Jennifer T. Fink

The relationship of individual comorbid chronic conditions to diabetes care quality

Objective Multimorbidity affects 26 million persons with diabetes, and care for comorbid chronic conditions may impact diabetes care quality. The aim of this study was to determine which chronic conditions were related to lack of achievement or achievement of diabetes care quality goals to determine potential targets for future interventions. Research design and methods This is an exploratory retrospective analysis of electronic health record data for 23 430 adults, aged 18–75, with diabetes who were seen at seven Midwestern US health systems. The main outcome measures were achievement of six diabetes quality metrics in the reporting year, 2011 (glycated haemoglobin (HbA1c) control and testing, low-density lipoprotein control and testing, blood pressure control, kidney testing). Explanatory variables were 62 chronic condition indicators. Analyses were adjusted for baseline patient sociodemographic and healthcare utilization factors. Results The 62 chronic conditions varied in their relationships to diabetes care goal achievement for specific care goals. Congestive heart failure was related to lack of achievement of cholesterol management goals. Obesity was related to lack of HbA1c and BP control. Mental health conditions were related to both lack of achievement and achievement of different care goals. Three conditions were related to lack of cholesterol testing, including congestive heart failure and substance-use disorders. Of 17 conditions related to achieving control goals, 16 were related to achieving HbA1c control. One-half of the comorbid conditions did not predict diabetes care quality. Conclusions Future interventions could target patients at risk for not achieving diabetes care for specific care goals based on their individual comorbidities.

Discordant Documentation of Obesity Body Mass Index and Obesity Diagnosis in Electronic Medical Records

Purpose: This study examined concordance between presence of obesity body mass index (BMI), defined as BMI ≥ 30, in the patient’s electronic medical record (EMR) and a documented diagnosis of obesity. Methods: We conducted a retrospective review of the EMR in a large health care system for a 1-year period (2012). A total of 397,313 patients met the study criteria of having at least one physician visit, being at least 18 years of age, and not being pregnant. Of those, 158,327 (40%) had a recorded BMI ≥ 30. We examined the EMR of these obese patients to determine whether a diagnosis of obesity was recorded, and whether demographics or comorbid diagnoses impacted the likelihood of a recorded obesity diagnosis. Results: Obesity appeared on the EMR problem list for only 35% of patients with BMI ≥ 30. Obesity diagnosis was documented more frequently in women, middle-aged patients and blacks. The presence of some comorbidities (e.g. sleep apnea, hypertension, diabetes) led to significantly more frequent diagnosis of obesity. There was a significant positive association between the number of comorbid diagnoses per patient and an obesity diagnosis appearing on the problem list. Conclusions: Obesity remains underrecorded in the EMR problem list despite the presence of obesity BMI in the EMR. Patient demographics and comorbidities should be considered when identifying best practices for weight management. New practices should be patient-centered and consider cultural context as well as the social and physical resources available to patients – all crucial for enacting systems change in a true accountable care environment. (J Patient-Centered Res Rev. 2014;1:164-170.)

Impact of the Heart WATCH Program on Patients at Risk of Developing Metabolic Syndrome, Prediabetes or Cardiovascular Disease

Methods Our institution’s Heart WATCH program consists of screening sessions with a multidisciplinary team (physician/nurse, nutritionist and psychologist), a minimum of three visits with a nurse practitioner and weekly follow-up phone calls for a 14-week period. Sociodemographic variables were obtained at initial visit. Biometric testing indices and self-reported clinical and behavioral health measures were recorded pre- and postintervention, and compared using paired t-tests or McNemar’s test as appropriate. Results Heart WATCH enrolled 242 women from November 2006 to April 2014, and 193 (80%) completed all phases of the 14-week lifestyle intervention. Postintervention, participants demonstrated improved health status in all areas and improved significantly in the following areas: diet/nutrition (P=0.014), exercise (P<0.001), stress (P<0.0001), quality of life (P=0.003), weight (P<0.0001), waist circumference (P=0.01) and total cholesterol (P=0.019). Clinically meaningful improvements were realized by participants who moved to a healthier classification in a number of vital signs and blood panel indices. Conclusions These findings suggest the “elevated risk profile” for women with components of metabolic syndrome can be reversed through a lifestyle program focused on reducing risk factors associated with cardiovascular disease and prediabetes. Future research is needed to determine mechanisms of risk reduction as well as optimal patient-centered and culturally appropriate approaches to weight management. (J Patient-Centered Res Rev. 2015;2:56-63.)

Facilitating Factors and Barriers to Weight Management in Women: Physician Perspectives

Purpose The complexity of addressing overweight and obesity in women has been an ongoing public health and health care challenge. While the mechanism for addressing overweight and obesity in women remains unclear, it has been speculated that disparities in overweight and obesity by race and gender contribute to the complexity. The purpose of the present study was to examine perceptions of primary care physicians when discussing weight management with their patients. Methods We conducted focus group discussions exploring facilitators and barriers to discussing weight management and weight loss among women patients. Participants included 18 family medicine and internal medicine physicians who were recruited using a snowball sampling technique from two large urban institutions. Focus group discussions were transcribed verbatim. Responses were then codified and analyzed in frequency of occurrence using specialized computer software. Results Nine themes emerged from group discussions. These recurring themes reflected three overarching critical points: 1) potential utility of the primary care setting to address weight management; 2) the importance of positive patient-provider communication in supporting weight loss efforts; and 3) acknowledgement of motivation as intrinsic or extrinsic, and its role in obesity treatment. Conclusions Physician perceptions of their own lack of education or training and their inability to influence patient behaviors play crucial roles in discussing weight management with patients.

The importance of frequent return visits and hypertension control among US young adults: a multidisciplinary group practice observational study

Young adults (aged 18 to 39 years) have the lowest hypertension control rates compared with older adults. Shorter follow‐up encounter intervals are associated with faster hypertension control rates in older adults; however, optimal intervals are unknown for young adults. The study objective was to evaluate the relationship between ambulatory blood pressure encounter intervals (average number of provider visits with blood pressures over time) and hypertension control rates among young adults with incident hypertension. A retrospective analysis was conducted of patients aged 18 to 39 years (n = 2990) with incident hypertension using Kaplan‐Meier survival and Cox proportional hazards analyses over 24 months. Shorter encounter intervals were associated with higher hypertension control: <1 month (91%), 1 to 2 months (76%), 2 to 3 months (65%), 3 to 6 months (40%), and >6 months (13%). Young adults with shorter encounter intervals also had lower medication initiation, supporting the effectiveness of lifestyle modifications. Sustainable interventions for timely young adult follow‐up are essential to improve hypertension control in this hard‐to‐reach population.

Weight loss associated with employee income in an incentivized employee wellness program

Objective: We examined the relationship between the type of incentivized wellness program and employee weight loss and the effects of participant income. Methods: We retrospectively examined employees who participated in one of six weight loss wellness programs, which were categorized for the present analysis: reweigh/body mass index, Coaching, and Weight Watchers/Meal Replacement. Those who participated were eligible for a

Increasing Consumer Engagement by Tailoring a Public Reporting Website on the Quality of Diabetes Care: A Qualitative Study

350/year insurance premium discount. Results: Employees in the low-income category of

Stratifying patients with diabetes into clinically relevant groups by combination of chronic conditions to identify gaps in quality of care

45K or less participated at a higher rate, however, did not lose as much weight as those participants in the higher income categories of

Obesity remains underdiagnosed: discordant documentation of obesity body mass index and obesity diagnosis in patients' electronic medical record

70K or more. We found a positive association with weight loss in two of the categories, reweigh/body mass index, and Weight Watchers/Meal Replacement programs. Conclusion: Wellness programs have a significant impact on employee weight loss, but this relationship may vary across the income level of participants.

Physician Use of Electronic Health Records in Obesity Management.

Background The majority of health care utilization decisions in the United States are made by persons with multiple chronic conditions. Existing public reports of health system quality do not distinguish care for these persons and are often not used by the consumers they aim to reach. Objective Our goal was to determine if tailoring quality reports to persons with diabetes mellitus and co-occurring chronic conditions would increase user engagement with a website that publicly reports the quality of diabetes care. Methods We adapted an existing consumer-focused public reporting website using adult learning theory to display diabetes quality reports tailored to the user’s chronic condition profile. We conducted in-depth cognitive interviews with 20 individuals who either had diabetes and/or cared for someone with diabetes to assess the website. Interviews were audiotaped and transcribed, then analyzed using thematic content analysis. Results Three themes emerged that suggested increased engagement from tailoring the site to a user’s chronic conditions: ability to interact, relevance, and feeling empowered to act. Conclusions We conclude that tailoring can be used to improve public reporting sites for individuals with chronic conditions, ultimately allowing consumers to make more informed health care decisions.