who were overweight and obese. Methods: Observational study conducted among primary care patients (n = 282) who completed a survey that measured receipt of provider advice about weight loss/management, chronic health conditions, perceived weight status, and perceptions about shared decision making about weight loss/management. Results: Fifty-nine percent of participants had been advised by their physician to lose weight. Participants who were obese were more likely than those who were overweight to report provider advice (odds ratio [OR] = 1.31, 95% CI = 1.25-4.34, P = .001). Similarly, participants who believed they were obese/overweight had a greater likelihood of reporting provider advice compared with those who did not believe they were obese/overweight (OR = 1.40, 95% CI = 2.43-6.37, P = .0001). Shared decision making about weight loss/management was associated with an increased likelihood of reporting provider advice (OR = 3.30, 95% CI = 2.62-4.12, P = .0001). Conclusions: Patient beliefs about their weight status and perceptions about shared decision-making are important to receiving provider advice about weight loss/management among primary care patients. Practice Implications: Continued efforts are needed to enhance provider advice about weight loss/management among obese/overweight patients.

Validation of clinic weights from electronic health records against standardized weight measurements in weight loss trials

OBJECTIVE

To validate clinic weights in electronic health records against researcher-measured weights for outcome assessment in weight loss trials.

METHODS

Clinic and researcher-measured weights from a published trial (BE WELL) were compared using Lin's concordance correlation coefficient, Bland and Altman's limits of agreement, and polynomial regression model. Changes in clinic and researcher-measured weights in BE WELL and another trial, E-LITE, were analyzed using growth curve modeling.

RESULTS

Among BE WELL (n = 330) and E-LITE (n = 241) participants, 96% and 90% had clinic weights (mean [SD] of 5.8 [6.1] and 3.7 [3.9] records) over 12 and 15 months of follow-up, respectively. The concordance correlation coefficient was 0.99, and limits of agreement plots showed no pattern between or within treatment groups, suggesting overall good agreement between researcher-measured and nearest-in-time clinic weights up to 3 months. The 95% confidence intervals for predicted percent differences fell within ±3% for clinic weights within 3 months of the researcher-measured weights. Furthermore, the growth curve slopes for clinic and researcher-measured weights by treatment group did not differ significantly, suggesting similar inferences about treatment effects over time, in both trials.

CONCLUSIONS

Compared with researcher-measured weights, close-in-time clinic weights showed high agreement and inference validity. Clinic weights could be a valid pragmatic outcome measure in weight loss studies.

The prevalence of obesity documentation in Primary Care Electronic Medical Records. Are we acknowledging the problem?

BACKGROUND

Although obesity is a growing problem, primary care physicians often inadequately address it. The objective of this study is to examine the prevalence of obesity documentation in the patient's problem list for patients with eligible body mass indexes (BMI) as contained in the patients' electronic medical record (EMR). Additionally, we examined the prevalence of selected chronic conditions across BMI levels.

METHOD

This study is a retrospective study using EMR data for adult patients visiting an outpatient clinic between June 2012 and June 2015. International Classification of Diseases, Ninth Revision, (ICD-9) codes were used to identify obesity documentation in the EMR problem list. Univariate and multivariate logistic regression analyses were used.

RESULTS

Out of 10,540, a total of 3,868 patients were included in the study. 2,003 (52%) patients met the criteria for obesity (BMI ≥ 30.0); however, only 112 (5.6%) patient records included obesity in the problem list. Moreover, in a multivariate analysis, in addition to age and gender, morbid obesity and cumulative number of comorbidities were significantly associated with obesity documentation, OR=1.6 and OR=1.3, respectively, with 95% CI [1.4, 1.9] and [1.0, 1.7], respectively. For those with obesity documentation, exercise counseling was provided more often than diet counselling.

CONCLUSION

Based on EHR documentation, obesity is under coded and generally not identified as a significant problem in primary care. Physicians are more likely to document obesity in the patient record for those with higher BMI scores who are morbidly obese. Moreover, physicians more frequently provide exercise than diet counseling for the documented obese.

Priorities and Preferences for Weight Management and Cardiovascular Risk Reduction in Primary Care

Implementing behavioral interventions for cardiovascular risk reduction and weight management is challenging in primary care. Primary care patients and providers were recruited for qualitative interviews to identify priorities and preferences for addressing weight management. Thematic analysis was used to identify relevant resources, barriers to lifestyle modification, health behavior change, and implementation of weight management strategies into care. Patients and providers prioritized increasing physical activity and healthy diets when managing chronic disease; and reported decreased patient motivation, knowledge, and limited organizational capacity and time among providers to deliver intensive interventions. Providers and patients disagreed regarding who owns accountability for weight management.

Disparities in Who Receives Weight-Loss Advice From a Health Care Provider: Does Income Make a Difference?

Introduction

The US Preventive Services Task Force recommends that all patients be screened for obesity and, if needed, be provided weight-loss advice. However, the prevalence of such advice is low and varies by patient demographics. This study aimed to describe the determinants of receiving weight-loss advice among a sample with a high proportion of low-income, racial/ethnic minority individuals.

Methods

Data were collected from a telephone survey of 1,708 households in 2009 and 2010 in 5 cities in New Jersey. Analyses were limited to 1,109 overweight or obese adults. Multivariate logistic regression determined the association of participants’ characteristics with receiving weight-loss advice from their health care provider. Two models were used to determine differences by income and insurance status.

Results

Of all overweight or obese respondents, 35% reported receiving advice to lose weight. Receiving advice was significantly associated with income in multivariate analysis. Compared with those with an income at or below 100% of the federal poverty level (FPL), those within 200% to 399% of the FPL had 1.60 higher odds of receiving advice (P = .02), and those with an income of 400% or more of the FPL had 1.73 higher odds of receiving advice (P = .03). The strength of the association did not change after adjusting for health insurance.

Conclusion

Income is a significant predictor of whether or not overweight or obese adults receive weight-loss advice after adjustment for demographic variables, health status, and insurance status. Further work is needed to examine why disparities exist in who receives weight-loss advice. Health care providers should provide weight-loss advice to all patients, regardless of income.

Weight loss advice and prospective weight change among overweight firefighters

BACKGROUND

Obesity compromises firefighter safety, yet more than 70% of firefighters are overweight. Though healthcare professionals are encouraged to counsel overweight patients, the effectiveness of weight counseling is not consistent across studies.

OBJECTIVE

Examine longitudinal changes in cardiovascular risk factors and determine the role of healthcare professional weight loss advice on six-month weight changes among a national sample of male, overweight and obese firefighters.

METHODS

This study included baseline and six-month assessments of 757 firefighters. Medical and demographic data were collected using questionnaires. Investigators collected height, weight, percent body fat, waist circumference, blood pressure, and fasting serum samples (total cholesterol, high-density lipoprotein, low-density lipoprotein, glucose). Multilevel linear regression assessed the association between weight advice and outcomes.

RESULTS

Participants lost an average of 0.55 kg (95%CI: 0.17-0.93), and experienced significant improvements in systolic blood pressure (mean: 3.75 mm Hg; 95% CI: 2.35-5.14) and non-significant improvements in other clinical outcomes. Healthcare professional weight advice was not significantly associated with weight loss or other outcomes.

CONCLUSION

Similar to other studies, results show little benefit of low intensity weight loss counseling. Additional research is needed to identify effective and feasible weight management strategies to address firefighter obesity.

What methods are used to apply positive deviance within healthcare organisations? A systematic review

BACKGROUND

The positive deviance approach focuses on those who demonstrate exceptional performance, despite facing the same constraints as others. 'Positive deviants' are identified and hypotheses about how they succeed are generated. These hypotheses are tested and then disseminated within the wider community. The positive deviance approach is being increasingly applied within healthcare organisations, although limited guidance exists and different methods, of varying quality, are used. This paper systematically reviews healthcare applications of the positive deviance approach to explore how positive deviance is defined, the quality of existing applications and the methods used within them, including the extent to which staff and patients are involved.

METHODS

Peer-reviewed articles, published prior to September 2014, reporting empirical research on the use of the positive deviance approach within healthcare, were identified from seven electronic databases. A previously defined four-stage process for positive deviance in healthcare was used as the basis for data extraction. Quality assessments were conducted using a validated tool, and a narrative synthesis approach was followed.

RESULTS

37 of 818 articles met the inclusion criteria. The positive deviance approach was most frequently applied within North America, in secondary care, and to address healthcare-associated infections. Research predominantly identified positive deviants and generated hypotheses about how they succeeded. The approach and processes followed were poorly defined. Research quality was low, articles lacked detail and comparison groups were rarely included. Applications of positive deviance typically lacked staff and/or patient involvement, and the methods used often required extensive resources.

CONCLUSION

Further research is required to develop high quality yet practical methods which involve staff and patients in all stages of the positive deviance approach. The efficacy and efficiency of positive deviance must be assessed and compared with other quality improvement approaches.

PROSPERO REGISTRATION NUMBER

CRD42014009365.

The State of Nutrition Education at US Medical Schools

Purpose. To assess the state of nutrition education at US medical schools and compare it with recommended instructional targets. Method. We surveyed all 133 US medical schools with a four-year curriculum about the extent and type of required nutrition education during the 2012/13 academic year. Results. Responses came from 121 institutions (91% response rate). Most US medical schools (86/121, 71%) fail to provide the recommended minimum 25 hours of nutrition education; 43 (36%) provide less than half that much. Nutrition instruction is still largely confined to preclinical courses, with an average of 14.3 hours occurring in this context. Less than half of all schools report teaching any nutrition in clinical practice; practice accounts for an average of only 4.7 hours overall. Seven of the 8 schools reporting at least 40 hours of nutrition instruction provided integrated courses together with clinical practice sessions. Conclusions. Many US medical schools still fail to prepare future physicians for everyday nutrition challenges in clinical practice. It cannot be a realistic expectation for physicians to effectively address obesity, diabetes, metabolic syndrome, hospital malnutrition, and many other conditions as long as they are not taught during medical school and residency training how to recognize and treat the nutritional root causes.

A systematic review of motivational interviewing for weight loss among adults in primary care

Motivational interviewing (MI) is a client-centred method of intervention focused on enhancing intrinsic motivation and behaviour change. A previous review of the literature and meta-analyses support the effectiveness of MI for weight loss. None of these studies, however, focused on the bourgeoning literature examining MI for weight loss among adults within primary care settings, which confers unique barriers to providing weight loss treatment. Further, the current review includes 19 studies not included in previous reviews or meta-analyses. We conducted a comprehensive review of PubMed, MI review papers, and citations from relevant papers. A total of 24 adult randomized controlled trials were identified. MI interventions typically were provided individually by a range of clinicians and compared with usual care. Few studies provided adequate information regarding MI treatment fidelity. Nine studies (37.5%) reported significant weight loss at post-treatment assessment for the MI condition compared with control groups. Thirteen studies (54.2%) reported MI patients achieving at least 5% loss of initial body weight. There is potential for MI to help primary care patients lose weight. Conclusions, however, must be drawn cautiously as more than half of the reviewed studies showed no significant weight loss compared with usual care and few reported MI treatment fidelity.

Middle-aged women's decisions about body weight management: needs assessment and testing of a knowledge translation tool

OBJECTIVE

This study aims to assess middle-aged women's needs when making body weight management decisions and to evaluate a knowledge translation tool for addressing their needs.

METHODS

A mixed-methods study used an interview-guided theory-based survey of professional women aged 40 to 65 years. The tool summarized evidence to address their needs and enabled women to monitor actions taken. Acceptability and usability were reported descriptively.

RESULTS

Sixty female participants had a mean body mass index of 28.0 kg/m(2) (range, 17.0-44.9 kg/m(2)), and half were premenopausal. Common options for losing (82%) or maintaining (18%) weight included increasing physical activity (60%), eating healthier (57%), and getting support (40%). Decision-making involved getting information on options (52%), soliciting others' decisions/advice (20%), and being self-motivated (20%). Preferred information sources included written information (97%), counseling (90%), and social networking websites (43%). Five professionals (dietitian, personal trainer, occupational therapist, and two physicians) had similar responses. Of 53 women sent the tool, 27 provided acceptability feedback. They rated it as good to excellent for information on menopause (96%), body weight changes (85%), and managing body weight (85%). Most would tell others about it (81%). After 4 weeks of use, 25 women reported that the wording made sense (96%) and that the tool had clear instructions (92%) and was easy to use across time (88%). The amount of information was rated as just right (64%), but the tool had limited space for responding (72%).

CONCLUSIONS

When making decisions about body weight management, women's needs were "getting information" and "getting support." The knowledge translation tool was acceptable and usable, but further evaluation is required.

The impact of physician weight discussion on weight loss in US adults

PROBLEM

The increasing prevalence of overweight and obesity in the United States and worldwide is at epidemic levels. Physicians may play a vital role in addressing this epidemic. We aimed to examine the association of a physician's discussion of patients’ weight status with self-reported weight loss. We hypothesized that physician discussion of patients’ being overweight is associated with increased weight loss in patients with overweight and obesity.

METHODS

Data analysis of participants (n = 5054) in the National Health and Nutritional Examination Survey (NHANES) in 2005-2008. The main outcome was rates of self-reported weight loss and the association with physicians’ discussion of their patients’ weight status.

RESULTS

Overweight and obese participants were significantly more likely to report a 5% weight loss in the past year if their doctor had told them they were overweight (adjusted OR (AOR) 1.88; 95% CI 1.45-2.44; AOR 1.79; 95% CI 1.30-2.46, respectively).

CONCLUSIONS

Physicians’ direct discussion of their patients’ weight status is associated with clinically significant patient weight loss and may be a targetable intervention. Further studies are needed to determine if increasing physician discussion of patients’ weight status leads to significant weight loss.

Physician weight recommendations for overweight and obese firefighters, United States, 2011-2012

INTRODUCTION

National guidelines state that health care professionals (HCPs) should advise patients on the importance of maintaining a healthy weight. Firefighters have high rates of obesity, and cardiovascular events are the leading cause of line-of-duty deaths in firefighters. This study assessed the association of age and body mass index (BMI) with HCP weight recommendations among male firefighters.

METHODS

We used data on self-reported HCP weight recommendations and measured BMI from a 2011-2012 national sample of male firefighters (N = 1,002). HCP recommendations were recorded as no advice, maintain, gain, or lose weight, and BMI was categorized as normal (<25.0 kg/m(2)), overweight (25.0-29.9 kg/m(2)), class I obese (30.0-34.9 kg/m(2)), and class II or III obese (≥35.0 kg/m(2)). We used multinomial logistic regression to estimate the odds of receiving weight advice by age and BMI categories.

RESULTS

Most firefighters (96%) reported visiting an HCP in the past year. Most (69%) firefighters and 48% of class I to III obese firefighters reported receiving no weight advice. Higher BMI predicted HCP advice to lose weight (odds ratio class I obese vs normal weight: 12.98; 95% confidence interval: 5.38-31.34). Younger firefighters were less likely to receive weight loss advice than older firefighters, except among those who were class II or III obese.

CONCLUSIONS

HCPs are important sources of health information for firefighters. Overweight and obese firefighters, particularly those who are younger, do not consistently receive HCP advice to lose weight. This marks a missed opportunity to prevent further weight gain and reduce obesity-related health outcomes.

Physically active, low-income African American women: an exploration of activity maintenance in the context of sociodemographic factors associated with inactivity

Increasing physical activity among low-income African American women is an important target for addressing racial and economic disparities in chronic conditions and related risk factors. While barriers to physical activity for women have been examined empirically, successful strategies for navigating those barriers among physically active, low-income women have not been thoroughly explored. Informed by grounded theory, we conducted in-depth individual interviews between 2007-2010 with 14 low-income African American women who were physically active at nationally recommended levels for one year or more. We analyzed the data using thematic analysis techniques. Key themes emerged in three main categories: motivation for maintaining active lifestyle, strategies for maintaining physical activity, and challenges to maintaining physical activity. Important motivations included getting or staying healthy, social connections, and gratification. Two planning strategies emerged: flexibility and freedom. Critical challenges included financial constraints, physical strain and history of sedentary relapse. The motivations, strategies and challenges reported by low-income African American women who successfully maintained an active lifestyle provided important information for developing effective health promotion strategies for their inactive and underactive counterparts. A qualitative, asset-based approach to physical activity research contributes rich data to bridge the gap between epidemiological knowledge and community health improvement.

What does high and low have to do with it? Performance classification to identify health system factors associated with effective prevention of mother-to-child transmission of HIV delivery in Mozambique

Introduction

Efforts to implement and take to scale highly efficacious, low-cost interventions to prevent mother-to-child HIV transmission (pMTCT) have been a cornerstone of reproductive health services in sub-Saharan Africa for over a decade. Yet efforts to increase access and utilization of these services remain far from optimal. This study developed and applied an approach to systematically classify pMTCT performance to identify modifiable health system factors associated with pMTCT performance which may be replicated in other pMTCT systems.

Methods

Facility-level performance measures were collected at 30 sites over a 12-month period and reviewed for consistency. Five combinations of three indicators (1. HIV testing; 2. CD4 testing; 3. antiretroviral prophylaxis and combined antiretroviral therapy initiation) were compared including a composite of all three, a combination of 1. and 3., and each individually. Approaches were visually assessed to describe facility performance, focusing on rank order consistency across high, medium and low categories. Modifiable and non-modifiable factors were ascertained at each site and ranking process was reviewed to estimate association with facility performance through unadjusted Chi-square tests and logistic regression. After describing factors associated with high versus low performing pMTCT clinics, the effect of inclusion of the 10 middle performers was assessed.

Results

The indicator most consistently associated with the reference composite indicator (HIV testing, antiretroviral prophylaxis and combined antiretroviral therapy) was the single measure of antiretroviral prophylaxis and combined antiretroviral therapy. Lower performing pMTCT clinics ranked consistently low across measurement strategies; high and middle performing clinics demonstrated more variability. Association between clinic characteristics and high pMTCT performance varied markedly across ranking strategies. Using the reference composite indicator, larger catchment area, higher number of institutional deliveries, onsite CD4 point-of-care capacity, and higher numbers of nurses and doctors were associated with high clinic performance while clinic location, NGO support, women's support group, community linkages patient-tracking systems and stock-outs were not associated with high performance.

Conclusions

Classifying high and low performance provided consistent results across ranking measures, though granularity was improved by aggregating middle performers with either high or low performers. Human resources, catchment size and utilization were positively associated with effective pMTCT service delivery.