The Incomplete Medicalization of Obesity: Physician Office Visits, Diagnoses, and Treatments, 1996-2014

Factors associated with receiving an obesity diagnosis and obesity-related treatment for patients with obesity class II and III within a single integrated health system

Objectives

The prevalence and associated adverse effects of obesity on health and healthcare cost make it a primary public health concern. However, individuals with the physiological features of obesity may be underdiagnosed and undertreated. We aimed to determine the prevalence of obesity diagnoses and obesity-related treatments in an integrated health system and determine the factors associated with receiving an obesity diagnosis and treatment for this indication.

Methods

This retrospective cross-sectional study of data from the Henry Ford Health electronic health record included adult patients with a body mass index (BMI) indicating clinical evidence of class II and III (severe) obesity in 2017 and who received treatment through 2019. The primary outcome was prevalence of obesity diagnosis and obesity-related treatment. Logistic regression evaluated the patient-level factors associated with odds of having obesity diagnosis and treatment.

Results

Among 64,741 patients meeting the clinical definition of definition of severe obesity, only 40.7 % were clinically diagnosed with obesity, and 23.5 % received an obesity-related intervention. Patients with BMI≥40 kg/m2 (class III) were more likely to be diagnosed with obesity than those with BMI 35-39.9 kg/m2 (class II) (odds ratio [OR] 5.84; 95 % CI, 5.62-6.07). Patients with a diagnosis of obesity (OR 2.92; 95 % CI, 2.80-3.05), Black patients (OR 1.46; 95 % CI, 1.40-1.53), and female patients (OR 1.47; 95 % CI, 1.41-1.54) were more likely to be offered obesity-related treatment.

Conclusions

Severe obesity may be underdiagnosed in patients who have BMI 35-39.9 kg/m2 and 1 comorbidity.

Impact of lower-respiratory tract infections on healthcare utilization and mortality in older adults: a Swedish population-based cohort study

BACKGROUND

Lower respiratory tract infections (LRTIs) have an immediate significant impact on morbidity and mortality among older adults. However, the impact following the infectious period of LRTI remains understudied. We aimed to assess the short- to long-term impact of LRTIs on hospitalization, mortality, and healthcare utilization in older adults.

METHODS

Data from the Swedish National Study of Aging and Care in Kungsholmen (SNAC-K) was analyzed, with data from 2001 to 2019 for mortality and 2001-2016 for healthcare utilization. LRTI-exposed participants were identified and matched with LRTI-nonexposed based on sociodemographics, lifestyle factors, and functional and clinical characteristics. Statistical models evaluated post-LRTI hospitalization risk, days of inpatient hospital admissions, healthcare visits, and mortality.

RESULTS

567 LRTIs-exposed participants during the study period and were matched with 1.701 unexposed individuals. LRTI-exposed individuals exhibited increased risk of hospitalization at 1-year (HR 2.14, CI 1.74, 2.63), 3-years (HR 1.74, CI 1.46, 2.07), and 5-years (HR 1.59, CI 1.33, 1.89). They also experienced longer post-LRTI hospital stays (IRR 1.40, CI 1.18, 1.66), more healthcare visits (IRR 1.47, CI 1.26, 1.71), specialist-care visits (IRR 1.46, CI 1.24, 1.73), and hospital admissions (IRR 1.57, CI 1.34, 1.83) compared to nonexposed participants over 16-years of potential follow-up. Additionally, the 19-year risk of mortality was higher among LRTI-exposed participants (HR 1.45, CI 1.24, 1.70). Men exhibited stronger associations with these risks compared to women.

CONCLUSIONS

LRTIs pose both short- and long-term risks for older adults, including increased risks of mortality, hospitalization, and healthcare visits that transpire beyond the acute infection period, although these effects diminish over time. Men exhibit higher risks across these outcomes compared to women. Given the potential preventability of LRTIs, further public health measures to mitigate infection risk are warranted.

Artifical intelligence in surgery: ethical considerations in the light of social trends in the perception of health and medicine

The use of artificial intelligence (AI) in medicine and surgery is currently predicted to be very promising. However, AI has the potential to change the doctor's role and the doctor-patient relationship. It has the potential to support people's desires for health, along with the potential to nudge or push people to behave in a certain way. To understand these potentials, we must see AI in the light of social developments that have brought about changes in how medicine's role, in a given society, is understood. The trends of 'privatisation of medicine' and 'public-healthisation of the private' are proposed as a contextual backdrop to explain why AI raises ethical concerns different from those previously caused by new medical technologies, and which therefore need to be addressed specifically for AI.

Pragmatic Implementation of Online Obesity Treatment and Maintenance Interventions in Primary Care: A Randomized Clinical Trial

Importance

Behavioral weight loss interventions have achieved success in primary care; however, to our knowledge, pragmatic implementation of a fully automated treatment that requires little researcher oversight has not been tested. Moreover, weight loss maintenance remains a challenge.

Objective

To evaluate the long-term effectiveness of an automated, online, behavioral obesity treatment program (Rx Weight Loss [RxWL]) at 12 months (primary end point) and 24 months when delivered pragmatically in primary care and to compare the effectiveness of 3 weight loss maintenance approaches.

Design, Setting, and Participants

This randomized clinical trial of RxWL, an online weight loss program, recruited patients from a Rhode Island primary care network with approximately 60 practices and 100 physicians. Eligible participants were primary care patients aged 18 to 75 years with overweight or obesity who were referred by their nurse care manager and enrolled between 2018 and 2020. All participants were included in the intention-to-treat analysis, whereas only those who engaged with maintenance intervention were included in the per-protocol analysis. Data were analyzed from August 2022 to September 2023.

Interventions

All participants were offered the same 3-month weight loss program, with randomization to one of three 9-month maintenance programs: control intervention (monthly online newsletters), monthly intervention (9 monthly video lessons and 1 week of self-monitoring per month), or refresher intervention (an introductory session and two 4-week periods of lessons and self-monitoring at 7 and 10 months).

Main Outcomes and Measures

The primary outcome was weight change at 12 months using height and weight data collected from electronic medical records through 24 months.

Results

Among the 540 participants (mean [SD] age, 52.8 [13.4] years; 384 females [71.1%]) in the intention-to-treat analysis, mean estimated 3-month weight loss was 3.60 (95% CI, -4.32 to -2.88) kg. At the 12-month primary end point, the amount of weight regained in the monthly (0.37 [95% CI, -0.06 to 0.81] kg) and refresher (0.45 [95% CI, 0.27 to 0.87] kg) maintenance groups was significantly less than that in the newsletter control maintenance group (1.28 [95% CI, 0.85 to 1.71] kg; P = .004). The difference in weight regain between the monthly and refresher maintenance groups was not statistically significant. This pattern persisted at 24 months. In the per-protocol analysis of 253 participants, mean weight loss at the end of the initial 3-month intervention was 6.19 (95% CI, -7.25 to -5.13) kg. Similarly, at 12 months there was less weight regain in the monthly (0.61 kg) and refresher (0.96 kg) maintenance groups than in the newsletter control maintenance group (1.86 kg).

Conclusions and Relevance

Results of this randomized clinical trial indicate that pragmatic implementation of a 12-month automated, online, behavioral obesity treatment that includes 9 months of active maintenance produces clinically significant weight loss over 2 years in primary care patients with overweight or obesity. These findings underscore the importance of providing ongoing maintenance intervention to prevent weight regain.

Trial Registration

ClinicalTrials.gov Identifier: NCT03488212.

Economic costs of obesity: a systematic review

INTRODUCTION

Obesity is a growing public health problem leading to substantial economic impact. This study aimed to summarize the economic impact of obesity and to critically analyze the methods used in the cost-of-illness (COI) studies on obesity.

METHODS

We conducted systematic search in PubMed and Scopus from September 1, 2016, to July 22, 2022. Original COI studies estimating the economic cost of obesity and/or overweight in at least one country, published in English were included. To facilitate the comparison of estimates across countries, we converted the cost estimates of different years to 2022 purchasing power parity (PPP) values using each country's consumer price index (CPI) and PPP conversion rate.

RESULTS

Nineteen studies were included. All studies employed a prevalence-based approach using Population Attributable Fraction (PAF) methodology. About half of the included studies (53%) were conducted in high-income countries while the others (47%) were conducted in middle-income countries. The economic burden of obesity ranged between PPP 15 million in Brazil to PPP 126 billion in the USA, in the year 2022. Direct medical costs accounted for 0.7% to 17.8% of the health system expenditure. Furthermore, the total costs of obesity ranged from 0.05% to 2.42% of the country's gross domestic product (GDP). Of the seven studies that estimated both direct and indirect costs, indirect costs accounted for the largest portion of five studies. Nevertheless, a variety in methodology across studies was identified. The number of co-morbidities included in the analysis varied across studies.

CONCLUSIONS

Although there was a variety of methodologies across studies, consistent evidence indicated that the economic burden of obesity was substantial. Obesity prevention and control should be a public health priority, especially among countries with high prevalence of obesity.

Patient perceptions about obesity management in the context of concomitant care for other chronic diseases

Background

Approximately 15% of Canadian adults live with two or more chronic diseases, many of which are obesity related. The degree to which Canadian obesity treatment guidelines are integrated into chronic disease management is unknown.

Methods

We conducted a 12-min online survey among a non-probability sample of 2506 adult Canadians who met at least one of the following criteria: 1) BMI ≥30 kg/m2; 2) medical diagnosis of obesity; 3) undergone medically supervised treatment for obesity; or 4) a belief that excess/abnormal adipose tissue impairs their health. Participants must have been diagnosed with at least one of 12 prevalent obesity-related chronic diseases. Data analysis consisted of descriptive statistics.

Results

One in four (26.4%) reported a diagnosis of obesity, but only 9.2% said they had received medically supervised obesity treatment. The majority (55%) agreed obesity makes managing their other chronic diseases challenging; 39% agreed their chronic disease(s) have progressed or gotten worse because of their obesity. While over half (54%) reported being aware that obesity is classified as a chronic disease, 78% responded obesity was their responsibility to manage on their own. Only 33% of respondents responded they have had success with obesity treatment.

Interpretation

While awareness of obesity as a chronic disease is increasing, obesity care within the context of a wider chronic disease management model is suboptimal. More work remains to be done to make Canadian obesity guidelines standard for obesity care.

Bariatric surgery alters mitochondrial function in gut mucosa

BACKGROUND

The obesity pandemic has worsened global disease burden, including type 2 diabetes, cardiovascular disease, and cancer. Metabolic/bariatric surgery (MBS) is the most effective and durable obesity treatment, but the mechanisms underlying its long-term weight loss efficacy remain unclear. MBS drives substrate oxidation that has been linked to improvements in metabolic function and improved glycemic control that are potentially mediated by mitochondria-a primary site of energy production. As such, augmentation of intestinal mitochondrial function may drive processes underlying the systemic metabolic benefits of MBS. Herein, we applied a highly sensitive technique to evaluate intestinal mitochondrial function ex vivo in a mouse model of MBS.

METHODS

Mice were randomized to surgery, sham, or non-operative control. A simplified model of MBS, ileal interposition, was performed by interposition of a 2-cm segment of terminal ileum into the proximal bowel 5 mm from the ligament of Treitz. After a four-week recovery period, intestinal mucosa of duodenum, jejunum, ileum, and interposed ileum were assayed for determination of mitochondrial respiratory function. Citrate synthase activity was measured as a marker of mitochondrial content.

RESULTS

Ileal interposition was well tolerated and associated with modest body weight loss and transient hypophagia relative to controls. Mitochondrial capacity declined in the native duodenum and jejunum of animals following ileal interposition relative to controls, although respiration remained unchanged in these segments. Similarly, ileal interposition lowered citrate synthase activity in the duodenum and jejunum following relative to controls but ileal function remained constant across all groups.

CONCLUSION

Ileal interposition decreases mitochondrial volume in the proximal intestinal mucosa of mice. This change in concentration with preserved respiration suggests a global mucosal response to segment specific nutrition signals in the distal bowel. Future studies are required to understand the causes underlying these mitochondrial changes.

"Anti-obesity medications" or "medications to treat obesity" instead of "weight loss drugs" - why language matters - an official statement of the Brazilian Association for the Study of Obesity and Metabolic Syndrome (ABESO) and the Brazilian Society of Endocrinology and Metabolism (SBEM)

Obesity is largely undertreated, in part because of the stigma surrounding the disease and its treatment. The use of the term "weight loss drugs" to refer to medications for the treatment of obesity may contribute to this stigma, leading to the idea that anyone who wants to lose weight could use them and that short-term use, only in the active weight loss phase would be enough. On the contrary, the use of terms such as "medications to treat obesity" or "anti-obesity medications" conveys the idea that the treatment is directed at the disease rather than the symptom. This joint statement by the Brazilian Association for the Study of Obesity and Metabolic Syndrome (ABESO) and the Brazilian Society of Endocrinology and Metabolism (SBEM) intends to alert the press, healthcare professionals and scientific community about the importance of the appropriate use of language, with the aim of improving obesity care.

Challenges and Opportunities in Diagnosis and Management of Cardiometabolic Risk in Adolescents

PURPOSE OF REVIEW

This review aims to elucidate the limitations of diagnosing metabolic syndrome in adolescents as well as challenges and opportunities in the identification and reduction of cardiometabolic risk in this population.

RECENT FINDINGS

There are multiple criticisms of how we define and approach obesity in clinical practice and scientific research, and weight stigma further complicates the process of making and communicating weight-related diagnoses. While the goal of diagnosing and managing metabolic syndrome in adolescents would be to identify individuals at elevated future cardiometabolic risk and intervene to reduce the modifiable component of this risk, there is evidence that identifying cardiometabolic risk factor clustering may be more useful in adolescents than establishing a cutoff-based diagnosis of metabolic syndrome. It has also become clear that many heritable factors and social and structural determinants of health contribute more to weight and body mass index than do individual behavioral choices about nutrition and physical activity. Promoting cardiometabolic health equity requires that we intervene on the obesogenic environment and mitigate the compounding effects of weight stigma and systemic racism. The existing options to diagnose and manage future cardiometabolic risk in children and adolescents are flawed and limited. While striving to improve population health through policy and societal interventions, there are opportunities to intervene at all levels of the socioecological model in order to decrease future morbidity and mortality from the chronic cardiometabolic diseases associated with central adiposity in both children and adults. More research is needed to identify the most effective interventions.

The Relative Value of Anti-Obesity Medications Compared to Similar Therapies

Purpose

To demonstrate a need for improved health insurance coverage for anti-obesity medications (AOMs) by comparing clinical and economic benefits of obesity treatments to covered medications for selected therapeutic areas.

Methods

Using a grey literature search, we identified and prioritized therapeutic areas and treatment analogues for comparison to obesity. A targeted literature review identified clinical and economic outcomes research across the therapeutic area analogues. Associated comorbidities, clinical evidence, indirect costs (ie, absenteeism and productivity loss), and direct medical costs were evaluated to determine the relative value of treating obesity.

Results

Four therapeutic areas/treatment analogues were selected for comparison to obesity: smoking cessation (varenicline), daytime sleepiness (modafinil), migraines (erenumab), and fibromyalgia (pregabalin). Obesity was associated with 17 comorbidities, more than migraine (9), smoking (8), daytime sleepiness (5), and fibromyalgia (2). Economic burden was greatest for obesity, followed by smoking, with yearly indirect and direct medical costs totaling $676 and $345 billion, respectively. AOMs resulted in cost savings of $2586 in direct medical costs per patient per year (PPPY), greater than that for varenicline at $930 PPPY, modafinil at $1045 PPPY, and erenumab at $468 PPPY; pregabalin utilization increased costs by $924 PPPY. AOMs were covered by 10-16% of United States health insurance plans, compared to 45-59% for the four comparators.

Conclusion

Compared to four therapeutic analogues, obesity represented the highest economic burden and was associated with more comorbidities. AOMs provide greater cost savings compared to selected analogues. However, AOMs have limited formulary coverage. Improved coverage of AOMs may increase access to these treatments and may help address the clinical and economic burden associated with obesity and its comorbidities.

The role of bariatric and metabolic surgery in the development, diagnosis, and treatment of endometrial cancer

The obesity pandemic continues to contribute to a worsening burden of disease worldwide. The link between obesity and diseases such as diabetes, cardiovascular disease, and cancer has been well established, yet most patients living with obesity remain untreated or undertreated. Metabolic and bariatric surgery is the most effective and durable treatment for obesity, is safe, and may have a protective benefit with respect to cancer incidence. In this review, an overview of the link between obesity, metabolic surgery, and cancer is discussed with emphasis on indications for endometrial cancer, the malignancy most strongly associated with obesity. Considerable evidence from retrospective and prospective cohort studies supports a decreased risk of endometrial cancer in patients with obesity who undergo bariatric surgery compared with nonsurgical controls. Survivors of endometrial cancer are at increased risk of poor health outcomes associated with obesity, and women with endometrial cancer are more likely to die of cardiovascular disease and other obesity-related illnesses than of the malignancy itself. Recent advances in anticancer drug therapies have targeted pathways that may also be therapeutically altered with metabolic surgery. Metabolic surgery has significant potential to enter the treatment paradigm for endometrial cancer, and gynecologic oncologist visits present an opportunity to identify patients who may benefit the most.

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.

Qualitative inquiry with primary care providers and specialists about adult weight management care and referrals

Obesity is a highly prevalent disease and providers are expected to offer or refer patients for weight management yet increasingly fewer clinical visits address obesity. Challenges to offering care are known but less is known about referrals and how specialists who treat obesity-related comorbidities address care and referrals. This study explored perceptions of primary care providers (PCPs) and specialty providers regarding care and referrals for weight management, specifically referrals to programs in the community setting. A qualitative design was used to interview 33 PCPs (mean age 54 years) and 31 specialists (cardiology, gynecology, endocrinology, and orthopedics [mean age 62 years]) in the USA during 2019. Each interview was conducted by telephone, audio-recorded, and transcribed verbatim. Inductive analysis was used and followed the constant comparative method. Four themes emerged from the data including (a) Clinical guidelines and provider discretion influence obesity care; (b) Facilitators and barriers to discussing weight and small step strategies; (c) Informal referrals are made for weight management in community settings; and (d) Opportunities and challenges for integrating clinical and community services for weight management. Facilitating referrals to effective programs, ideally with a feedback loop could coordinate care and enhance accountability, but education, compliance, and cost issues need addressed. Care may be offered but not be well-aligned with clinical guidelines. Knowledge gaps regarding community programs' offerings and efficacy were evident. Referrals could be systematically promoted, facilitated, and tracked to advance weight management objectives.

Evaluation of a Lifestyle and Weight Management Program Within Rural General Practice

Introduction:

Australia has one of the highest rates of obesity in the developed world. In response to increasing rates of overweight and obesity in rural Australia, one regional primary health network commissioned the development of a multi-faceted weight and lifestyle management program, addressing nutrition, physical activity, and psychological approaches to behavioral change. This study evaluated the success of the program that was implemented in multiple general practices within regional New South Wales.

Methods:

De-identified data were received from 16 general practices that participated in the Murrumbidgee Lifestyle and Weight Management Program (MLWMP). Patient weight outcome and functional status measures were determined using descriptive statistics (SPSS).

Results:

Mean body mass index (BMI) of the 1217 participants was 37.4 kg/m² and 75% of participants were female. Almost 40% of participants who had a BMI ≥ 40 kg/m² had been diagnosed with a mental health condition. Upon completion of the program at 6 months, participants had lost an average of 3.2 kg. Over 31% of participants had lost at least 5% of their initial weight and 40% had reduced their waist circumference by at least 5 cm. Overall health and functional status measures were significantly higher upon program completion. There were significant improvements in quality of life measures regardless of level of weight loss during the program.

Conclusions:

The MLWMP, implemented in general practices within rural and regional Australia, had positive effects on both practices and participants demonstrating the value of intervention programs in primary care. Participants achieved a modest reduction in BMI, waist circumference, and weight. Further work is needed to determine the longer-term success of the program.

Impact of Sustained Weight Loss on Cardiometabolic Outcomes

Obesity increases the risk of developing type 2 diabetes, hypertension, and hyperlipidemia. We sought to determine the impact of obesity maintenance, weight regain, weight loss maintenance, and magnitudes of weight loss on future risk and time to developing these cardiometabolic conditions. This was a retrospective cohort study of adults receiving primary care at Geisinger Health System between 2001 and 2017. Using electronic health records, patients with ≥3-weight measurements over a 2-year index period were identified and categorized. Obesity maintainers (OM) had obesity (body mass index ≥30 kg/m²) and maintained their weight within ±3% from baseline (reference group). Both weight loss rebounders (WLR) and weight loss maintainers (WLM) had obesity at baseline and lost >5% body weight in year 1; WLR regained ≥20% of weight loss by end of year 2 and WLM maintained ≥80% of weight loss. Incident type 2 diabetes, hypertension, and hyperlipidemia, and time-to-outcome were determined for each study group and by weight loss category for WLM. Of the 63,567 patients included, 67% were OM, 19% were WLR, and 14% were WLM. The mean duration of follow-up was 6.6 years (SD, 3.9). Time until the development of electronic health record-documented type 2 diabetes, hypertension, and hyperlipidemia was longest for WLM and shortest for OM (log-rank test p <0.0001). WLM had the lowest incident type 2 diabetes (adjusted hazard ratio [HR] 0.676 [95% confidence interval [CI] 0.617 to 0.740]; p <0.0001), hypertension (adjusted HR 0.723 [95% CI 0.655 to 0.799]; p <0.0001), and hyperlipidemia (adjusted HR 0.864 [95% CI 0.803 to 0.929]; p <0.0001). WLM with the greatest weight loss (>15%) had a longer time to develop any of the outcomes compared with those with the least amount of weight loss (<7%) (p <0.0001). In an integrated delivery network population, sustained weight loss was associated with a delayed onset of cardiometabolic diseases, particularly with a greater magnitude of weight loss.

The Most Undertreated Chronic Disease: Addressing Obesity in Primary Care Settings

PURPOSE OF REVIEW

While obesity-related comorbidities are frequently addressed and treated in primary care (PC), obesity itself is undertreated. We review the current treatments for obesity and provide potential provider and system-level strategies for integrating weight management and improving longer term obesity care within PC settings.

RECENT FINDINGS

We now understand that the body develops multiple mechanisms to resist weight loss and promote weight regain, making both weight loss and weight loss maintenance challenging. Therefore, weight management often requires medically supervised interventions and should be treated on a long-term basis. However, there are multiple barriers to improving obesity care within PC settings. Clinically, utilizing strategies such as a shared decision-making approach and the 5As to discuss treatment options can facilitate formulating an obesity treatment plan. Utilizing telehealth, a team-based approach, and community partnering can increase patient access to intensive behavioral interventions. Future studies should evaluate other cost-effective methods to implement obesity care into the PC setting.

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.

Communicating personalized risk of diabetes and offering weight reduction program choice: Recruitment, participation, and outcomes

OBJECTIVE

Low patient recruitment into diabetes prevention programs is a challenge. The primary aim of this study was to demonstrate that an increased recruitment rate can be achieved by communicating personalized risk of progression to type 2 diabetes, estimating risk reduction with weight loss, and offering program choice. Secondary aims included program participation rate, weight loss, and short-term decreased diabetes risk.

METHODS

In this single-arm study, persons with prediabetes from 3 primary care sites received a letter that communicated their personalized risk of progression to diabetes within 3-years, estimated risk reduction with 5, 10, 15 % weight loss, reported in pounds, and offered a choice of 5 free, 6-month, programs. A one-sided test was used to compare the recruitment rate against the maximum expected rate of (10 %).

RESULTS

Recruitment response rate was 25.3 % (81/328, 95 % CI=[20.0 %, 29.4 %]) which was significantly higher than expected (p < 0.0001). Overall, 65 % of participants completed >75 % of contacts. BMI, HbA1c, and diabetes risk (all p < 0.0001) improved at 6 months; BMI (p < 0.0001) and HbA1c (p < 0.05) improved at 12 months.

CONCLUSION

Recruitment response rate was better than expected.

PRACTICE IMPLICATIONS

Communicating personalized risk and reduction estimates with a choice of programs resulted in favorable outcomes, sustained at 1-year.

Clearing the cobwebs: An analysis of the timing of youth concussion legislation in U.S. states

After decades of ignoring head injury in youth sports, U.S. states passed youth concussion legislation with stipulations about when athletes can return to play. Why were some states slower to pass laws than others? We consider this question through the lens of institutional medicalization, where medically informed policies are enacted. Our study recognizes the uneven nature of policy enactment across time and space with event history methods. We explore the influence of high school sport participation and other variables on the timing of legislation in all fifty states, 2007-2014. States with more high school football participation, as well as states with a strong college football presence, passed concussion laws later. Conversely, states with stronger orientations toward gender egalitarianism adopted laws sooner. These factors reflect sources of receptivity and resistance that underlie the process of institutional medicalization. Our approach offers one of the few quantitative studies of institutional medicalization and provides a template for future quantitative research in this area.