Online Supplemenary Appendicies

ONLINE SUPPLEMENARY APPENDICIES

Examining the dose-response relationship in the Veterans Health Administration’s MOVE!® weight management program: a nationwide observational study

Stephanie H. Chan, MPH and Susan D. Raffa, PhD

CORRESPONDENCE:

Stephanie H. Chan

200 Springs Road, Building 61, Bedford, Massachusetts 01730. Email:

LIST OF APPENDICES:

APPENDIX A. Inclusion Criteria for Defining MOVE! Contacts…………………………..2

APPENDIX B. Weight and Height Data Cleaning………………………………………….4

APPENDIX C. Cohort Exclusions…………………………………………………………...6

APPENDIX D. Odds of Achieving Clinically Relevant Weight Loss at 12 Months…….7

APPENDIX A. Inclusion Criteria for Defining MOVE! Contacts.

Within VHA’s EHR, clinical encounters carry primary and secondary codes to indicate the nature of the workload completed in the encounter. There are two codes associated with the MOVE! program – code 372 for MOVE! programming delivered individually to a Veteran (in-person, by phone, or by video) and code 373 for MOVE! programming delivered to a group of Veterans (in-person or by video). While there are many reasons for a clinical encounter to be entered into the health record (e.g., a telephone call to schedule an appointment), only encounters determined to have involved clinical workload (e.g., appropriate procedure and diagnosis coding, associated appointments that were not missed, etc.) are included in this analysis.

Of the 6,388,542 clinical encounters carrying the 372 or 373 codes completed in the timeframe, approximately 23% were excluded because they were duplicate encounters or were simultaneously coded as associated with one of the following:

Employee MOVE! program (code 999), a similar but separate program for VA employees through the Occupational Health and Employee Wellness group,
Video visits (codes 645, 648, 692, or 693) and are duplicate encounters used to denote the location of the provider (whereas encounters associated with the Veteran’s location are included),
Research study visits (code 474) that include participation in interventions for weight management that may or may not be similar to MOVE! programming,
TeleMOVE! (codes 371, 683, 684, or 685), an 82-day weight management disease management protocol delivered through home telehealth technologies, i.e., in-home messaging devices.

Additionally, as described in the Methods, each Veteran’s MOVE! participation was conceptualized as episodes of MOVE! care, where episodes were separated by the absence of a MOVE! visit for ≥6 months, as applicable. For example, a first episode of care may have consisted of 5 weekly sessions, followed by an 8-month period without a MOVE! visit, and then a return for a second episode of MOVE! care of 10 weekly sessions. In this example, the most recent episode of care begins with the return to care after the 8-month break and continues for the 10 weekly sessions. From a clinical perspective, an absence of contact for weight management with the health system of ≥6 months would indicate disengagement from treatment. While there may be Veterans who continue self-monitoring and self-management of weight independently from the VHA health system (e.g., on their own, or with a commercial program, etc.), their return to contact with the MOVE! program is seen as a new treatment episode.

APPENDIX B. Weight and Height Data Cleaning.

A total of 26,542,249 weights and 9,478,959 heights were recorded from 10/1/1999 (the earliest recorded weights available) to 9/30/2015 in the EHR for the 588,839 Veterans whose most recent episode of MOVE! participation began between 10/1/2004 and 9/30/2015. These weights and heights include those taken through the MOVE! program and those taken outside the program in a VHA clinic (e.g., at a primary care visit).

A two-step cleaning process was used to identify outlier heights recorded in the EHR. First, heights that were recorded as <48 inches or >84 inches were excluded as implausible (42,087 height records). The second step was to calculate each Veteran’s mean height and standard deviation from the remaining height records. Then, heights in the EHR that were greater than 3 standard deviations from the mean, an additional 104,455 heights, were excluded. Overall, following the two-step cleaning procedure, a total of 146,542 (1.55%) heights were excluded from the analysis leaving 9,332,417 heights available for inclusion. An average of the remaining heights was then used for subsequent calculations of body mass index (BMI).

A three-step cleaning process was used to identify outlier weights recorded in the EHR. The first step was to exclude 70,636 (0.27%) weights in the EHR with values less than 22.7 kg (50 lbs) or greater than 340.2 kg (750 lbs), as these extreme values are implausible. The second step was to calculate each Veteran’s BMI using the average height, in order to identify the 45,318 weights that were similarly implausible (defined as a BMI ≤10 or BMI ≥100) for exclusion. Then, for the third step, each Veteran’s mean weight and standard deviation were determined from the remaining weights available. Weights in the EHR that were greater than 3 standard deviations from the mean, an additional 162,349 weights, were excluded. Overall, following the three-step cleaning procedure, a total of 278,303 (1.05%) weights were excluded from the analysis leaving 26,263,946 weights available for inclusion.

Of note, the cohort of Veterans for this analysis was defined, in part, by the presence of a sufficient number of weights taken in appropriate timeframes. The weight data cleaning procedure was conducted prior to defining the cohort.

APPENDIX C. Cohort Exclusions.

A large number (n = 351,262) of Veterans were excluded from the cohort due to insufficient weight data, which and may have introduced bias; thus our findings are limited to participants who remained engaged in care with the VHA (and, thereby, had recorded weight measurements) for at least one year post-initiation. The Veterans excluded have been characterized in the table below in comparison to those included in the cohort. The excluded Veterans appear to very similar to the cohort in demographic characteristics. Of note, TeleMOVE! participation, leptogenic medication use, and obesogenic medication use were higher in the cohort compared to those excluded. It is likely that the presence of recorded weight measures is related to health system engagement, and potentially also with comorbidities that require health system contact.

TABLE.Cohort Demographics and Characteristics.

Cohort
(n = 237,577) / Excluded Veterans
(n = 351,262)
Demographic Characteristics
Age in years, Mean (SD) / 54.4 (18.0) / 52.1 (18.7)
Male, n (%) / 207,534 (87.4) / 306,110 (87.2)
White, n (%) / 225,129 (72.9) / 323,804 (73.5)
Married, n (%) / 120,051 (50.6) / 186,449 (53.3)
Clinical Characteristics
Initiation weight in kg, Mean (SD) / 110.8 (23.7) / 109.0 (23.2)*
Overweight, n (%) / 37,418 (15.8) / 44,875 (17.2)*
Obese – Class I, n (%) / 77,932 (32.8) / 91,899 (35.1)*
Obese – Class II, n (%) / 61,846 (26.0) / 66,169 (25.3)*
Obese – Class III, n (%) / 54,785 (23.1) / 51,785 (19.8)*
TeleMOVE! participation, n (%) / 8,321 (3.5) / 9,803 (2.8)
Leptogenic medication use, n (%) / 8,562 (3.6) / 5,906 (1.7)
Obesogenic medication use, n (%) / 151,371 (63.7%) / 140,291 (39.9%)

*Initiation weight was missing for 25.5% of the excluded Veterans (n = 89,550), preventing their inclusion in calculating mean initiation weight and BMI classification.

APPENDIX D. Odds of Achieving Clinically Relevant Weight Loss at 12 Months.

TABLE.Odds of Achieving Clinically Relevant Weight Loss at 12 Months.

Number of Post-Initiation Contacts Per Veteran / n / Proportion Achieving Clinically Relevant Weight Loss / Unadjusted Odds Ratio (95% CI) / Adjusted* Odds Ratio (95% CI)
1 / 93,200 / 18.7% / Referent / Referent
2 to 5 / 73,612 / 18.8% / 1.01 (0.99 to 1.04) / 1.00 (0.98 to 1.03)
6 to 9 / 32,897 / 21.2% / 1.17 (1.14 to 1.21) / 1.17 (1.13 to 1.20)
10 to 13 / 17,988 / 26.1% / 1.54 (1.48 to 1.60) / 1.53 (1.47 to 1.59)
14 to 17 / 7,424 / 30.2% / 1.89 (1.79 to 1.99) / 1.84 (1.74 to 1.94)
18 or More / 12,456 / 32.3% / 2.27 (2.18 to 2.37) / 2.21 (2.12 to 2.31)

*Adjusted for age, gender, race, marital status, TeleMOVE! participation, history of obesogenic medication use, and history of leptogenic medication use.