Population-Level Weight Loss Seen With Primary Care Protocol
CHICAGO — Encouraging patients to talk with their primary care physicians about weight management led to increased visits for obesity, population-wide weight loss, and increased revenue, researchers at the University of Colorado Anschutz School of Medicine (CU Anschutz) reported here at the American Diabetes Association (ADA) 85th Scientific Sessions.
The researchers presented data from a 4-year study of the PATHWEIGH protocol, which was implemented at 56 primary care clinics across Colorado. Ultimately, 274,182 patients were part of the study, which has not yet been published.
Although weight loss was low in the intervention group — 0.1 kg at 18 months — the intervention eliminated the typical expected weight gain population-wide. And indeed, that weight gain was about 0.1 kg in those who did not receive the intervention.
"Our data is the first to scale an intervention to more than a quarter of a million people and prevent population weight gain," said Leigh Perreault, MD, associate professor of medicine in the division of endocrinology, metabolism and diabetes at CU Anschutz, who presented the data.
Using a stepped-wedge cluster randomized trial design, researchers randomized clinics to offer usual care or the intervention. Each clinic eventually moved to using the intervention. Patients who received usual care would have visits during which weight could be discussed but clinicians did not have access to PATHWEIGH tools. Those who received the intervention had weight-specific visits and their doctors had access to the protocol.
The Colorado group created PATHWEIGH to help primary care physicians fill the gap in obesity care in the face of growing numbers of overweight and obese Americans.
Patients in the usual care or intervention group were alerted to the opportunity to have a weight-prioritized visit with their primary care physician.
In the intervention group, patients were asked to complete a weight-management questionnaire before the visit, which the physician could then use as a prompt to talk with the patient during the visit. Researchers also provided clinicians with specialized support tools, education, and most importantly, a weight-specific template embedded in the electronic medical record. The template allowed for diagnosis, documentation of a weight-related discussion (for reimbursement), and orders for referrals, tests, and procedures, which streamlined workflow and made it easier to help patients, said Perreault.
Physicians were asked to follow up with patients at least every 4 to 6 weeks.
Use of the tools was optional, however. This meant that patients in the intervention group could get usual care with or without PATHWEIGH.
At baseline, the mean age of patients was 54 years. About 53% were female, and 78% were non-Hispanic White, 11% Latino, 4% Black, and 2% Asian. Two thirds had commercial insurance and about a third were Medicare enrollees. Mean BMI was 31 kg/m2.
At the end of the 4-year study, researchers found only about 25% of patients with a BMI of 25 kg/m2 or more received any discernible care for their weight, said Perreault. Discernible care might include adequate counseling about diet, exercise, and behavioral modification, referral to a dietitian or bariatric surgeon, or prescription of an anti-obesity medication.
More people in the intervention group received such care. Those most likely to receive care had a BMI of at least 25 kg/m2, tended to be closer to age 50, were commercially insured, and were Latino or Black.
However, said Perreault, an A1c in the prediabetes range, an estimated glomerular filtration rate in the stage 2 chronic kidney disease range, or the presence of a weight-related disease or complication did not prompt clinicians to offer help.
Patients who did receive weight-related care during the intervention lost 2.37 kg more than those in the intervention group who received no care. Getting any sort of help with weight management made a difference, even outside the intervention. Those who received usual care offered weight management assistance lost 1.73 kg more than patients in the usual care group who received no care.
Perreault said that providers spent no extra time on weight-prioritized visits and that using weight-related International Classification of Diseases 10 codes added more than $15 million to the health system's revenues over the 4-year study. PATHWEIGH outreach also resulted in "more than twice as many" visits for weight management, she said.
'Monumental' But Not 'Hugely Successful'
"This is monumental work," said Ildiko Lingvay, MD, MPH, MSCS, a professor of internal medicine at University of Texas Southwestern Medical Center, Dallas, who chaired the session during which the study results were presented.
Changing population weight by a pound is "like moving mountains," she said.
However, added Lingvay, "It's not that I think this intervention was hugely successful." She's excited to see how the intervention works as it is adopted by others.
Robert Kushner, MD, MS, a professor of medicine at Northwestern University Feinberg School of Medicine, Chicago, Illinois, offered the Colorado group "a big congratulations."
"This is a really tough nut to crack," said Kushner, who was asked for comment.
"There are significant barriers and challenges to treating obesity in primary care," he said. Many approaches basically remove the primary care physician from the equation by diverting patients to online platforms, coaching, or self-help, or weight-loss programs.
"Embedding" the primary care physician is "the road less taken, to be honest," said Kushner, which PATHWEIGH successfully does. And it is an "innovative program for a healthcare system, population-level approach to the management of obesity."
Looking ahead, the researchers should determine how to increase both clinician and patient engagement, said Kushner. It would also be useful to examine what triggers referrals to other services and to assess clinical outcomes and mediators of weight change, he said.
Lastly, researchers should "determine the use and effectiveness of obesity medications. That's extremely important in the day we live," said Kushner.
The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases. Perreault has disclosed receiving personal fees for speaking and/or consulting from Novo Nordisk, Eli Lilly, Boehringer Ingelheim, Ascendis, Medscape, WebMD, and UpToDate. Lingvay has reported consulting for AbbVie, Altimmune, Amgen, Alveus, Antag Therapeutics, AstraZeneca, Bayer, Betagenon, Bioio, Biomea, Boehringer Ingelheim, Carmot, Cytoki Pharma, Eli Lilly, Intercept, Janssen/J&J, Juvena, Keros Ther, Novo Nordisk, PharmaVentures, Pfizer, Regeneron, Roche, Sanofi, Shionogi, Source Bio, Structure Therapeutics, Target RWE, Terns Pharmaceuticals, The Comm Group, WebMD, and Zealand Pharma. Kushner has reported no conflicts related to PATHWEIGH but disclosed being a board member for Altimmune, Currax, Novo Nordisk, Structure Therapeutics, and Weight Watchers International, and a consultant for Eli Lilly and Regeneron.
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