The Impact of and Management of Obesity At Kaiser Permanente

Academy Health National Health Policy ConferenceFebruary 4-5, 2008Washington, D.C.

Francis J. Crosson, MDSenior Medical Director

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Agenda

The prevalence of obesity among Kaiser Permanente members

The impact of obesity on morbidity and system costs

The range of clinical interventions at Kaiser Permanente

Evidence of relative effectiveness

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Kaiser Permanente

America’s oldest and largest private, nonprofit, integrated health care delivery and financing system — Founded in 1945

Multi-specialty group practice prepayment program — Headquartered in Oakland, CA

8.7 million members — more than 6 million members in California

Over 13,000 physicians representing all specialties and 156,000 additional employees

Operations in nine states and Washington, D.C.

KP Research Centers — $100,000,000 in external funding in 2003 for Health Systems Research

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We have been at this a long time!

… It is Our Heritage

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17.419.3

20.7

25.6

23

10

15

20

25

30

%

1993 1996 1999 2002 2005

Note: Estimated using self-reported height and weight data from KP NCal Member Health Surveys, weighted to the age-gender-geographic composition of the membership for the survey year; age 25-79. N Gordon.

Time Trends: BMI > 30 (N Cal)

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Adult BMI Measurement: Northwest Region

BMI measured in 70.5% of Adult Members 70% Overweight/Obese 38% Obese 7% Extreme Obesity

34%33%

7%

30% 32%

5%

0%

10%

20%

30%

40%

BMI 25-29.9 BMI 30-39.9 BMI ≥ 40

KP (2004) NHANES (2003-2004)

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3.6

5.1

2.6 2.8

1.3

9.3

14.8

3.2

6.1

0.6

6

8.3

4.3 4

1.4

0

2

4

6

8

10

12

14

16

All 25-79 Female 25-64 Male 25-64 Female 65-79 Male 65-79

%

White AA Latino

Note: Estimated using self-reported height and weight data from KP NCal Member Health Surveys, weighted to the age-gender-geographic composition of the membership for the survey year

BMI > 40 by Race/Ethnicity: NCal

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Obesity Comordidities

Obesity is strongly associated with comorbidities

• 53% of obese KP members report three or more comorbidities

• > 40% of KP members with asthma, chronic pain, and CHF are obese

• 57% of KP members with DM are obese

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0%5%

10%15%20%25%30%35%40%45%50%

BMI 18-24 BMI 25-29 BMI 30-39 BMI > 40

DM Prediabetes Either

KPNW 2004

Diabetes and Prediabetes

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Comparison to BMI 20-25

• BMI 30-35 25% Increase

• BMI > 35 44% Increase

• BMI > 40 78% Increase

Outpatient Utilization: 37% increase

Inpatient Utilization: 70% increase

Quesenberry C Arch Int Med 1998 Volume 158(5) pp 466-472

Increased Health Care Costs: KP Northern California

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Costs in obese compared to normal weight members over eight year time frame:• Primary care visits: 39% higher • Inpatient days: 49% higher • Pharmacy costs: 100% higher

– 13X increase in DM meds; 3 X increase in CV meds

Weight gains of 20 lbs or greater are associated with increased annual medical care costs of more $500 over the following three years

Quesenberry C Arch Int Med 1998 Volume 158(5) pp 466-472 Thompson D Obes Res 2001; Elmer PJ Int J Ob 2004

Increased Health Care Costs: KP Northwest

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Incremental Costs in Chronic Conditions

CAD + Obesity

CADDM + Obesity

CHF + Obesity

DM

CHF

Note: Analysis is based on utilization and standardized unit costs.

CMI 2003

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Increased Work Loss

Employer Costs – Work Loss

KP Data: HealthMedia Succeed Participants

3.75 3.774.92

6.8

9.2

0

2

4

6

8

10

Average Hours of Work Missed Per Month Due to Illness

Underweight (<18.5) Healthy (18.5-24.9) Overweight (25-29.9)

Obese (30-39.9) Extremely Obese (40+)

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Multifaceted Public Health Approach to the Prevention and Treatment of Obesity

Research network

Legislation/public policy

Successful practice dissemination

Clinical management

Communitypartnerships

Kaiser Permanente’s Strategic Approach

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Key Elements of Kaiser Permanente’s Clinical Approach

Office-based approaches• Measurement of BMI

• Effective patient-clinician communication and partnership

• Brief primary care intervention and referral for behavior change support

Direct-to-member approaches• Health Education and Web-based programs• Throughout the lifespan and obesity spectrum

Pharmacotherapy Bariatric Surgery

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Risk Stratification KP Interventions

BMI Risk Strata Proposed Interventions

Normal Advice: “Maintain, Don’t Gain,”BMI 18 - 24.9 Prevention, 10,000 steps®

Overweight BalanceTM , 10,000 Steps®, BMI 25 - 29.9 Weight Watchers® Local KP Program,

NourishTM, RelaxTM

Obese I BalanceTM, 10,000 Steps®, BMI 30 - 34.9 Weight Watchers® Local KP

Program, NourishTM, RelaxTM

Obese II Bariatric Surgery, BMI 35 - 35.9 Local KP programs

Obese III Bariatric Surgery, Regional Medical BMI > 40 Weight Management Program

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Supporting the Office Visit

KP HealthConnect EMR tools

• Weight tracking tools

• Decision support

Exam room poster and tip sheets

“BMI as a vital sign” staff and clinician training

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Decision Support – KP HealthConnect

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BMI as a Vital Sign

Implemented in Medicine, OBGYN, and Pediatrics Office systems tools (poster, tip sheet, BMI calculator) Staff training (BMI, communication skills)

• Over 2,000 Permanente and Community Physicians trained

Significant improvement in BMI measurement

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28

43

62 6674

0

10

20

30

40

50

60

70

80

2nd Qtr 03

3rd Qtr 03

4th Qtr 03

2nd Qtr 04

4th Qtr 04

2nd Qtr 05

% Visits BMI Recorded

KPNCR 2003-5 BMI Completion Rates at Well Child Care Visits Ages 2-18 Years

Improving BMI Measurement

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Balance® Online Weight Management Program

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0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

Overweight (25-29.9) Obese (30-39.9) Extremely Obese (40+)

Lost - 10 Percent or Greater

Lost - 7.5 to 10 Percent

Lost - 5 to 7.5 Percent

180 Days post-program completion

% Weight Loss in Balance by BMI

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2.6

3.3

2.83.2

2

2.5

3

3.5

4

BASELINE 6 MONTH 12 MONTH

Balance - weight mgmt

Comparison

Time

Ave

rag

e #

ou

tpa

tien

t vis

itso

ver

pre

viou

s si

x m

on

ths

MANOVA repeated measures test, F=4.1; p<.05; n=478

(6.5)

(5.4)

Balance® RCT: Outpatient Visits

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Pharmacotherapy

The two medications approved for long-term use- Orlistat and Sibutramine are available to Kaiser Permanente members, but usually at cost

Two regions piloted a full rebate program involving a structured weight management class and weight loss goals

Patients rarely refilled prescriptions at month 3, because of disappointment with the degree of weight loss and drug side effects

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Why Treat with Bariatric Surgery?

Benefits

• Resolution of diabetes

• Improvement of OSA, metabolic syndrome, hypertension,

• Longest weight maintenance after weight loss

• Improved mobility

• Improved mortality

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Bariatric Surgery: General Themes

Patient selection is critical

Need well informed, motivated patients committed to long term lifestyle changes

Potential benefit must outweigh potential risk of short and long term complications

Weight maintenance can be problematic —Need commitment to long term behavior change and support

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Gastric Bypass Outcomes

Metaanalysis: weight loss and comorbidity resolution• Total weight loss: 24%

• Excess weight loss: 68%

• Mean weight loss: 40 kg.

• Resolution Improved or Resolved

Diabetes 84% 91%

OSA 87% 95%

HTN 75% 87%

Buchwald H JAMA 2004

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Farmers’ Markets Promote Environmental Change

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KP Farmers’ Markets — Key Findings

A total of 71% patrons (excluding 12% of the sample who were first time shoppers) across all sites reported eating at least “a little more” fruits and vegetables as a result of shopping at the market

32% of all patrons reported eating “a lot more” fruits and vegetables because of the market

A total of 63% of patrons reported eating at least “a few more kinds” of fruits and vegetables

18% of all patrons reported eating “many more kinds” of fruits and vegetables.

82% of patrons are KP staff, physicians, or members

11% of community members visit the market to shop

Patients are scheduling their doctors appointments to coincide with the farmers market

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When We Arrive…

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Contact Information

If you have questions about Kaiser Permanente’s Weight Management Initiative, please contact:

Trina Histon, PhDKaiser PermanenteCare Management InstituteOne Kaiser Plaza, 16LOakland, CA 94612trina.histon@kp.org(510) 271-2667

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Thank You