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Treating Obesity During the COVID-19 Pandemic

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Treating Obesity During the COVID-19 Pandemic cASE STUDY Weighing in onTreating obesity duringObesity the COVID-19 pandemic By Elizabeth Ciemins, Ph.D., M.P.H., M.A. he COVID-19 pandemic has had a profound impact on of adults in the U.S.1 Obesity is associated with serious com- the treatment of patients with chronic diseases, and plications, such as diabetes, cardiovascular disease, chronic those with obesity are especially at risk. AMGA mem- obstructive pulmonary disease (COPD), and sleep apnea and bers were the vanguard of obesity treatment before is associated with direct and indirect costs nearing $2 tril- Tthe public health crisis, and the strategies and processes lion.2 The COVID-19 pandemic has exacerbated the issue. they have put in place are enabling them to continue to pro- With ambulatory visits for chronic disease management down, vide valuable care to this vulnerable population. people who are working to manage their obesity are not get- While chronic disease management is clearly taking a hit ting the care they need. Making things worse, obesity is one during the COVID-19 pandemic, it remains a crucial area of of the most common comorbidities of hospitalized COVID-19 focus for population health improvement as healthcare orga- patients, along with hypertension and type 2 diabetes.3,4 nizations take on more risk in the movement to value-based While the current situation may look bleak, before the care. Diseases like obesity are associated with numerous pandemic, AMGA members were making significant strides comorbid conditions that result in high costs to health in the identification, treatment, and management of people systems, payers, patients, and employers—not only direct with obesity. In 2017, AMGA launched a three-year Obesity healthcare costs, but also costs associated with absenteeism, Care Model Collaborative (OCMC) to define, pilot, and evalu- presenteeism, and disability. ate a framework and its necessary components to address Rates of obesity have been increasing since 2010; the most obesity in primary care within multispecialty medical groups, recent studies report that prevalence of obesity is over 40% integrated health systems, or academic medical centers. AMGA.ORG 14 JULY/AUGUST 2020 on Obesity During the collaborative, 10 par- between Seattle and Spokane. ticipating healthcare organizations OCMC Strategies Confluence Health is tackling identified and shared innovations, obesity head-on across their entire successes, and challenges, and for Obesity organization. They have trans- tested models of care to address formed the treatment of obesity obesity (see “OCMC Strategies Management by establishing a centralized for Obesity Management”). Three weight management center based of those participating organiza- Strategies for a successful obesity management in primary care, where medical program: tions have achieved remarkable weight-loss therapies can be pro- outcomes. X Dedicated obesity clinic or clinic hours vided in addition to interventions X Obesity support groups from registered dieticians and Confluence Health X Shared medical appointments behavioral health providers. The Confluence Health is an inte- X Culinary medicine programs obesity initiative team forged com- grated healthcare delivery system X Community gardens and food pharmacies munity partnerships, and among X Obesity nurse navigators of two hospitals, 270 physicians other strategies (see “Confluence X Electronic health record (EHR)-embedded best representing 40 medical special- Health Strategies to Address practice alerts (BPAs) for elevated body mass ties, and primary care clinics in 12 indexes (BMIs) without accompanying diagnoses Obesity in Primary Care”) focused communities across North Central X Weight-friendly waiting and exam rooms on provider and staff education to Washington, based in Wenatchee, X Champions across disciplines, e.g., MDs, DOs, help increase conversations with Washington. It is the major medi- RNs, MAs, office staff, specialists, etc. patients about weight and reduce iStock.com/pepifoto/Michael Burrell iStock.com/pepifoto/Michael cal provider for patients who live X Walk with the Doc programs bias against people with obesity. AMGA.ORG JULY/AUGUST 2020 15 cASE STUDY Figure 1 Confluence Health Obesity Diagnosis Rates Over Time 100% 90% ■ Obesity pilot group 90% 80% ■ Organization 70% 77% 72% % 60% 66 64% 50% % 40% 48 46% 41% 30% 37% % 20 24% 24% % 10% 18 0% % Patients with obesity code captured Baseline Final Baseline Final Baseline Final Class I Class II Class III Baseline: Q3 2017; Final: Q2 2019 30% 27.8% Confluence25% Health Strategies to Address Obesity20% in Primary Care 15.8% X Provider15 %and staff education on reducing bias, increasing X Common nutritional approaches and calorie conversations about weight 11.7% recommendations % X Develop10 and integrate a simple treatment algorithm (and X Coding tip sheets share openly with other participating health systems) X Exercise prescription forms 5% 3.8% X Change the paradigm of obesity treatment X Pharmacotherapy information on anti-obesity% medications 3.0 % % % % 1.9 X Distribute a patient1.5 roadmap0.8% 1.0% 0.8% 1.4X Common medications1.4 associated with weight gain % X Understand0 behavioral and psychological factors related X Counseling handouts to obesity X Shadowing board-certified obesity physician champions These efforts led to dramatic improvements in increasing Dr. Toth effortlessly switched between languages, truly obesity diagnoses of patients with a body mass index (BMI) meeting patients where they were, with gentle but firm >30 (see Figure 1) and in prescriptions for anti-obesity encouragement and kindness. As Dr. Toth shared, “In a prac- medications (see Figure 2). Improved outcomes are demon- tical sense, truly listening to the patient’s story of how they strated when the obesity pilot group is compared to the entire ended up in your office, and then providing accountability as organization from baseline measurement (Q3 2017) to a final well as the practical tools and knowledge the patient is seek- measurement nearly two years later (Q2 2019). Diagnosis ing, provides a powerful catalyst to help our patients begin rates increased 54% and 66% overall and in their pilot clinics, their journey of lifestyle change and weight loss.” respectively. In pilot clinics, the diagnosis rate increased to 90%. That means 90% of patients with a BMI and clinic pre- Mercy East sentation indicative of obesity were appropriately diagnosed Another participant in AMGA’s Obesity Care Model Collaborative, by the end of the Collaborative. Mercy Clinic East Communities, or Mercy East, took a different Confluence Health saw equally impressive improvements approach, with a dedicated clinic that exclusively treats patients in anti-obesity medication prescriptions, particularly in their with obesity. Located in St. Louis, Missouri, this integrated deliv- pilot sites, where prescribing rates went from 1.5% to 27.8% ery system has five acute care hospitals, a virtual care center, among appropriate patients. 340 physician practices, and 112 clinic locations. For their OCMC On a site visit, AMGA staff saw how Dr. Andrew Toth, the project, Mercy East focused efforts at three pilot primary care primary care champion who led the obesity program, saw clinics and established the Weight and Wellness Center, a ded- patients during a dedicated afternoon obesity clinic (held icated clinic established to take care of patients with overweight at his primary care clinic office two afternoons per week). or obesity. The center is in the same building as the three primary Alternating between English- and Spanish-speaking patients, care clinics, making it easy to refer patients to receive targeted AMGA.ORG 16 JULY/AUGUST 2020 100% 90% 90% 80% 70% 77% 72% % 60% 66 64% 50% % 40% 48 46% 41% 30% 37% % 20 24% 24% % 10% 18 Figure 2 0% Confluence Health Anti-obesity Medication Prescribing Rates Over Time 30% 27.8% ■ Obesity pilot 25% ■ Organization 20% 15.8% 15% 11.7% 10% % % % Patients with AOM Rx 5 3.8 % 3.0 % % % % 1.9 1.5 0.8% 1.0% 0.8% 1.4 1.4 0% Baseline: Q3 2017 Q2 2019 Baseline: Q3 2017 Q2 2019 Baseline: Q3 2017 Q2 2019 Class I Class II Class III weight loss guidance. Physicians Mercy East’s program was led in all clinics received education on Mercy East by physician champion, Dr. Kara obesity medicine, access to internal Mayes, who showcased the Weight and external resources for patients, Smart-Phrases and Wellness Center during an as well as electronic health record Mercy East integrates Smart-Phrases into the AMGA site visit. The center has (EHR) best practice alerts (BPAs) EHR to help providers care for patients with obe- size-appropriate chairs and exam and Epic Smart-Phrases to facil- sity. These Smart-Phrases provided direct links tables and uses a Medical Body itate documentation (see “Mercy for providers to share with patients during an Composition Analyzer to assess East Smart-Phrases”), referrals, encounter and on the after-visit summary: patients and monitor their progress and awareness of patients with over time. According to Dr. Mayes, X WTLGENERALTIPS, for general healthy eating ideas elevated BMIs. X WTLRECIPE, for cookbooks and websites with “Mercy’s Weight and Wellness Center These efforts resulted in a move- healthy recipes provides a place where physicians ment in weight class of patients X WTLSNACKCALORIE, for snacks under from across Mercy East can refer seen at the Weight and Wellness 200 calories and snacks 200–300 calories patients who need a focused weight Center (see Figure 3). X WTLSNACKLIST, for list of healthy snack ideas management program. With care Figure 3 Changes in Weight Class from Initial to Final Visit, 03/01/2018–04/30/2019 % 0.30% 1.21% Good Range 100 % 9.39% ■ Good Range BMI<25 90 % 17.88 ■ % Overweight 80 22.73% ■ Obesity Class 2 Overweight % ■ Obesity Class 1 70 % 25<BMI 30 24.55 ■ Obesity Class 3 60% Obesity Class 1 50% 27.27% 30<BMI 35 40% 25.45% Obesity Class 2 % of patients 30% 35<BMI 40 20% 40.30% % % 30.61 Obesity Class 3 10 40<BMI 0% Starting Weight Class Ending Weight Class AMGA.ORG JULY/AUGUST 2020 17 cASE STUDY A site visit to TIC inspired AMGA Analytics to examine the potential financial impact of improved HCC coding for obesity across AMGA member healthcare organizations.
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