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2023 HSR&D/QUERI National Conference Abstract

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1126 — Factors influencing why patients with spinal cord injury may be overlooked for obesity screening in the Veterans Health Administration

Lead/Presenter: Andrea Nevedal,  COIN - Palo Alto
All Authors: Nevedal AL (Center for Innovation to Implementation, VA Palo Alto Health Care System), Wu J (Center for Innovation to Implementation, VA Palo Alto Health Care System) LaVela S (Center of Innovation for Complex Chronic Care, VA Edward Hines Jr; Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University) Sox-Harris A (Center for Innovation to Implementation, VA Palo Alto Health Care System; Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine) Frayne S (Center for Innovation to Implementation, VA Palo Alto Health Care System; Department of Medicine, Stanford University School of Medicine) Arnow K (Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine) Barreto N (Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine) Davis K (Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine) Eisenberg E (Center for Innovation to Implementation, VA Palo Alto Health Care System; Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine)

Objectives:
Although annual obesity screening using body mass index (BMI) is mandated by the United States Veterans Health Administration (VHA) guidelines, our recent study found that 37.9% of patients with Spinal Cord Injury (SCI) did not receive annual obesity screening and facilities had highly variable rates of missing screenings, which ranged from 11.1% to 75.7%. The factors influencing lower rates of obesity screening among patients with SCI are not well described in the literature to date. To address knowledge gaps, we sought to identify and explain factors influencing reduced rates of obesity screening for patients with SCI in VHA.

Methods:
We used VHA administrative data to identify a purposeful stratified sample of SCI healthcare providers and patients with SCI from SCI facilities with low, improving, and high rates of obesity screenings across VHA. We conducted semi-structured interviews with providers and patients to understand experiences with obesity screenings, including height/weight measurement, use of BMI, and causes of missing data. We performed rapid qualitative data analysis, a systematic yet streamlined approach, using directed content analysis. Specifically, detailed interview notes were immediately coded into a Microsoft Excel matrix that was organized by interview guide domains, and then the matrix data were analyzed for salience and participant group differences.

Results:
Participants included 36 providers (physicians, nurse practitioners, registered nurses) and 37 patients (35% women, 41% non-white). Providers explained that obesity screenings were a lower priority compared to other health conditions deemed more concerning (“There’s a lot more to think about in the SCI world than simply a BMI being elevated”) and that they preferred visual assessments over BMI thresholds to detect obesity in persons with SCI. Provider, patient, and system-level barriers to obtaining weight and height among patients with SCI were also identified, such as insufficient equipment to obtain weight and height in clinics (“Should have a scale to weigh the chair”), staffing shortages limiting opportunities for transfers during weight measurement (“I’m the only nurse in clinic”), measurement and documentation errors (“An issue with what is on the bed at the time), patient preferences not to be screened for obesity (“It’s a sensitive topic for me”), reduced access to screenings (“Haven’t been there in 3 years”), and lack of guidance specific to this population (“Don’t know when height was checked”).

Implications:
Barriers to obesity screenings exist for patients with SCI receiving care in VHA. Provider and patient interviews suggest possible solutions to facilitate inclusive care, including standardizing height and weight measurement processes and documentation for individuals with SCI, updating guidelines and providing provider and patient education to clarify whether to use standard or SCI-specific BMI thresholds, ensuring that SCI clinics are equipped with appropriate equipment and staffing to measure height and weight, and increasing access to supportive services and equipment for patients with SCI.

Impacts:
As part of VHA’s ongoing efforts to grow as a learning health system, it is critical to take lessons learned in this study about obesity screening to ensure individuals with SCI have access to preventative and equitable health care.