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IIR 05-121 – HSR&D Study

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IIR 05-121
Obesity Care Practices in the Veterans Health Administration
Polly Hitchcock Noel PhD MA BA
South Texas Health Care System, San Antonio, TX
San Antonio, TX
Funding Period: April 2006 - June 2010

BACKGROUND/RATIONALE:
Obesity is associated with substantial morbidity and is a modifiable risk factor for a variety of chronic illnesses, including several leading causes of death. Most clinical practice guidelines are based on carefully controlled trials with highly motivated subjects. Little research has documented the extent to which obesity is routinely managed or the types of care that are provided to obese patients in clinical practice.

OBJECTIVE(S):
1) Describe variations in obesity care practices in the VHA and examine system, provider, and patient level factors that predict these variations; 2) examine the impact of obesity care practices on weight and clinical outcomes; 3) identify longitudinal patterns of weight trends and predictors of latent class membership; and 4) examine the impact of obesity on outcomes for patients hospitalized for sepsis and/or pneumonia.

METHODS:
This retrospective cohort study utilized VHA clinical and administrative databases from Fiscal Years (FY) 2002-FY2006. Participants were veterans from one of six geographically dispersed VISNs who met the following inclusion criteria: primary care in FY2002; baseline body mass index (BMI) greater than or equal to 30 mg/k2, based upon heights and weights; survival through FY2006; and active care, defined as 1 or more visits in at least 3 of the 4 follow-up years (FY2003-FY2006). Obesity care included: provider recorded diagnosis for patients with a BMI > 30, and obesity treatments [outpatient visits for nutrition, exercise, or weight management; weight loss medications; and bariatric surgery]. Additional analyses compared clinical outcomes in obese/non-obese veterans who developed sepsis and/or pneumonia from FY2002-2006.

FINDINGS/RESULTS:
Among obese patients that survived and received active care in FY2003-2006 (N=264,667), 53.5% had a diagnosis of obesity recorded in the electronic medical record, 34.1% received obesity-related education, 0.4% received weight loss medications, and 0.2% had bariatric surgery. Although better than or comparable to rates reported in the private sector, 46.5% of patients did not have recorded obesity diagnoses when warranted. Obesity-related counseling that was more intense or sustained was significantly associated with greater increases in 5-year BMI compared to no counseling, or counseling that was limited or irregular. This finding was especially pronounced among veterans who were primarily in their 50s and 60s, compared to the oldest veterans. In contrast, the youngest veterans (age 18-35) were least likely to lose weight and their BMI tended to increase regardless of counseling intensity and duration. Alternate treatment strategies or modalities may be needed to combat increasing weight trajectories among veterans who are already obese. Although obesity was not associated with clinical outcomes for veterans hospitalized with pneumonia, obese patients had lower rates of mortality compared to normal patients with sepsis.

IMPACT:
These findings regarding the routine management of obese patients FY2002-2006 will be helpful in evaluating the future success of the VHA's comprehensive, stepped care program to combat obesity, which was implemented in FY2006. As the program expands, significantly more overweight and obese veterans should benefit from its evidence-based practices. Periodic documentation of heights and weights is recommended for identifying obese patients and monitoring obesity's course or response to treatment; this will have implications for health services research and quality monitoring.

PUBLICATIONS:

Journal Articles

  1. Noël PH, Wang CP, Bollinger MJ, Pugh MJ, Copeland LA, Tsevat J, Nelson KM, Dundon MM, Hazuda HP. Intensity and duration of obesity-related counseling: association with 5-Year BMI trends among obese primary care patients. Obesity (Silver Spring). 2012 Apr 1; 20(4):773-82.
  2. Copeland LA, Pugh MJ, Hicks PB, Noel PH. Use of obesity-related care by psychiatric patients. Psychiatric services (Washington, D.C.). 2012 Mar 1; 63(3):230-6.
  3. Noël PH, Copeland LA, Perrin RA, Lancaster AE, Pugh MJ, Wang CP, Bollinger MJ, Hazuda HP. VHA Corporate Data Warehouse height and weight data: opportunities and challenges for health services research. Journal of rehabilitation research and development. 2010 Nov 9; 47(8):739-50.
  4. Noël PH, Copeland LA, Pugh MJ, Kahwati L, Tsevat J, Nelson K, Wang CP, Bollinger MJ, Hazuda HP. Obesity diagnosis and care practices in the Veterans Health Administration. Journal of general internal medicine. 2010 Jun 1; 25(6):510-6.
VA Cyberseminars

  1. Noel PH, Copeland LA. Using VA Corporate Data Warehouse to Assess Vitals. [Cyberseminar]. 2011 Mar 1.
  2. Noel PH, Copeland LA. VIReC Database and Methods Cyberseminar: Using VA corporate data warehouse to assess vitals. [Cyberseminar]. 2010 Mar 1.
Conference Presentations

  1. Hoerster K, Lai Z, Littman AJ, Damschroder l, Klingaman E, Nelson KM, Kilbourne A. Comparison of weight outcomes for Veterans with and without PTSD enrolled in VA's national weight management program. Poster session presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2013 Mar 20; San Francisco, CA.
  2. Noel PH, Wang C, Bollinger M, Pugh MJ, Copeland LA, Hazuda HP. Intensity and Duration of Obesity-Related Counseling: Association with 5-Year BMI Trends. Poster session presented at: AcademyHealth Annual Research Meeting; 2011 Jun 13; Seattle, WA.
  3. Noel PH, Copeland LA, Pugh MV, DeLeon C, Lee S, Kahwati LC, Tsevat J, Nelson KM, Arterburn D, Dundon M. Obesity care practices in the Veterans Health Administration. Poster session presented at: VA HSR&D National Meeting; 2009 Feb 11; Baltimore, MD.
  4. Noel PH. Obesity care practices in the VHA: Documentation of heights, weights, & obesity diagnoses. Invited speaker for Obesity: Causes, consequences & care in the VA integrated health system (panel). Paper presented at: AcademyHealth Annual Research Meeting; 2008 Jun 1; Washington, DC.
  5. Perrin, Bates, Noel, Copeland, Lancaster. National clinical data for VA research: The VA Corporate Data Warehouse. Paper presented at: VA HSR&D National Meeting; 2008 Feb 11; Baltimore, MD.


DRA: Health Systems
DRE: Treatment - Observational, Prevention
Keywords: Behavior (provider), Obesity, Practice patterns
MeSH Terms: none

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