General Hospital Psychiatry 37 (2015) 7–13
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
National evaluation of obesity screening and treatment among veterans with and without mental health disorders Alyson J. Littman, Ph.D. a,b,⁎, Laura J. Damschroder, M.S., M.P.H. c, Lilia Verchinina, Ph.D., M.S. c, Zongshan Lai, M.P.H. c,d, Hyungjin Myra Kim, Sc.D. c,e, Katherine D. Hoerster, Ph.D., M.P.H. f,g, Elizabeth A. Klingaman, Ph.D. h,k, Richard W. Goldberg, Ph.D. h, Richard R. Owen, M.D. i,j, David E. Goodrich, Ed.D. c,d a
VA Puget Sound Healthcare System, Seattle Division Epidemiologic Research and Information Center (ERIC), Seattle, WA, USA Department of Epidemiology, University of Washington, Seattle, WA, USA c Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI, 48105, USA d Department of Psychiatry, University of Michigan Medical School, North Campus Research Complex, 2800 Plymouth Road, Building 16, Ann Arbor, MI, 48109-2800, USA e Center for Statistical Consultation & Research, University of Michigan, Ann Arbor, MI f VA Puget Sound Healthcare System, Seattle Division Mental Health Service g Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA h VA Capitol Health Care Network Mental Illness Research, Education, and Clinical Center, Baltimore, MD i Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, AR j Department of Psychiatry, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR k Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD b
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Article history: Received 1 July 2014 Revised 10 November 2014 Accepted 13 November 2014 Keywords: Obesity Weight management Veterans Serious mental illness Depressive disorder
a b s t r a c t Objective: The objective was to determine whether obesity screening and weight management program participation and outcomes are equitable for individuals with serious mental illness (SMI) and depressive disorder (DD) compared to those without SMI/DD in Veterans Health Administration (VHA), the largest integrated US health system, which requires obesity screening and offers weight management to all in need. Methods: We used chart-reviewed, clinical and administrative VHA data from fiscal years 2010–2012 to estimate obesity screening and participation in the VHA’s weight management program (MOVE!) across groups. Six- and 12-month weight changes in MOVE! participants were estimated using linear mixed models adjusted for confounders. Results: Compared to individuals without SMI/DD, individuals with SMI or DD were less frequently screened for obesity (94%–94.7% vs. 95.7%) but had greater participation in MOVE! (10.1%–10.4% vs. 7.4%). MOVE! participants with SMI or DD lost approximately 1 lb less at 6 months. At 12 months, average weight loss for individuals with SMI or neither SMI/DD was comparable (−3.5 and −3.3 lb, respectively), but individuals with DD lost less weight (mean=−2.7 lb). Conclusions: Disparities in obesity screening and treatment outcomes across mental health diagnosis groups were modest. However, participation in MOVE! was low for every group, which limits population impact. Published by Elsevier Inc.
1. Introduction Obesity rates are remarkably high among individuals with mental health disorders (MHDs) [1,2]. Diabetes, cardiovascular disease, metabolic syndrome and other obesity-related conditions are highly prevalent and thought to partly explain the substantially shortened life ⁎ Corresponding author. VA Puget Sound Healthcare System, Seattle Epidemiologic Research and Information Center (ERIC), 1660 South Columbia Way, S-152-E, Seattle, WA, 98108, USA. Tel.: +1 206 277 4182; fax: +1 206 764 2563. E-mail addresses: [email protected] (A.J. Littman), [email protected] (L.J. Damschroder), [email protected] (L. Verchinina), [email protected] (Z. Lai), [email protected] (H.M. Kim), [email protected] (K.D. Hoerster), [email protected] (E.A. Klingaman), [email protected] (R.W. Goldberg), [email protected] (R.R. Owen), [email protected] (D.E. Goodrich). http://dx.doi.org/10.1016/j.genhosppsych.2014.11.005 0163-8343/Published by Elsevier Inc.
expectancy of individuals with MHD, who die 10–25 years earlier than the general population [3–9]. Multiple patient- and treatmentlevel factors are believed to increase the risk for obesity among people with MHD, including disparities in access and quality of health care [10]; low socioeconomic status and social isolation, limiting access to healthier, nutrient-dense foods and safe exercise facilities [11]; acute psychiatric symptoms that undermine motivation to be physical active [10]; cognitive deficits that reduce attention span, retention of information and compliance with recommendations made by health professionals [12]; and psychopharmacological treatments that cause weight gain and long-term cardiometabolic disturbances [11,13,14]. Despite a reasonably good understanding of the causes of obesity in people with MHDs, we have a limited understanding about how best to intervene on this population [15]. More than three dozen studies of
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A.J. Littman et al. / General Hospital Psychiatry 37 (2015) 7–13
behavioral interventions for weight management in adults with schizophrenia and associated disorders, bipolar disorder and major depressive disorder have been conducted [16–20]. A meta-analysis including 10 studies estimated 3.1 kg (6.9 lb) greater weight loss in the intervention than the control groups [16]. Collectively, these studies demonstrate that individuals with MHDs can lose a clinically important amount of weight, but results were variable. Furthermore, few of the interventions tested in these studies were scalable or were implemented in realworld settings [11]. The Veterans Health Administration (VHA) is the largest integrated US health care provider, caring for over 6 million Veterans each year [21]. Because obesity is so prevalent in Veterans [22,23], VHA began offering a weight management program (MOVE!) in 2006 and strongly encouraged universal screening for obesity and weight management counseling in 2008. As a leader in integrating mental and physical health care in primary care settings, VHA is in a unique position to evaluate the extent to which patients with MHDs participate and benefit from national weight management programs [24]. Thus, the aim of this study was to determine whether (a) obesity screening and weight management program participation, (b) program engagement and (c) weight outcomes are equitable for individuals with serious mental illness (SMI) and depressive disorder (DD), compared to those without SMI/DD, in an integrated health care system that makes these services available to all in need, free of charge.
2. Methods
To assess program engagement and 6- and 12-month weight outcomes, we used a database of all MOVE! participants (Fig. 2). This database includes anthropometric and utilization data for patients with at least one group or one-on-one MOVE! encounter. Data from the EPRP and MOVE! databases were each merged with VHA Corporate Data Warehouse to obtain demographic data, diagnoses [e.g., posttraumatic stress disorder (PTSD), diabetes], smoking status, service era (served in Iraq/Afghanistan wars or not), service-connected disability percentage and facility type (medical center or community-based outpatient clinic). This secondary data analysis was commissioned as a quality improvement project by VHA policymakers and therefore was exempt from institutional review board review per VA policy.
2.2. MOVE! program description The MOVE! weight management program is available in all VHA facilities, free of charge [25,26]. Program curriculum was informed by the National Institutes of Health guidelines for the treatment of obesity [27] and has been updated regularly based on emerging evidence and feedback from the field. Program staff at local VHA facilities have the flexibility to implement MOVE! to best suit available resources and their patient population. Frequently, MOVE! is delivered in a multisession group-based format, but one-on-one in-person and telephone counseling sessions are available, too. Between 2005 and 2010, over 500,000 patients [23] participated in at least one treatment session.
2.1. Study design, population and data sources 2.3. MHD categories We conducted a retrospective cohort study using data from fiscal years 2010–2012 (October 1, 2009, through September 30, 2012). To assess screening and participation, data were obtained for all VHA patients whose electronic medical records were manually abstracted as part of the VHA External Peer Review Program (EPRP, a quality improvement program) during the observation period (Fig. 1 [25]). EPRP comprises annual random samples of VHA patients drawn from more than 900 facilities throughout the United States. Patients at VHA community-based outpatient clinics, women and those with mental health diagnoses are oversampled. Because EPRP involves manual abstraction of text fields from electronic medical records by highly trained personnel, assessments of candidacy for weight management and weight management counseling are more accurate than would be possible with coded administrative data.
Individuals were classified into one of three MHD categories based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes consistent with previous studies [28,29]: (a) SMI: schizophrenia (ICD-9 codes 295.0–295.4, 295.6, 295.7, 295.8, 295.9), bipolar disorder (ICD-9 codes 296.0–296.1 and 296.4–296.8) or other psychotic disorders (ICD-9 codes 297–297.9 and 298–298.9), (b) DD: major depressive disorder (ICD-9 codes 296.2 and 296.3) or other depressive disorders (ICD-9 codes: 293.83, 296.90, 296.99, 300.4, 301.12, 309.0, 309.1, and 311) and (c) neither SMI nor DD diagnosis in the year prior to screening and/or MOVE! participation. Supplementary Table S1 includes detailed descriptions of the diagnoses for each ICD-9 code.
Included in analysis of obesity screening, VHA External Peer Review Program, FY 2010-2012, N=389,777 183,062 Neither SMI/DD 168,826 DD 37,889 SMI Exclusions (N=96,669) 96,669 Not a candidate for weight management (see footnote) 41,429 Neither SMI/DD 44,636 DD 10,604 SMI
Included in analysis of participation in weight management program N=293,108 141,633 Neither SMI/DD 124,190 DD 27,285 SMI Fig. 1. Flow diagram of inclusion/exclusion criteria for obesity screening and participation in weight management analyses. Definitions. Obesity screening: The first step involved documentation of weight and height. For those classified as a MOVE! candidate (defined below), additional requirements for screening were discussion of health risks of obesity and weight management treatment offered OR documentation of weight management program participation within the past year. Candidate for weight management: body mass index ≥30 kg/m2 or ≥25 with an obesity-related condition (diabetes, hypertension, hyper/dyslipidemia, obstructive sleep apnea, degenerative joint disease or metabolic syndrome) or an elevated waist circumference [N40 inches (102 cm) for men or N35 inches (88 cm) for women].
A.J. Littman et al. / General Hospital Psychiatry 37 (2015) 7–13
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>1 MOVE encounter,VHA MOVE! Database, FY 2010-2012*, N=228,390 132,193 Neither SMI/DD 81,711 DD 14,486 SMI Exclusions (N=21,259) 20,361 Age >70 yrs 898 BMI
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
National evaluation of obesity screening and treatment among veterans with and without mental health disorders Alyson J. Littman, Ph.D. a,b,⁎, Laura J. Damschroder, M.S., M.P.H. c, Lilia Verchinina, Ph.D., M.S. c, Zongshan Lai, M.P.H. c,d, Hyungjin Myra Kim, Sc.D. c,e, Katherine D. Hoerster, Ph.D., M.P.H. f,g, Elizabeth A. Klingaman, Ph.D. h,k, Richard W. Goldberg, Ph.D. h, Richard R. Owen, M.D. i,j, David E. Goodrich, Ed.D. c,d a
VA Puget Sound Healthcare System, Seattle Division Epidemiologic Research and Information Center (ERIC), Seattle, WA, USA Department of Epidemiology, University of Washington, Seattle, WA, USA c Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI, 48105, USA d Department of Psychiatry, University of Michigan Medical School, North Campus Research Complex, 2800 Plymouth Road, Building 16, Ann Arbor, MI, 48109-2800, USA e Center for Statistical Consultation & Research, University of Michigan, Ann Arbor, MI f VA Puget Sound Healthcare System, Seattle Division Mental Health Service g Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA h VA Capitol Health Care Network Mental Illness Research, Education, and Clinical Center, Baltimore, MD i Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, AR j Department of Psychiatry, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR k Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD b
a r t i c l e
i n f o
Article history: Received 1 July 2014 Revised 10 November 2014 Accepted 13 November 2014 Keywords: Obesity Weight management Veterans Serious mental illness Depressive disorder
a b s t r a c t Objective: The objective was to determine whether obesity screening and weight management program participation and outcomes are equitable for individuals with serious mental illness (SMI) and depressive disorder (DD) compared to those without SMI/DD in Veterans Health Administration (VHA), the largest integrated US health system, which requires obesity screening and offers weight management to all in need. Methods: We used chart-reviewed, clinical and administrative VHA data from fiscal years 2010–2012 to estimate obesity screening and participation in the VHA’s weight management program (MOVE!) across groups. Six- and 12-month weight changes in MOVE! participants were estimated using linear mixed models adjusted for confounders. Results: Compared to individuals without SMI/DD, individuals with SMI or DD were less frequently screened for obesity (94%–94.7% vs. 95.7%) but had greater participation in MOVE! (10.1%–10.4% vs. 7.4%). MOVE! participants with SMI or DD lost approximately 1 lb less at 6 months. At 12 months, average weight loss for individuals with SMI or neither SMI/DD was comparable (−3.5 and −3.3 lb, respectively), but individuals with DD lost less weight (mean=−2.7 lb). Conclusions: Disparities in obesity screening and treatment outcomes across mental health diagnosis groups were modest. However, participation in MOVE! was low for every group, which limits population impact. Published by Elsevier Inc.
1. Introduction Obesity rates are remarkably high among individuals with mental health disorders (MHDs) [1,2]. Diabetes, cardiovascular disease, metabolic syndrome and other obesity-related conditions are highly prevalent and thought to partly explain the substantially shortened life ⁎ Corresponding author. VA Puget Sound Healthcare System, Seattle Epidemiologic Research and Information Center (ERIC), 1660 South Columbia Way, S-152-E, Seattle, WA, 98108, USA. Tel.: +1 206 277 4182; fax: +1 206 764 2563. E-mail addresses: [email protected] (A.J. Littman), [email protected] (L.J. Damschroder), [email protected] (L. Verchinina), [email protected] (Z. Lai), [email protected] (H.M. Kim), [email protected] (K.D. Hoerster), [email protected] (E.A. Klingaman), [email protected] (R.W. Goldberg), [email protected] (R.R. Owen), [email protected] (D.E. Goodrich). http://dx.doi.org/10.1016/j.genhosppsych.2014.11.005 0163-8343/Published by Elsevier Inc.
expectancy of individuals with MHD, who die 10–25 years earlier than the general population [3–9]. Multiple patient- and treatmentlevel factors are believed to increase the risk for obesity among people with MHD, including disparities in access and quality of health care [10]; low socioeconomic status and social isolation, limiting access to healthier, nutrient-dense foods and safe exercise facilities [11]; acute psychiatric symptoms that undermine motivation to be physical active [10]; cognitive deficits that reduce attention span, retention of information and compliance with recommendations made by health professionals [12]; and psychopharmacological treatments that cause weight gain and long-term cardiometabolic disturbances [11,13,14]. Despite a reasonably good understanding of the causes of obesity in people with MHDs, we have a limited understanding about how best to intervene on this population [15]. More than three dozen studies of
8
A.J. Littman et al. / General Hospital Psychiatry 37 (2015) 7–13
behavioral interventions for weight management in adults with schizophrenia and associated disorders, bipolar disorder and major depressive disorder have been conducted [16–20]. A meta-analysis including 10 studies estimated 3.1 kg (6.9 lb) greater weight loss in the intervention than the control groups [16]. Collectively, these studies demonstrate that individuals with MHDs can lose a clinically important amount of weight, but results were variable. Furthermore, few of the interventions tested in these studies were scalable or were implemented in realworld settings [11]. The Veterans Health Administration (VHA) is the largest integrated US health care provider, caring for over 6 million Veterans each year [21]. Because obesity is so prevalent in Veterans [22,23], VHA began offering a weight management program (MOVE!) in 2006 and strongly encouraged universal screening for obesity and weight management counseling in 2008. As a leader in integrating mental and physical health care in primary care settings, VHA is in a unique position to evaluate the extent to which patients with MHDs participate and benefit from national weight management programs [24]. Thus, the aim of this study was to determine whether (a) obesity screening and weight management program participation, (b) program engagement and (c) weight outcomes are equitable for individuals with serious mental illness (SMI) and depressive disorder (DD), compared to those without SMI/DD, in an integrated health care system that makes these services available to all in need, free of charge.
2. Methods
To assess program engagement and 6- and 12-month weight outcomes, we used a database of all MOVE! participants (Fig. 2). This database includes anthropometric and utilization data for patients with at least one group or one-on-one MOVE! encounter. Data from the EPRP and MOVE! databases were each merged with VHA Corporate Data Warehouse to obtain demographic data, diagnoses [e.g., posttraumatic stress disorder (PTSD), diabetes], smoking status, service era (served in Iraq/Afghanistan wars or not), service-connected disability percentage and facility type (medical center or community-based outpatient clinic). This secondary data analysis was commissioned as a quality improvement project by VHA policymakers and therefore was exempt from institutional review board review per VA policy.
2.2. MOVE! program description The MOVE! weight management program is available in all VHA facilities, free of charge [25,26]. Program curriculum was informed by the National Institutes of Health guidelines for the treatment of obesity [27] and has been updated regularly based on emerging evidence and feedback from the field. Program staff at local VHA facilities have the flexibility to implement MOVE! to best suit available resources and their patient population. Frequently, MOVE! is delivered in a multisession group-based format, but one-on-one in-person and telephone counseling sessions are available, too. Between 2005 and 2010, over 500,000 patients [23] participated in at least one treatment session.
2.1. Study design, population and data sources 2.3. MHD categories We conducted a retrospective cohort study using data from fiscal years 2010–2012 (October 1, 2009, through September 30, 2012). To assess screening and participation, data were obtained for all VHA patients whose electronic medical records were manually abstracted as part of the VHA External Peer Review Program (EPRP, a quality improvement program) during the observation period (Fig. 1 [25]). EPRP comprises annual random samples of VHA patients drawn from more than 900 facilities throughout the United States. Patients at VHA community-based outpatient clinics, women and those with mental health diagnoses are oversampled. Because EPRP involves manual abstraction of text fields from electronic medical records by highly trained personnel, assessments of candidacy for weight management and weight management counseling are more accurate than would be possible with coded administrative data.
Individuals were classified into one of three MHD categories based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes consistent with previous studies [28,29]: (a) SMI: schizophrenia (ICD-9 codes 295.0–295.4, 295.6, 295.7, 295.8, 295.9), bipolar disorder (ICD-9 codes 296.0–296.1 and 296.4–296.8) or other psychotic disorders (ICD-9 codes 297–297.9 and 298–298.9), (b) DD: major depressive disorder (ICD-9 codes 296.2 and 296.3) or other depressive disorders (ICD-9 codes: 293.83, 296.90, 296.99, 300.4, 301.12, 309.0, 309.1, and 311) and (c) neither SMI nor DD diagnosis in the year prior to screening and/or MOVE! participation. Supplementary Table S1 includes detailed descriptions of the diagnoses for each ICD-9 code.
Included in analysis of obesity screening, VHA External Peer Review Program, FY 2010-2012, N=389,777 183,062 Neither SMI/DD 168,826 DD 37,889 SMI Exclusions (N=96,669) 96,669 Not a candidate for weight management (see footnote) 41,429 Neither SMI/DD 44,636 DD 10,604 SMI
Included in analysis of participation in weight management program N=293,108 141,633 Neither SMI/DD 124,190 DD 27,285 SMI Fig. 1. Flow diagram of inclusion/exclusion criteria for obesity screening and participation in weight management analyses. Definitions. Obesity screening: The first step involved documentation of weight and height. For those classified as a MOVE! candidate (defined below), additional requirements for screening were discussion of health risks of obesity and weight management treatment offered OR documentation of weight management program participation within the past year. Candidate for weight management: body mass index ≥30 kg/m2 or ≥25 with an obesity-related condition (diabetes, hypertension, hyper/dyslipidemia, obstructive sleep apnea, degenerative joint disease or metabolic syndrome) or an elevated waist circumference [N40 inches (102 cm) for men or N35 inches (88 cm) for women].
A.J. Littman et al. / General Hospital Psychiatry 37 (2015) 7–13
9
>1 MOVE encounter,VHA MOVE! Database, FY 2010-2012*, N=228,390 132,193 Neither SMI/DD 81,711 DD 14,486 SMI Exclusions (N=21,259) 20,361 Age >70 yrs 898 BMI
