JUNE 21, 2019 BY Jennifer Kraschnewski, MD, MPH

Study Update: PaTH To Health: Diabetes

Nearly 40% of adults are obese in the United States, making it our number one health concern. There is a well-established link between obesity and increased morbidity from hypertension, type-2 diabetes, coronary heart disease, stroke, and some cancers. Current clinical practice recommendations on diabetes care presented by the American Diabetes Association includes obesity management as a key component for individuals with diabetes. Even modest weight loss can improve or delay diabetes complications, making weight loss particularly important for this group. Recent policy changes and health insurance expansion have resulted in coverage for obesity counseling by Centers for Medicare and Medicaid to improve weight loss for adults either with or at high risk of type 2 diabetes. For our study, we are utilizing the PaTH network to analyze Electronic Health Record (EHR) data on over two million patients with or at risk of type 2 diabetes to understand the effectiveness of obesity counseling in improving weight loss and diabetes outcomes.

Funded by the Patient-Centered Outcomes Research Institute (PCORI), this project is led by Jennifer Kraschnewski, MD, MPH at the Penn State College of Medicine with partnership from 5 PaTH Network sites: Johns Hopkins (Co-I Jessica Yeh, PhD), the University of Pittsburgh (Co-I Cindy Bryce, PhD), Temple University (Co-I Anuradha Paranjape, MD, MPH), University of Utah (Co-I Rachel Hess, MD, MS) and Geisinger Health System (Co-I Les Kirchner, PhD). The project began in early 2016 and will run through 2021.

Because greater than 80% of Americans see a primary care provider regularly, primary care clinics may be an ideal setting for weight control interventions. To fill a gap in coverage of preventive services, the Centers for Medicare and Medicaid Services (CMS) implemented a healthcare procedure coding system for intensive behavioral therapy (IBT) for obesity within primary care settings in 2012 to facilitate payment for addressing obesity, followed by universal coverage by insurers for IBT for adults of all ages in 2013. However, the utilization and impact of this expanded coverage is largely unknown. Our study is unique, in that we are not recruiting patients to participate in study interventions. Instead we are utilizing de-identified EHR data over a period of 10 years (2009-2019) to answer our research questions.

Key to the first few years of our project while we were working on obtaining data, were the involvement of our patient partners and stakeholders. Our current team consists of six patient partners, six primary care providers, and ten stakeholders who continue to contribute their ideas, expertise and lived experience to this project. They have been the driving force of key study decisions, such as which patient-reported outcomes to include in our dataset, creation of a study website and other marketing materials, participation in trainings and outreach events. In 2016, our patient partners became official study co-investigators, the first patient partners to do so at Penn State, and are a constant reminder of why our research matters.

As of early this year, we have received data for both our diabetes and at risk cohorts from all participating institutions and are analyzing the data to determine utilization of obesity counseling across all sites. As we wait for additional claims data and provider level information to strengthen each cohort, we are preparing a manuscript that aims to understand current utilization of obesity counseling for the diabetes cohort only, and trends of uptake by gender, race, age, and rurality. Currently, there are 447,363 patients with diabetes in the PaTH network. While utilization of obesity counseling is low (0.12% in 2017), users tend to be younger (<65 years), female, non-white (black or Hispanic) and reside in urban areas. These findings raise important questions for future analyses over the next 2 years to determine important provider characteristics for understanding who is referring patients for obesity counseling.

Dr. Jennifer Kraschnewski is excited to begin a deeper dive into the data stating, "We are anxious to identify if patients who receive counseling have greater weight loss and improved diabetes outcomes (including controlled hemoglobin A1c, blood pressure, and statin medication use) compared to those who do not receive the counseling. Further, if we are able to identify practice sites that have successfully implemented intensive obesity counseling and they have improved diabetes outcomes, we will be able to disseminate their approach strategies to help other providers implement.""

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