Obesity Care Practices in the VHA: Documentation of Heights, Weights, & Obesity Diagnoses
Polly Hitchcock Noël Veterans Evidence-based Research,
Dissemination, & Implementation Center(VERDICT)
VA HSR&D IIR 05-121-2
Collaborators
VERDICT/UT Health Science Center San Antonio:
Copeland L, Hazuda H, Pugh MJ, Wang CP, McCarthy A, Bollinger M
VA National Ctr for Health Promotion & Disease Prevention:Kahwati L, Jones KR
Site PIs: Nelson K, Hoffman V, Dundon P, Tsevat J, Arterburn D, Foulis P, Mossop PA
BMI = wt (kg)/[h
t (m)]2
Relevance MOVE! uses population-based approach
to screening VHA “indicator” for screening
introduced FY08 – national clinical reminder under discussion % of PC & MH patients screened with BMI &
offered treatment if “at-risk” HEDIS/NCQA is developing & piloting
obesity screening measure
Presentation Objectives
A. What proportion of primary care patients had their hts & wts recorded in the EMR FY02-FY06? (“screening”)
B. Among a cohort of primary care patients meeting BMI criteria for obesity in FY02:1. What proportion had their hts/wtsrecorded in FY03-FY06? (“monitoring”)2. What proportion received a diagnosis of
obesity in FY02-FY06? (“recognition”)
Design inception cohort of primary care
patients with BMI > 30 heights & weights recorded in EMR in
FY02 followed FY03-FY06 6 regions (“VISNs”)
(early & late adopters of MOVE!)
Data Sources Administrative Data: Sociodemographic, diagnostic, and
utilization data from NPCD Pharmacy data from PBM Mortality data from MINI-VITALS Heights & weights obtained from VHA’s
new Corporate Data Warehouse (CDW)
Weight (& Height) Data
Inherently variable over time changes in energy balance disease, surgery, injury, or aging
Variety of sources/opportunities for error Measurement & reporting errors Data entry errors
Data Error Examples Among 847,976 primary care pts with
multiple hts recorded in same year, 21,051 (2.5%) had hts differ by > 2 -10 inches
Among 105,425 occurrences of pts > 2 wts recorded on same day, 10,054 (9.5%) had wts differ by >10-1,000 lbs
Obesity Screening > 1 PC visits each year for each VISN
(where majority of care received) hts & wts recorded in EMR in their
VISN for each FY02-FY06
50
55
6065
70
75
8085
90
95
FY02 FY03 FY04 FY05 FY06
Fiscal Year
% P
C P
atie
nts
Scr
een
ed
wit
h H
t &
Wt
VISN AVISN BVISN CVISN DVISN EVISN F
*Primary care population ↑ from 1,053,228 in FY02 to 1,342,688 in FY06
Cohort Identification
> 1 PC visits in the 6 VISNs in FY02 (N=1,053,228)
wts & hts filtered to remove “biologically implausible” values
wt & ht FY02: 844,066 (80.1%) wt FY02 & ht FY02-06: 89,018 ( 8.5%)Total: 933,088 (88.6%)
Cohort Identification: BMI Method 1
Maximum wt FY02 & Minimum ht FY02-FY06
Cohort Identification: BMI Method 1
Minimum ht/ Maximum wt
N (%) BMI>30
371,842 39.9%
BMI M (SD) 34.8 (4.8)
BMI Range 30.0 – 161.8
# BMI > 70 252
# ht<60 in 7,078
# wt<170 lb 4,006
Among 933,088 PC patients with ht FY02 & wt FY02-FY06
Cohort Identification: BMI Method 2
median wt for each quarter of FY02, then “median of median wts”
mode of all ht values FY02-FY06; in case of > 2 modes: if diff < 3 inches, averaged
if diff > 3 inches, eliminated
Cohort Identification & Refinement
Minimum ht/ Maximum wt
Modal ht/Mdof Median wts
N (%) obese 371,842 39.9%
330,802 35.5%
BMI M (SD) 34.8 (4.8) 34.5 (4.4)
BMI Range 30.0 – 161.8 30.0 – 95.4
# BMI > 70 252 70
# ht<60 in 7,078 2,968
# wt<170 lb
4,006 2,553Among 933,088 PC patients with ht FY02 & wt FY02-FY06
Obesity Monitoring Cohort survivors For those with PC visit, determined
proportion with wt & ht (or wt only) recorded each year FY03-FY06
Cohort Characteristics
SurvivorsN=290,558
NonSurvivors
N=40,244BMI > 35 33% 33%
> 60 yrs 53% 81%
Male 94% 97%
Minority 16% 15%Total Obese Cohort N=330,802
50556065707580859095
100
FY03 FY04 FY05 FY06
Fiscal Year
% O
bes
e C
oh
ort
Su
rviv
ors
M
on
ito
red
wit
h H
t &
Wt VISN A
VISN BVISN CVISN DVISN EVISN F
*Among 290,558 with PC visit each year (89.6% in FY02 to 82.3% in FY06)
50
60
70
80
90
100
110
FY03 FY04 FY05 FY06
Fiscal Year
% O
bes
e C
oh
ort
Su
rviv
ors
M
on
ito
red
wit
h H
t &
Wt
OR
Wt
On
lyVISN AVISN BVISN CVISN DVISN EVISN F
*Among 290,558 with PC visit each year (89.6% in FY02 to 82.3% in FY06)
Obesity Recognition Cohort survivors Proportion with ICD-9-CM codes
278, 278.00, 278.01, 259.9, V77.8 FY02 only and FY02-FY06
Cohort Survivors Diagnosed with Obesity
Diagnosis in FY02?
Diagnosis in FY02-06?
Yes 27% 51%
No 73% 49%
Total Survivors
290,558 290,558
Obesity Dx in Cohort Survivors with Class I vs Class II+ Obesity
Obesity DxFY02-FY06? BMI < 35 BMI > 35
Yes 41% 72%
No 59% 28%
Total 193,462 97,096
p < .0001, Cohort Survivors N=290,558
Limitations administrative data hts, wts, & dxs may be entered in “text
fields” & not captured by administrative data
recording & data entry errors cohort may be misspecified obesity based on BMI not representative of entire VHA
Discussion
Significant variation in screening & monitoringearly MOVE! adopters performed better
Characteristics of those not screened unknown
Significant # do not have dxs or hts recorded – perceptions of importance?
majority of cohort > 60 yrs BMI used to dose medications & calculate
ventilation unit parameters implications for health services research
Next Steps Describe variations in other obesity care
practices & factors that predict Examine the impact of obesity care
practices on BMI and other important clinical outcomes
Identify longitudinal patterns (latent classes) of BMI trends over time
Q U E S T I O N S ?