Abstract
BackgroundObesity is a major risk factor behind some of the most common problems encountered in primary care. Although effective models for obesity treatment have been developed, the ‘reach’ of these interventions is poor and only a small fraction of primary care patients receive evidence-based treatment. The purpose of this study is to identify factors that impact the uptake (reach) of an evidence-based obesity treatment program within the context of a pragmatic cluster randomized controlled trial comparing three models of care delivery.MethodsRecruitment and reach were evaluated by the following measures: 1) mailing response rates, 2) referral sources among participants contacting the study team, 3) eligibility rates, 4) participation rates, and 5) representativeness based on demographics, co-morbid conditions, and healthcare utilization of 1432 enrolled participants compared to > 17,000 non-participants from the clinic-based patient populations. Referral sources and participation rates were compared across study arms and level of clinic engagement.ResultsThe response rate to clinic-based mailings was 13.2% and accounted for 66% of overall program recruitment. An additional 22% of recruitment came from direct clinic referrals and 11% from media, family, or friends. Of those screened, 87% were eligible; among those eligible, 86% enrolled in the trial. Participation rates did not vary across the three care delivery arms, but were higher at clinics with high compared to low provider involvement. In addition, clinics with high provider involvement had a higher rate of in clinic referrals (33% versus 16%) and a more representative sample with regards to BMI, rurality, and months since last clinic visit. However, across clinics, enrolled participants compared to non-participants were older, more likely to be female, more likely to have had a joint replacement but less likely to have CVD or smoke, and had fewer hospitalizations.ConclusionsA combination of direct patient mailings and in-clinic referrals may enhance the reach of primary care behavioral weight loss interventions, although more proactive outreach is likely necessary for men, younger patients, and those at greater medial risk. Strategies are needed to enhance provider engagement in referring patients to behavioral weight loss programs.Trial registrationclnicialtrials.gov NCT02456636. Registered May 28, 2015, https://www.clinicaltrials.gov/ct2/results?cond=&term=RE-POWER&cntry=&state=&city=&dist=.
Highlights
Obesity is a major risk factor behind some of the most common problems encountered in primary care
In a review of 19 behavioral obesity trials conducted across various community and clinical settings, only 2 reported participation rates and 1 reported on the representativeness of the study sample, none of which were conducted in primary care clinics [16]
Clinics were randomized to one of three care delivery models: 1) individual face-to-face 15-min office visits modeled after the fee-for-service provision for the Centers for Medicaid and Medicare Intensive Behavior Therapy, [21] 2) 60-min group visits conducted after hours within the local practice modeled after patientcentered medical home standards (PCMH) that emphasize coordinated, comprehensive care with enhanced access, [22] and 3) 60-min group conference call visits conducted centrally modeled after a disease management approach (DM)
Summary
Obesity is a major risk factor behind some of the most common problems encountered in primary care. Primary care remains an underutilized yet important resource for patients with obesity who need assistance with weight loss [1,2,3]. This is especially the case for patients in underserved areas such as rural or other low socioeconomic communities where access to evidencebased programs are lacking [4,5,6]. Systematic reviews of obesity treatment trials in primary care settings have concluded they result in sustained modest weight loss, [7, 8] the reach of such interventions, including the proportion and representativeness of patients who participate, is largely unknown [9]. In a review of 19 behavioral obesity trials conducted across various community and clinical settings, only 2 reported participation rates and 1 reported on the representativeness of the study sample, none of which were conducted in primary care clinics [16]
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