State of the Art Conference on Weight Management in VHA · Screening and Management of Overweight...

VETERANS HEALTH ADMINISTRATION

State of the Art Conference on Weight Management in VHA

SOTA Plenary Session January 15, 2016


SOTA Goals

• Where is the evidence sufficient to move to implementation? – Reach consensus on policy recommendations to improve

implementation

• What important questions do not have sufficient evidence to guide practice and clinical policy? – Reach consensus on recommendations for research

• What issues or new developments are on the horizon that

may need to be considered in research, planning, and policy? – Prioritize issues for future consideration

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Purpose of Today’s Kick-off Call

• Orient everyone to SOTA process

• Clarify expectations and responsibilities ahead of work group meetings

• Answer any and all questions

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Usual SOTA Process

• Co-chairs convene planning committee to refine key questions, identify key subject matter experts, identify pre-readings

• Kick-off call to orient work group members to SOTA • Pre-readings/background materials are provided to work groups

– Identified/vetted by planning committee – Each article linked to SOTA objective and work group question

• 1.5 day face-to-face meeting (invitation only) – Each work group tackles questions assigned on their topic – Work groups summarize deliberations and present

recommendations to full SOTA participant group • Post-SOTA: products are developed—e.g., RFA to address

research gaps, journal supplement, recommendations for consideration of policy/practice changes

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Burden of Overweight/Obesity in VHA

• In FY15, 42% of Veterans treated in VHA were obese (BMI > 30)

• Another 37% were overweight (25<BMI<30)

• 3.9 million Veterans treated in VHA in FY15 were overweight/obese

Obesity and Overweight in VHA

Healthy Weight Overweight Obese

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Weight Management SOTA: Context

• Obesity is a tremendous challenge for patients and health systems, requires an approach that crosses silos of behavioral, pharmaceutical & surgical treatments

• No health system in the United States (or the world) integrates full spectrum of weight management interventions into a process that is seamless for eligible patients

• As an integrated health system with loyal patients, VA is ideally suited to develop such an approach

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VA/DoD Clinical Practice Guideline Screening and Management of Overweight and Obesity (2014)

Key Elements

1. Obesity is a chronic disease requiring lifelong commitment to treatment and long-term maintenance

2. Obesity may not be the chief complaint in a patient encounter, yet it requires foremost attention

3. The primary care team plays an integral role in weight management

4. Screening, documentation, and regular assessment are critical to weight management

5. Assessment for obesity-associated chronic health conditions is an essential component of treatment decisions

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VA/DoD Clinical Practice Guideline Screening and Management of Overweight and Obesity (2014)

Key Elements

6. Shared decision-making and assessment of patient motivation are fundamental to weight management

7. Comprehensive lifestyle intervention is central to successful and sustained weight loss

8. Tangible intermediate and long-term weight loss goals are critical to weight loss success

9. Energy deficit should be achieved through decreased caloric intake and increased physical activity

10. Pharmacotherapy and bariatric surgery may be considered as adjuncts to comprehensive lifestyle intervention

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Three Weight Management Interventions in VHA

• MOVE! Weight Management Program – Behavioral interventions work group

• Weight loss medications

– Pharmacotherapy work group

• Bariatric surgery – Bariatric surgery work group

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MOVE!® Weight Management Program

• Evidence-based comprehensive lifestyle program, launched in 2006 (www.move.va.gov)

• Available in individual and group formats, face-to-face and virtual: – Mostly offered in face-to-face group visits – Telephone care – Telehealth option – MOVE!® Coach mobile app – Led by MOVE! Coordinators in each medical facility

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http://www.move.va.gov/


Unique Veterans with BMI>25 with at least 1 MOVE! Interaction in FY14-FY15YTD

(n=263,189)


Unique Veterans Obtaining Weight Loss Medications, 2012 – Q1-Q3 2015

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VETERANS HEALTH ADMINISTRATION 12


Weight Management SOTA: Challenges and Opportunities

Challenges • Broad Scope of SOTA

• Behavioral interventions (population approach) • Pharmacologic interventions • Surgical interventions

• Critical question is how weight management interventions are delivered and implemented

The opportunity • Engaging independent systems to develop a framework

to integrate comprehensive programming

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SOTA Work Groups and Co-Leads

Three Work Groups 1. Behavioral Interventions

Co-Leads: Michael Goldstein & Robin Masheb 2. Pharmacotherapies

Co-Leads: Todd Semla & David Atkins 3. Bariatric Surgery

Co-Leads: Luke Funk & Matt Maciejewski

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Work Group Co-Leaders’ Roles

March 7 • Facilitate discussion of work group • Compile/summarize results of deliberations for

distribution to all SOTA participants March 8 • Present summary to all participants on March 8th Post-SOTA • Work with subgroup to plan for, further develop and

refine SOTA products 15


Role of Work Group Participants Prior to work group meetings

– Review pre-readings in context of work group questions – Think through responses to work group questions

Work group meeting(s) – Fully participate in work group deliberations – Generate research agenda and other recommendations

that will lead to new knowledge Post-SOTA

– Participate in development of SOTA summary or individual manuscripts as appropriate

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Charge to Work Groups

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Identify: • Where is the evidence sufficient to move to

implementation now? • Knowledge gaps—What do we need to know

more about? – Research and/or policy recommendations

• Future new technologies and implications for research, planning, and policy


Work Group Process

• Utilize a collaborative process to mine, align, and refine ideas – Pharmacotherapies Work Group will meet virtually 3-5

times during January/February – The other 2 groups will meet face-to-face March 7-8th – A sub group of Pharm will join the March 8th day for

reports and discussion

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Work Group Members Bariatric Surgery

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• Luke Funk (co-lead) • Matthew Maciejewski,

PhD (co-lead) • Jason Dominitz, MD, MHS • Dan Eisenberg, MD • Susan Frayne, MD, MPH • Melinda Gibbons, MD,

MSHS • William Gunnar, MD, JD

• Zafar Iqbal • Lisa Kearney, PhD • Edward Livingston, MD • Thomas Rutledge, PhD • Vivian Sanchez, MD • Brian Smith, MD • Hollis Weidenbacher


Work Group Members Behavioral Interventions

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• Michael Goldstein, MD (co-lead)

• Robin Masheb, PhD (co-lead) • Ronald Ackerman, MD,

MPH • Stephanie Chan, MPH • Paul Estabrooks, PhD • Gina Evans-Hudnall, PhD • Neil Evans, MD

• Theresa Gleason, PhD • Trina Histon, PhD • Alyson Littman, PhD, MPH • Tannaz Moin, MD, MBA • Karin Nelson, MD, MSHS • Sherry Pagoto, PhD • Nico Pronk, PhD, FACSM,

FAWHP • Susan Raffa, PhD • Deborah Tate, PhD


Work Group Members Pharmacotherapy

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• David Atkins, MD, MPH (co-lead)

• Todd Semla, PharmD, BCPS, FCCP, AGSF (co-lead)

• Donna Ames, MD • Caroline Apovian, MD,

FACP, FACN • Louis Aronne, MD • Charles Billington, MD

• Laurel Copeland, PhD, MPH • U Inge Ferguson, DO, FACOI • William Timothy Garvey, MD • Chester B. Good MD, MPH • Christopher Ruser, MD • Miriam (Mary) Smyth, PhD • Thomas Wadden, PhD • Susan Yanovski, MD


Bariatric Surgery Work Group Key Questions

• What is the average effect of bariatric surgery on: – Weight in the short-term and long-term (>2 years)? – Resolution/remission of obesity-related conditions (diabetes,

hypertension, sleep apnea, dyslipidemia) in the short-term and long-term (>2 years)?

– Short-term complications and long-term mortality? – Costs in the short-term and long-term (>2 years)?

• What is the best time in weight loss management to begin considering a

surgical treatment option? For example, how long should behavioral interventions be pursued before considering surgery? Is there a definition of “success” or “failure” that should prompt consideration of surgery?

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Bariatric Surgery Work Group Key Questions

• What are the facilitators and barriers to the referral of eligible VA patients for bariatric surgery, at the level of the individual patient, the referring provider, the practice or facility, and the health system. Once referred, what are the barriers and facilitators to eligible patients receiving surgery, at the level of the individual patient, the surgical practice, the facility and health system?

• What strategies should be considered before performing bariatric surgery on the patient considered “super obese?”

• How will the intragastric balloon therapy, recently FDA approved, impact the care and treatment of the obese? What do we need to know to develop appropriate policy for its use in the VA?

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Behavioral Interventions Work Group Key Questions

EFFICACY • Optimal Treatment Dose: What is the evidence that the effectiveness of

behavioral interventions varies by the number of visits, and length of treatment (the “dose” of behavioral intervention)? What is the evidence that there is a threshold effect (i.e. minimum dose) or a plateau effect?

• Desirable Behavioral Interventions: What components or modalities (ways of delivering) of behavioral interventions have proven effective and should be emphasized for behavioral weight management?

• Stepped-care: What is the definition of “failure” to lose weight via behavioral weight management that would make a Veteran eligible/appropriate for weight loss medications or weight loss surgery?

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EFFECTIVENESS/IMPLEMENTATION • BARRIERS & FACILITATORS: What are the barriers and facilitators at the level of the

patient, provider, facility and health system to identification, referral, and sustained engagement of obese patients in behavioral weight management?

• REACH: What is the effect of offering a less intensive (though still effective) intervention on reach and overall impact? How does reach (% of Veterans who utilize an intervention) vary by dose of intervention e.g., minimal effective versus maximal effective dose?

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EFFECTIVENESS/IMPLEMENTATION • DESIREABLE IMPLEMENTATION COMPONENTS: What is the most effective strategy

(climate, facilitation roles, etc.) for implementing a standardized behavioral weight management, based on the lessons from the most effective sites?

• VARIABILITY IN IMPLEMENTATION: Within VHA, what is the variation by site and modality in the staffing, content, dosing and variation in mean and median percent weight loss in the short-term and long-term (>2 years)?

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Pharmacotherapy Work Group Key Questions

• What are the patient and health system barriers and facilitators to identification and referral to prescribing pharmacotherapy for obesity for VA patients?

• In which patients (i.e. based on level of obesity, weight loss history, concurrent therapies, etc.) has addition of pharmacotherapy proven effective in enhancing weight loss compared to standard care?

• What is the average effect of weight loss medication on weight and VA costs in the short-term and long-term (>2 years)?

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Pharmacotherapy Work Group Key Questions

• What parameters should be considered to determine the duration of weight loss medication for patients and what patient characteristics are useful for determining which drug is most likely to be effective or safest for a given patient based on what is known about the drugs’ mechanisms of action?

• Do Veterans who have adjunctive pharmacotherapy concurrent with behavioral weight management have greater weight change (short-term and long-term) than Veterans only receiving behavioral weight management?

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Weight Management SOTA Opportunity: Integrated Framework

• March 8 – Full SOTA group discussion of an integrated framework

for weight management policy and implementation

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Weight Management SOTA Integrated Framework Questions

Strategies to Maximize Population Health: System Issues • What are the barriers and facilitators for Integrating

behavioral, pharma, and bariatric surgical interventions in a cohesive system-wide approach to weight management?

• What are the best strategies for coordinating weight management across different service lines that provide different interventions (e.g. Primary Care/PACT, specialty care)?

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Weight Management SOTA Integrated Framework Questions

Strategies to Maximize Individual Outcomes: • What framework can support the appropriate

selection of the initial weight loss strategy for individual patients, including eliciting patient’s particular preferences, risk factors, weight loss history, barriers and use of shared decision making?

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SOTA Resources

SOTA Website for Work Groups: • Participant lists • Readings, reports, etc. http://www.hsrd.research.va.gov/meetings/sota/weight-management/ Questions: Gerry McGlynn

[email protected], 617 991-7940

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http://www.hsrd.research.va.gov/meetings/sota/weight-management/

http://www.hsrd.research.va.gov/meetings/sota/weight-management/

http://www.hsrd.research.va.gov/meetings/sota/weight-management/resources/

mailto:[email protected]


Weight Management SOTA Plenary Session

• Questions?

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State of the Art Conference on Weight Management in VHA · Screening and Management of Overweight...

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