Mail and phone interventions for weight loss in a managed-care setting: weigh-to-be 2-year outcomes.

OBJECTIVE: Evaluate effectiveness of weight-loss interventions in a managed care setting. METHODS: Three-arm randomized clinical trial: usual care, mail, and phone intervention. Participants were 1801 overweight managed care organization (MCO) members. Measures included baseline height, weight at baseline and 24 months, self-reported weight at 18 months. Intervention and participation in other weight-related programs was monitored across 24 months. RESULTS: Weight losses were 2.2, 2.4, and 1.9 kg at 18 months in the mail, phone, and usual care groups, respectively. Mail and phone group weight changes were not significantly different from usual care (P<0.35). Weight losses at 24 months did not differ by condition (0.7 kg mail, 1.0 kg phone, and 0.6 kg usual care, P=0.55). Despite treatment availability over 24 months, participation diminished after 6 months. Participation was a significant predictor of outcomes in the mail and phone groups at 18 months and the mail group at 24 months. Cost-effectiveness of phone counseling was $132 per 1 kg of weight loss with mail and usual care achieving similar cost-efficiency of $72 per 1 kg of weight loss. CONCLUSION: Although mail- and phone-based weight-loss programs are a reasonably efficient way to deliver weight-loss services, additional work is needed to enhance their short- and long-term efficacy.

The comparative and cumulative effects of a dietary restriction and exercise on weight loss.

OBJECTIVE: To assess the independence of changes made in diet and physical activity for weight loss; and, to examine the comparative and cumulative effects of these behavioral changes on weight loss outcomes. DESIGN: The observational study is based on longitudinal data collected from 674 women and 288 men enrolled in a 2-year weight loss program introduced into a managed care setting. MEASUREMENTS: The outcome variable was body mass index (BMI) change from baseline to 2-year follow-up. Primary independent variables were changes in physical activity and dietary fat intake, assessed as continuous measures using the Paffenbarger Physical Activity Questionnaire and Block Fat Screener Questionnaire, respectively. Two-way ANCOVA was used to assess the relative effect on BMI of behavioral changes. RESULTS: Study results showed no preference for diet or physical activity change as a weight loss strategy. For both genders, the relationship between the two behaviors was synergistic rather than compensatory. Examination of the comparative benefits of behavioral changes indicated that, for women and men, restricting fat intake was more effective than increasing exercise for weight loss. While fat restrictions alone contributed to weight loss in both genders, exercise alone provided weight loss benefits to men, only. The cumulative effect of weight loss behaviors varied by gender. In women, an interaction was observed. The response of weight to fat restriction was greater among those who increased their exercise moderately or substantially. In men, there was no interaction; exercise increases helped to offset weight gain or provided small weight loss benefits at all levels of dietary fat change. CONCLUSION: Dietary changes appeared to be more effective than increased physical activity for weight loss. For women, the cumulative effect of concomitant changes in diet and exercise on weight loss was more than additive.

Weight loss goals and treatment outcomes among overweight men and women enrolled in a weight loss trial.

Participants in weight loss programs typically set unrealistically high weight loss goals that some believe are detrimental to success. This study examined outcomes associated with goal and ideal body mass index (BMI). Participants (N=1801) were enrolled in a weight loss trial comprised of low-intensity mail or telephone interventions vs usual care. Goal and ideal weight losses were assessed by asking participants how many pounds they expect to lose in the program (goal) and how much they would like to weigh (ideal). Goal and ideal weight losses were unrealistically high (men: -16 and -19%, women: -21 and -27%). For women, less realistic goals were associated with greater weight loss at 24 months. Goals were not associated with participation or weight loss for men. Results are more supportive of the idea that higher goals motivate women to lose weight than of the hypothesis that high goals undermine effort.

Binge eating disorder, weight control self-efficacy, and depression in overweight men and women.

OBJECTIVE: To examine binge eating, depression, weight self-efficacy, and weight control success among obese individuals seeking treatment in a managed care organization. DESIGN: Gender-stratified analyses of associations between binge eating, depression, weight self-efficacy, and weight change, using data from a randomized clinical trial that compared low-cost telephone-based, mail-based, and usual care interventions for weight loss. SUBJECTS: A total of 1632 overweight individuals (460 men, 1172 women; mean age: 50.7 y; mean body mass index: 34.2 kg/m(2)) were recruited from a large Midwestern US managed care organization. MEASUREMENTS: Height and weight were measured by study personnel at baseline, and self-reported weight was assessed at 6 and 12 months; self-reported depression status, binge eating, and self-efficacy for weight control were assessed at baseline. RESULTS: Lifetime prevalence rates for depression and probable binge eating disorder were high. Weight self-efficacy was inversely related to weight in both men and women. For women, depression was associated with lower weight self-efficacy and higher body weight. Women reporting depression or lower weight self-efficacy at baseline had less weight loss success at 6 and 12 months. Depression, binge eating disorder, and weight self-efficacy were not significantly associated with weight loss success in men. CONCLUSION: Negative emotional states are highly prevalent and predict poor treatment outcomes, particularly for obese women. As obese women with clinical depression typically are excluded from intervention studies, further research on how to address the intersection of obesity intervention and mood management may be warranted.

Mail and phone interventions for weight loss in a managed-care setting: Weigh-To-Be one-year outcomes.

OBJECTIVE: To describe methods, recruitment success, and 1-y results of a study evaluating the effectiveness of phone- and mail-based weight-loss interventions in a managed care setting. DESIGN: Randomized clinical trial with three groups, that is, usual care, mail intervention, and phone intervention. SUBJECTS: In total, 1801 overweight members of a managed-care organization (MCO). MEASUREMENTS: Height, weight, medical status, and weight-loss history were measured at baseline. Participation in intervention activities was monitored for 12 months in the two active treatment groups. Self-reported weight was obtained at 6 and 12 months. RESULTS: More individuals assigned to mail treatment started it (88%) than did those assigned to phone treatment (69%). However, program completion rates were higher in the phone (36%) than mail (7%) intervention. The mean weight losses were 1.93, 2.38, and 1.47 kg at 6 months in the mail, phone, and usual care groups, respectively. The differences between the phone and usual care groups were statistically significant. The mean weight losses at 12 months did not differ by treatment group (2.28 kg mail, 2.29 kg phone, and 1.92 kg usual care). Greater weight loss was seen in men, older participants, and those with no prior experience in a weight-loss program. Heavier participants and those who reported current treatment for depression lost less weight. CONCLUSION: Although mail- and phone-based weight-loss programs can be delivered to large numbers of people in an MCO setting, additional work is needed to enhance their clinical efficacy as well as to assess their costs.

Physical inactivity and short-term all-cause mortality in adults with chronic disease.

OBJECTIVE: To ascertain the relationship of physical inactivity and short-term all-cause mortality in a prospective cohort of randomly selected managed care organization members aged 40 years and older who have multiple chronic diseases. METHODS: Clinical databases were used to identify all health plan members aged 40 years and older with 2 or more chronic health conditions (hypertension, coronary heart disease, diabetes mellitus, or dyslipemia) in 1994. A random sample of 2336 members was surveyed by mail and telephone interview regarding their health-related behaviors. Survey data were linked to mortality data from the 1995 to 1997 Minnesota Death Index. Cox proportional hazards regression was used to ascertain the association between physical inactivity and subsequent all-cause mortality, adjusting for potential confounders. RESULTS: Members who reported less than 30 minutes a week of physical activity at baseline had a subsequent mortality risk ratio of 2.82 (P<.001) vs those with 30 or more minutes of physical activity a week. Increased mortality risk persisted (mortality risk ratio, 2.15; P<.001) after adjustments for age, sex, current smoking, functional impairment, and comorbidity score. CONCLUSIONS: In adults with chronic diseases, the physically inactive had higher observed mortality within a 42-month period. If physical inactivity reflects an independent mortality risk, efforts to maintain physical activity in such patients may yield significant clinical benefits within a short period. By contrast, if inactivity is primarily a proxy for other factors that elevate mortality risks, a simple physician inquiry regarding inactivity may help to identify patients at risk of death.

Professional advice and readiness to change behavioral risk factors among members of a managed care organization.

OBJECTIVE: To ascertain factors related to readiness to change behavioral risk factors in members of a managed care organization (MCO). STUDY DESIGN: Cross-sectional study. PATIENTS AND METHODS: A telephone survey reached 4667 (73%) of 6409 adult members of a Minnesota MCO attending 2 primary care clinics. Of these, 3826 members (82%) completed an interview designed to identify behavioral risk factors (smoking, consuming a high-fat diet, and physical inactivity) and readiness to change these behaviors. RESULTS: Among MCO members consuming a high-fat diet, those most ready to change were older, were women, used more preventive services, and reported receiving professional advice about diet. For physical inactivity, those most ready to change were younger, women, and more educated; used more preventive services; and reported receiving professional advice about physical activity. Among smokers, those with higher readiness to change smoked fewer than 15 cigarettes a day, had higher self-efficacy, had no other smokers in the household, and reported receiving professional advice about smoking. After controlling for demographic variables and for use of preventive services, greater readiness to change for smoking (beta = 0.336, odds ratio [OR] = 1.40, P = .056), physical activity (beta = 0.651, OR = 1.92, P < .001), and diet (beta = 0.532, OR = 1.70, P < .001) was associated with having received professional advice to change these behaviors. CONCLUSIONS: Levels of readiness to change behaviors in MCO members who smoke, are inactive, or consume high-fat diets are similar to those reported in other populations. The association of professional advice to change behaviors with increased readiness to change for smoking, physical activity, and diet suggests that receiving professional advice on these topics might assist patients in changing adverse health-related behaviors.

Health promotion programs, modifiable health risks, and employee absenteeism.

This literature review demonstrates that the health risks and failure of employees to participate in fitness and health promotion programs are associated with higher rates of employee absenteeism. When determining how to manage absenteeism, employers should carefully consider the impact that health promotion programs can have on rates of absenteeism and other employee-related expenses.

Screening for diabetes mellitus in high-risk patients: cost, yield, and acceptability.

CONTEXT: Although universal screening for diabetes mellitus is generally not recommended, recent reports suggest that screening individuals with multiple diabetes risk factors may be worthwhile. Little is known about the cost, yield, or acceptability of this kind of screening. PRACTICE PATTERN EXAMINED: Screening of high-risk patients for diabetes mellitus using a two-step, glucose-based screening protocol: Patients were initially screened with a random glucose test; those with abnormal results received a follow-up fasting, 2-hour, 75-gram oral glucose tolerance test. CLINIC SELECTION: Three volunteer clinics from a large medical group in Minnesota. PATIENT SELECTION: Of 38,989 adults receiving care at the three clinics, we identified 1548 high-risk patients with evidence of both dyslipidemia and hypertension in laboratory and administrative databases. Many of these 1548 patients were not eligible for screening: Twenty-five percent already had diagnosed diabetes; 41% had been screened for diabetes in the past year; and 3% had died, disenrolled, or changed clinics before screening commenced. The remaining 30% (n = 469) were invited for diabetes screening. RESULTS: Of the 469 high-risk patients invited, 206 (44%) initiated screening; 176 (38%) completed diabetes screening. Five new patients with diabetes were identified in this high-risk group (one from the random glucose test and four from the glucose tolerance test). One new patient with diabetes was identified for every 40 high-risk patients screened. The program cost $4064 per new case of diabetes identified (screening costs alone). CONCLUSION: In this high-risk managed care population, the yield and acceptability of systematic diabetes screening were low, and the costs were relatively high. The acceptability of office-based diabetes screening may be improved by using a one-step screening test, such as glycosylated hemoglobin, during routine visits.

The role of the certified diabetes educator in telephone counseling.

PURPOSE: This paper describes a telephone-based, outcomes-focused approach to diabetes education provided by certified diabetes educators (CDEs). METHODS: Random chart audits were conducted to evaluate the scope of practice and effectiveness of telephone-based interventions provided by CDEs to people with diabetes. Four case studies and a sample prevention case are used to illustrate the role of telephone-based CDEs in providing diabetes education. RESULTS: Counseling provided by CDEs helped to identify potential barriers and strategies for making lifestyle behavioral changes. CONCLUSIONS: Telephone-based counseling is a brief, effective, ongoing intervention that gives patients with diabetes immediate access to CDEs who provide education to support lifestyle behavioral changes.

Relationship between modifiable health risks and short-term health care charges.

CONTEXT: If physical inactivity, obesity, and smoking status prove to contribute significantly to increased health care charges within a short period of time, health plans and payers may wish to invest in strategies to modify these risk factors. However, few data are available to guide such resource allocation decisions. OBJECTIVE: To examine the relationship of modifiable health risks to subsequent health care charges after controlling for age, race, sex, and chronic conditions. DESIGN, SETTING, AND PARTICIPANTS: Cohort study of a stratified random sample of 5689 adults (75.5% of total sample of 7535) aged 40 years or older who were enrolled in a Minnesota health plan and completed a 60-item questionnaire. MAIN OUTCOME MEASURE: Resource use as measured by billed health care charges from July 1, 1995, to December 31, 1996, compared by health risk (physical activity, body mass index [BMI], and smoking status). RESULTS: The mean annual per patient charge in the total study population was $3570 (median, $600), and 15% of patients had no charges during the study period. After adjustment-for age, race, sex, and chronic disease status, physical activity (4.7% lower health care charges per active day per week), BMI (1.9% higher charges per BMI unit), current smoking status (18% higher charges), and history of tobacco use (25.8% higher charges) were prospectively related to health care charges over 18 months. Never-smokers with a BMI of 25 kg/m2 and who participated in physical activity 3 days per week had mean annual health care charges that were approximately 49% lower than physically inactive smokers with a BMI of 27.5 kg/m2. CONCLUSIONS: Our data suggest that adverse health risks translate into significantly higher health care charges within 18 months. Health plans or payers seeking to minimize health care charges may wish to consider strategic investments in interventions that effectively modify adverse health risks.

Obesity, fitness, willingness to communicate and health care costs.

BACKGROUND: Obesity and low levels of physical fitness are independently associated with a variety of diseases and disorders. These conditions are modifiable and affect health care utilization. The degree to which these health risks are modifiable is directly related to the readiness of individuals to change the underlying behaviors. This study analyzes the relationship between health care costs, obesity, physical fitness, and willingness to communicate. In addition, we tested the hypothesis that willingness to communicate is directly associated with an individual's readiness to change behavior. METHODS: Multiple regression was used to estimate the relationship between adverse behavioral health outcomes, willingness to communicate, and annualized health care costs incurred over a period of 33 months before the completion of a health risk assessment survey in an employed population enrolled in a Midwestern managed care organization (N = 8822). RESULTS: High body mass index (BMI), low physical fitness (predicted VO2max), and greater willingness to communicate were directly and significantly (P < 0.05) associated with higher health care costs. Relative to low-risk, annualized health care costs for each of the high-risk factors were 8% higher for BMI (rate ratio, 1.08; 95% confidence interval, 1.01-1.15), 10% higher for low predicted VO2max (rate ratio 1.10, 95% confidence interval, 1.02-1.18), and 22% higher for willingness to communicate (rate ratio, 1.22, 95% confidence interval, 1.14-1.30). The association between these health risks and health care costs was independent of age, sex, age-sex interaction, role-mental and role-physical limitations, and nine chronic conditions. Furthermore, willingness to communicate was directly related to a greater readiness to change behavior. CONCLUSIONS: The prevalence of obesity and low physical fitness is high, and these health risks are directly related to health care costs. Willingness of health plan members to communicate around health improvement opportunities appears greatest among those who incur higher costs, and these patients also have more favorable readiness to change profiles. Effective, proactive population-based health improvement efforts appear to have significant potential for positive economic impact.

Systems approach to childhood and adolescent obesity prevention and treatment in a managed care organization.

OBJECTIVE: To outline an intervention approach to childhood and adolescent obesity prevention and treatment, that will systematically facilitate effective communication, provide long-term social support and access to resources, that may be accessed proactively or on demand. Furthermore, this approach operates in an environment that involves all critical parties: child/adolescent, family-unit, physician and allied health professionals. SYSTEMS THINKING APPROACH: The objective is to bring together all key stakeholders and consider the interrelationships among them as a common process. In a managed care setting, this may be accomplished by optimizing the contributions of care delivery, health promotion and information systems. SETTING: A not-for-profit, community governed Managed Care Organization (MCO) in the Midwestern United States. Telephone-based, centralized services facilitate a process of access, communication, documentation and intervention implementation. CASE STUDIES: Two case studies are presented as examples of how access is obtained, the intervention is tailored to individual needs, communication is established, documentation is organized and long-term support is facilitated. CONCLUSIONS: A systems thinking approach to obesity prevention and treatment in youth has great potential. In a MCO setting, such an approach may be implemented, since integrated health care delivery systems may allow a common process to be established that can bring together all key stakeholders.

Early- and late-stage breast cancer in a managed care setting in relation to mammography screening.

A case-control study was conducted to ascertain occurrence of advanced- and early-stage breast cancer, use of mammography, and the relationship between the two. All women with stage III/IV breast cancer (N = 46) were matched to two controls (stage 0/I and stage II) by year of diagnosis and age. Matched-pair analyses assessed antecedent use of screening mammography. Results indicated that advanced-stage patients were significantly less likely than their stage 0/I counterparts to have had antecedent screening within 13 months of diagnosis [chi2: 5.78; OR: 6.0; p < 0.05]. Cases compared with stage II controls did not differ statistically. Efforts should focus on increasing mammography in currently targeted age groups. Considerations might be toward extending regular screening for women 40 to 49 and over 75.

The association between physical fitness and diagnosed chronic disease in health maintenance organization members.

PURPOSE: The purpose of this investigation was to determine the relationship between predicted cardiorespiratory fitness (predicted VO2max) and diagnosed chronic disease. DESIGN: A stratified random sample of individuals was surveyed. SETTING: Large Health Maintenance Organization (HMO) in the upper Midwest. SUBJECTS: HMO members (N = 8000), age 40 and over, with none, one, or two or more of the following diagnosed chronic conditions: hypertension, diabetes, dyslipidemia, and heart disease. MEASURES: Predicted VO2max was estimated for those respondents who completed the survey providing all critical data elements (n = 4121; representing 51.5% of total sample). Predicted VO2max was compared across chronic conditions using analysis of variance. The proportion of subjects across fitness quintiles by number of chronic conditions was tested using the chi 2 test. RESULTS: Subjects without chronic conditions showed higher predicted VO2max values (29.8 +/- 7.7 ml/kg/min) than those with one (25.9 +/- 7.8 ml/kg/min) or two or more conditions (25.7 +/- 7.9 ml/kg/min) (p < .0001). Subjects with diabetes, hypertension, and heart disease reported lower predicted VO2max than their healthier counterparts (p < .0001), but this was not the case for dyslipidemia subjects (27.6 +/- 7.6 vs. 27.4 +/- 8.2 ml/kg/min, respectively; p > .58). A larger proportion of diseased subjects was in the lowest fitness quintile for diabetes, hypertension, and heart disease, but not for dyslipidemia. CONCLUSIONS: As a group, chronic disease patients appear to have lower levels of physical fitness than subjects without chronic disease. Physical fitness improvement in diseased populations should be supported in the clinical setting.

Identifying diabetes mellitus or heart disease among health maintenance organization members: sensitivity, specificity, predictive value, and cost of survey and database methods.

We conducted a study of the sensitivity, specificity, positive predictive value, and cost of two methods of identifying diagnosed diabetes mellitus or heart disease among members of a health maintenance organization (HMO). Among 3186 adult HMO members who were attending one primary care clinic, 2326 were reached for a telephone survey (efficiency = 0.73). Among these members, 1991 answered standardized questions to ascertain whether they had diabetes or heart disease (corrected response rate = 0.85). Linkage was then made to computerized diagnostic databases. By means of both a database method and a survey method, the 1976 members with complete data for analysis were classified as having or not having diabetes or heart disease. When results with the two methods disagreed, charts were reviewed to confirm the presence or absence of diabetes or heart disease. Diabetes was identified among 4.7% of adult members, and heart disease was identified among 3.7%. Identification of diabetes differed between the database method and the survey method (sensitivity 0.91 vs 0.98, specificity 0.99 vs 0.99, positive predictive value 0.94 vs 0.83). Identification of heart attach history was similar for the database method and the survey method (sensitivity 0.89 vs 0.95, specificity 0.99 vs 0.99, positive predictive value 0.79 vs 0.81). The cost of obtaining data was $13.50 per member for the survey method and $0.30 per member for the database method. Database methods or survey methods of identifying selected chronic diseases among HMO members may be acceptable for various purposes, but database identification methods appear to be less expensive and provide information on a higher proportion of HMO members than do survey methods. Accurate identification of chronic diseases among patients supports clinic-level measures for clinical improvement, research, and accountability.

Does professional advice influence aspirin use to prevent heart disease in an HMO population?

OBJECTIVE: Aspirin use seems to reduce coronary artery disease events in some groups of patients. Factors associated with use of aspirin to prevent heart disease in an HMO population were examined. DESIGN: A population-based survey. SETTING: A large HMO in the midwestern United States. PARTICIPANTS: 8000 health plan members 40 years of age and older. MAIN OUTCOME MEASURES: The survey assessed use of aspirin, professional advice to use aspirin, and coronary heart disease risk factors and status. The sample was stratified by whether members had none, one, or more than one of the following chronic conditions: diabetes, hypertension, lipid disorder, or heart disease. The mailed survey had a corrected response rate of 82.4%. RESULTS: Overall, 38% of respondents reported using aspirin at least three times a week to prevent heart disease. Aspirin use did not vary in owned versus contracted clinics. Aspirin use was 71.3% in patients with and 27.7% in patients without diagnosed coronary heart disease (P < 0.001). In logistic regression models, professional advice to take aspirin was strongly associated with self-reported use of aspirin (odds ratio, 13.86) (P < 0.001) after adjustment for age, sex, level of education, and chronic disease status. CONCLUSIONS: Aspirin is widely used by HMO members with coronary artery disease to prevent subsequent coronary artery disease events. Professional advice to use aspirin seems to be strongly related to aspirin use.

Integrating population health concepts, clinical guidelines, and ambulatory medical systems to improve diabetes care.

The integration of clinical guidelines with office systems has great potential to improve population health. This article shows how simple office systems can be developed and applied to expand the impact of clinical guidelines on the health of populations of patients enrolled in managed care organizations, using diabetes as an example. The basic tools needed to improve population health include (1) clinical guidelines that clearly articulate important and specific health goals; (2) a clinical database that can identify patients who are eligible for guideline-recommended care, monitor this group of patients, and classify patients who need different levels of intervention; and (3) clinics that are organized in a way that facilitates provision of guideline-directed clinical care based on cues from the clinical database. This article illustrates a successful application of this strategy to improve the care of a population of patients with diabetes enrolled in health maintenance organization-owned clinics.

Stages of change for physical activity, diet, and smoking among HMO members with chronic conditions.

PURPOSE: This paper investigated whether stage of change for health behaviors was associated with the presence of chronic conditions. DESIGN: A stratified cross-sectional survey by mail with telephone follow-up. SETTINGS: This study was conducted at a mixed-model HMO with 650,000 members based in Minnesota. SUBJECTS: The sample consisted of a random sample of 8000 HMO members age 40 or over with systematic oversampling of members with hypertension, diabetes, dyslipidemia, or heart disease. MEASURES: In addition to demographics, readiness to change for physical activity, fat intake, fruit and vegetable intake, and smoking were assessed. RESULTS: The adjusted response rate was 82.4%. In a logistic regression analysis, members with one or more than one chronic condition had greater readiness to change for three out of four risk factors compared to members with no chronic conditions. CONCLUSIONS: The stage-of-change distribution of HMO members with chronic conditions suggests that members at highest risk of adverse health outcomes have the greatest readiness to change behavioral risk factors. Based on these observations, targeted, stage-specific efforts to support behavior change are likely to be both acceptable and effective in HMO members with chronic conditions. Improving stage of change for behavioral risk factors for members with diabetes may present special problems and opportunities.

Database system to identify biological risk in managed care organizations: implications for clinical care.

The investigators constructed an index measure of cardiovascular risk and scored 1.991 adults as having high, average, or low cardiovascular risk. High cardiovascular risk was positively associated with hospital admissions (odds ratio [OR] = 3.9, p < 0.0001), total hospital days (OR = 4.0, p < 0.001), primary care clinic visits (OR = 7.3, p < 0.0001), and subspecialty clinic visits (OR = 2.3, p = 0.0003), compared to low cardiovascular risk, after controlling in multivariate analyses for gender and age. The index can provide estimates of utilization, costs, and potential preventability of adverse cardiovascular events, can be used to identify groups of patients in need of various systematic interventions, and can provide population-based ways to evaluate the results of interventions.