Despite the burgeoning epidemic of obesity in the VHA and the potential benefits of treating obesity, our findings indicate suboptimal rates of obesity care among our cohort of obese primary care patients. In FY2002 alone, 20% of primary care patients did not have sufficient height or weight data to calculate their BMI, and 72% of obese primary care patients did not have obesity diagnoses recorded when warranted. The rates we found in the VHA, however, are comparable or better than those recently reported in the private sector.28,29
The relatively higher rates of weight and height documentation within the VHA may be due to its EMR. Nevertheless, our findings suggest that a critical missing link occurs between the automatic calculation of BMI that occurs within the VHA’s EMR, if a height and weight are entered, and clinicians’ formal recognition and diagnosis of an obesity disorder. We found that an obesity diagnosis, and not BMI per se, was the strongest predictor of receiving obesity-related education. These findings suggest that a diagnosis of obesity may serve as a “marker” to reflect level of provider concern and/or patient interest in seeking obesity treatment, a finding consistent with previous reports that brief physician counseling for obesity occurs more frequently for obese patients who have an obesity diagnosis recorded.11
Periodic documentation of heights and weights is recommended for identifying obese patients and monitoring obesity’s course or response to treatment.1–6
Failure to record obesity diagnoses, heights, and weights could be caused by a number of factors, including perceptions of importance, time constraints, and competing clinical demands.10,11,30
Their omission from the medical record has implications for health services research and quality monitoring. Recent plans by health care institutions such as the VHA and National Committee for Quality Assurance to implement performance measures to assess how consistently physicians calculate BMI may improve documentation rates in the future.13,31,32
During the time period covered by this study, few VHA facilities had implemented clinical reminders that automatically prompt clinicians to record a diagnosis of obesity after a BMI is generated in the EMR, and there was no performance measure requiring screening for obesity; however, beginning in 2006 the VHA issued policies and provided facilities with tools to systematically identify obese patients and offer them treatment through the MOVE!
Weight Management Program for Veterans.15
Our data indicate that only about 10–13% of obese veterans received individual or group outpatient education in nutrition, exercise, or weight management on an annual basis, and only about one-third received any obesity-related education over the 5-year study period. Obese patients who were older than 65 years, prescribed fewer types of medications, or lacking an EMR diagnosis of obesity or diabetes were less likely to have outpatient obesity-related education. We cannot determine whether this was due to patient preference or other factors, but our findings suggest that providers may need to be especially vigilant in offering obesity-related education and engaging such patients in treatment if they would benefit from treatment.
We also found limited utilization of weight loss medications and of bariatric surgery, which may be partially due to system barriers. National policies in place during the study period allowed VHA facilities to make anti-obesity medications available to eligible patients who met criteria for use through non-formulary drug requests, but despite this, facilities have varied widely in their use.31
The adverse effect profile of these medications, however, also makes them a poor choice for many veterans, who tend to be older and sicker than the population in which the medications were tested and approved. Compared with national rates reported for the general population (24 per 100,000 adults) in 2002,8
the bariatric surgery rates we found also appear lower (407 in FY2002–FY2006 and just 68 in FY2002 alone for our cohort). With only 12 approved VHA bariatric centers nationwide, however, access was limited.
Disease burden among these patients was great, especially considering that the final cohort excluded more than 40,000 obese patients who died during the 5-year study period. Patients were more likely to receive obesity-related instruction as their number of prescribed medication classes increased, suggesting that patients are less likely to receive counseling or education when their burden of illness is low. Obesity-related comorbidities were common and included those explicitly recommended by guidelines to trigger considering obesity treatment.1
A diagnosis of diabetes conferred the highest probability of receiving obesity-related education. Although psychiatric comorbidities were highly prevalent in our obesity cohort, they did not appear to pose a barrier to obesity education.
Controlling for other factors, obese males were less likely to be diagnosed with obesity than were obese females. In addition, older patients, especially those over 65, were considerably less likely to receive a diagnosis of obesity or obesity-related education. This may reflect uncertainty on the part of clinicians in identifying and treating obesity in older adults in whom the relationship between BMI and health risks is less clear and weight management goals may differ from younger adults. Because of the large number of patients with unknown ethnicity, we were not able to include this important factor in the multivariable analyses. Distance of home residence from most frequently used VA facility did not significantly impact access to obesity care.
Limitations of this retrospective cohort study include its reliance on administrative height and weight data, which likely contain data entry errors.16
Although we may have misclassified some patients as obese/not obese, we believe that the approach used to control for outliers and define the cohort was conservative. Furthermore, it is clear that we identified more obese patients using heights and weights than would have been identified by relying on ICD-9-CM codes for obesity. Because clinicians’ notes are not captured in the VHA’s national administrative data, we were not able to identify any instances of brief physician counseling that may have occurred during routine visits. Other studies, however, using chart reviews suggest that obesity counseling by physicians is provided to only a minority of patients.11
Furthermore, although brief physician counseling may increase motivation to lose weight and result in greater weight loss in some patients, systematic reviews indicate that most obese patients require moderate-intensity counseling (defined as more than 1 visit per month for the first 3 months) to successfully lose weight and maintain weight loss.6
When we looked for this level of intensity in our cohort, we found only 1.6% received it, a negligible proportion. We were also unable to determine from our administrative data if additional patients may have been referred for obesity counseling, but failed to attend, or to ascertain patients’ level of motivation, which clearly plays an important role in determining whether patients receive treatment for obesity.
Although not representative of the entire VHA, our cohort was identified from a population of 1.5 million primary care patients served by six geographically diverse care networks, representing about 20% of the VHA’s 5.4 million patients. Large health care systems such as the VHA may be more likely to have dietitians, exercise counselors, or behavior specialists, and subspecialty clinicians to provide a comprehensive range of treatment options for obesity, but smaller clinics and independent providers can refer patients to specialists and community-based programs, or utilize an increasing array of Internet- and web-based options. In any case, the current study provides valuable information about the different types and amount of obesity care provided in routine clinical practice to a population of mostly male obese primary care patients, finding that the receipt of such care varied by patients’ sociodemographic and clinical factors. Future analyses will examine the influence of system-level factors on receipt of obesity care, including facility-level variability in the implementation of MOVE!
, the VHA’s nationwide program for managing obesity.15