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CDP 12-252 – HSR&D Study

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CDP 12-252
Improving Weight Management at VA: Enhancing the MOVE!23 for Primary Care (CDA 10-206)
Melanie R. Jay MD MS
Manhattan Campus of the VA NY Harbor Healthcare System, New York, NY
New York, NY
Funding Period: October 2012 - June 2018

BACKGROUND/RATIONALE:
Veterans shoulder a disproportionate burden of obesity and its co-morbidities, and modest weight loss in obese patients through diet and exercise improves health outcomes. The VA currently offers the MOVE! program to treat obesity, but only 9% of eligible patients utilize this consultation service. At the same time, Veterans on average see their Primary Care Providers (PCPs) 3.6 times per year, supporting the importance of developing primary care-based interventions. Interactive behavior change technologies utilizing expert system software programs can facilitate behavior change in primary care. The MOVE!23 software is an expert system program for patients referred to MOVE!, but is not currently used in primary care by PACT. For my CDP, I will use qualitative methods to better understand the optimal use of goal-setting for weight management in an urban VA patient population and use state-of-the-art software evaluation methods to identify ways to enhance the MOVE!23 software to better facilitate goal-setting. I will then use this information to develop a brief intervention to treat obesity in Veterans that utilizes the enhanced MOVE!23 software and PACT to promote goal-setting, behavior change, and weight loss.

OBJECTIVE(S):
The three main objectives of my CDA are to: 1) using qualitative methods, enhance the MOVE!23 software and determine optimal goal setting processes to develop a brief, computer-assisted intervention to treat obesity; 2) determine the feasibility and acceptability of this brief intervention for urban, obese, VA patients within PACT; 3) explore the impact of this brief intervention on intermediate, behavioral, and weight loss outcomes at 3, 6, and 12 months post-intervention.

METHODS:
Based on focus groups (n=56), key informant interviews (n=25), and usability testing of the MOVE!23 questionnaire, we developed the MOVE Towards Your Goals Intervention (MTG).
Pilot test of intervention: Veterans with overweight/obesity and upcoming primary care visits are recruited to participate in MTG through mailings and phone calls. The first 11 Veterans were recruited into a non-randomized pilot test and received the MTG (MOVE Towards Your Goals Intervention) intervention. The pilot test (n=11) informed the development of a pilot randomized controlled trial (RCT).


Pilot RCT: Veterans with a Body Mass Index 30 or 25-29.99 kg/m2 with existing comorbidities were recruited by phone in two phases approximately six months apart, and randomized to MTG or "Enhanced Usual Care (EUC)," a control group. Participants in MTG meet with a health coach to set lifestyle and weight-loss goals and use a tablet-delivered goal-setting tool to facilitate in-person and phone coaching. In Phase 1, patients received baseline counseling immediately prior to their PC visit in order to activate discussion with their doctor. In Phase 2, we changed the protocol so that patient met with the health coach independent of the PC visit in order to facilitate scheduling and recruitment. In both phases, patients in the control met briefly with a coach to receive patient education materials. At baseline, 3, 6, and 12 months, participants were weighed and completed surveys. We assessed differences in outcomes between phase one and two.

FINDINGS/RESULTS:
Non-Randomized Pilot Test of MTG Intervention: We recruited 11 Veterans to participate in the non-randomized pilot study (91% male, 46% Black, 27% White, 27% Hispanic, mean age= 55.36 years (SD=15.10), mean BMI=30.1 kg/m2 (SD=4.47)). Immediately after the baseline health coaching session, 11/11 participants had set lifestyle goals, 8/11 increased or maintained motivation to lose weight, and 11/11 increased or maintained confidence in ability to lose weight. Two participants dropped out of the study and 1 was lost to follow up. At 3 months, a per-protocol analysis found that 8/8 participants engaged in phone coaching (range 2-6 calls, mean of 4 calls). Furthermore, 7/8 participants expressed interest in involvement in intensive weight loss programs at the VA and of those, 1 participant enrolled in and showed continued involvement. Four (50%) participants lost more than 1 kg, 3 of whom (37.5%) had 5% weight loss. Two (25%) stayed within 1 kg of their original weight, and 2 (25%) gained more than 1 kg. The mean weight change was -1.33 kg (SD 5.5).

Pilot RCT of MTG Intervention: 31 Veterans enrolled in phase 1 (mean age 53.48, 63% male, mean BMI 31.71, 54.84% African American, 22.58% White) and 14 enrolled in phase 2 (mean age 56.57, 79% male, mean BMI 30.27, 50% African American, 23.08% Hispanic). Overall, participants in the MTG intervention arm (phase 1 and phase 2 combined, N=21) tended to lose more weight at three-months, six-months and 12-months as compared to EUC (-0.80 ± 1.95 vs. 0.07 ± 2.40; p= 0.07, -1.52±3.05 vs. 0.23 ± 3.64; p=0.08 and-1.02 ± 4.16 vs. 0.74 ± 4.90; p=0.40 for three-, six-, and twelve- months, respectively). There were no statistically significant differences in dietary or physical activity changes between the two groups. Intervention participants also reported higher dietary self-efficacy (4.89 ± 9.02) than control (0.30 ± 13.69) p=0.22.

Conclusion:
The MTG intervention was shown to be feasible and acceptable to patients within the patient-centered medical home model of care at the Veterans Affairs and led to small amounts of weight loss at 12 months A major limitation of this study was that we were underpowered to see statistically significant change in weight loss and other clinically-important outcomes. Future research is needed to test the efficacy and cost-effectiveness.

IMPACT:
This study provided pilot data for two funded randomized controlled trials to test the efficacy of interventions based on the MTG intervention. More specifically, these results led to improvements in the training of both health coaches and primary care physicians at the Veterans Health Administration.

This study informed the development of the following two studies:

1. National Institutes of Health R01: DK111928-01 09/2016-08/2021 $2,740, 895: Testing the Efficacy of a Technology-Assisted Weight Management Intervention within Patient-Centered Medical Homes: The GEM (Goals for Eating and Moving) Study (R01)
Description: This study is testing the intervention (formerly called MTG) in a cluster randomized trial conducted at the Manhattan VA and at Montefiore Medical Center using non-clinician student health coaches

2. VA Health Services Research and Development IIR: HX002119-01A1 06/2017-5/2020 $1,100,000 :Testing the efficacy of a technology-assisted intervention to improve weight management of obese patients within Patient Aligned Care Teams at the VA( IIR )
Description: This study will test the intervention at the Brooklyn VA in a cluster randomized controlled trial using Veteran peer- health coaches)

PUBLICATIONS:

Journal Articles

  1. Perez HR, Nick MW, Mateo KF, Squires A, Sherman SE, Kalet A, Jay M. Adapting a weight management tool for Latina women: a usability study of the Veteran Health Administration's MOVE!23 tool. BMC medical informatics and decision making. 2016 Oct 5; 16(1):128.
  2. Rogers ES, Sherman SE, Malaspina D, Jay M. Prevalence and Predictors of Obesity-Related Counseling Provided by Outpatient Psychiatrists in the United States. Psychiatric services (Washington, D.C.). 2016 Oct 1; 67(10):1156-1159.
  3. Jay M, Mateo KF, Squires AP, Kalet AL, Sherman SE. Military service and other socioecological factors influencing weight and health behavior change in overweight and obese Veterans: a qualitative study to inform intervention development within primary care at the United States Veterans Health Administration. BMC obesity. 2016 Feb 1; 3:5.
  4. Jay M, Chintapalli S, Squires A, Mateo KF, Sherman SE, Kalet AL. Barriers and facilitators to providing primary care-based weight management services in a patient centered medical home for Veterans: a qualitative study. BMC family practice. 2015 Nov 14; 16:167.
  5. Levine DM, Savarimuthu S, Squires A, Nicholson J, Jay M. Technology-assisted weight loss interventions in primary care: a systematic review. Journal of general internal medicine. 2015 Jan 1; 30(1):107-17.
  6. Acosta A, Azzalin A, Emmons CJ, Shuster JJ, Jay M, Lo MC. Improving residents' clinical approach to obesity: impact of a multidisciplinary didactic curriculum. Postgraduate Medical Journal. 2014 Nov 1; 90(1069):630-7.
  7. Jay M, Gutnick D, Squires A, Tagliaferro B, Gerchow L, Savarimuthu S, Chintapalli S, Shedlin MG, Kalet A. In our country tortilla doesn't make us fat: cultural factors influencing lifestyle goal-setting for overweight and obese Urban, Latina patients. Journal of health care for the poor and underserved. 2014 Nov 1; 25(4):1603-22.
  8. Gerchow L, Tagliaferro B, Squires A, Nicholson J, Savarimuthu SM, Gutnick D, Jay M. Latina food patterns in the United States: a qualitative metasynthesis. Nursing Research. 2014 May 1; 63(3):182-93.
  9. Jay MR, Chintapalli S, Oi K, Squires A, Sherman S, Kalet A. Identifying barrier and facilitators to improving the implementation of weight management services within a patient-centered medical home. Journal of general internal medicine. 2014 Apr 25; 29(Supplement 1):S115.
  10. Jay MR, Mateo KM, Horne M, Squires A, Kalet A, Sherman S. "In the military, your body and your life aren't your own": Unique factors influencing health behavior change in overweight and obese veterans. Journal of general internal medicine. 2014 Apr 25; 29(Supplement 1):S3.
  11. Perez HR, Nick MW, Mateo KM, Sherman S, Kalet A, Jay MR. "None of them apply to me": A usability study of the VA's MOVE!23 online weight management software in Latina Women. Journal of general internal medicine. 2014 Apr 23; 29(Supplement 1):S4.
  12. Creighton S, Jay MR. Are Non-Nutritive Sweetened Beverages Comparable to Water in Weight Loss Trials. Journal of clinical outcomes management : JCOM. 2014 Jan 1; 21(11):490-2.
  13. Gutnick D, Reims K, Davis C, Gainforth H, Jay MR, Cole S. Brief Action Planning to Facilitate Behavior Change and Support Patient Self-Management. Journal of clinical outcomes management : JCOM. 2014 Jan 1; 21(1):17-29.
  14. Levine D, Jay MR. Another Win for Veggies - Article Review. Journal of clinical outcomes management : JCOM. 2014 Jan 1; 21(5):207-9.
  15. Mateo KF, Jay MR. Access to a Behavioral Weight Loss Website With or Without Group Sessions Increased Weight Loss in Statewide Campaign - Article Review. Journal of clinical outcomes management : JCOM. 2014 Jan 1; 21(8):345-8.
  16. Perez H, Jay MR. Good Midlife Dietary Habits May Increase Likelihood of Healthy Aging - Article Review. Journal of clinical outcomes management : JCOM. 2014 Jan 1; 21(3):105-9.
Conference Presentations

  1. Jay MR, Chintapalli S, Squires A, Sherman S, Kalet A. How communication, roles, and outcome expectancy affect obesity counseling and practices within primary care at the VA (Health Services Research Section Poster Excellence Award). Poster session presented at: Obesity Society Annual Scientific Meeting; 2014 Oct 1; Boston, MA.
  2. Jay MR, Mateo KF, Squires A, Kalet A, Sherman S. Identifying unique factors influencing health behavior change in overweight and obese veterans to inform intervention development in primary care at the VA (Health Services Research Section Poster Excellence Award). Presented at: Obesity Society Annual Scientific Meeting; 2014 Oct 1; Boston, MA.
  3. Jay MR, Chintapalli S, Oi K, Squires A, Sherman S, Kalet A. Identifying barrier and facilitators to improving the implementation of weight management services within a patient-centered medical home. Presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 25; San Diego, CA.
  4. Jay MR, Mateo KF, Horne M, Squires A, Kalet A, Sherman S. "In the military, your body and your life aren’t your own": Unique factors influencing health behavior change in overweight and obese veterans. Presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 25; San Diego, CA.
  5. Perez HR, Nick MW, Mateo KF, Sherman S, Kalet A, Jay MR. "None of them apply to me": A usability study of the VA’s MOVE!23 online weight management software in Latina Women. Presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 23; San Diego, CA.


DRA: Diabetes and Related Disorders
DRE: Treatment - Observational, Technology Development and Assessment
Keywords: Career Development
MeSH Terms: none