For the past five years, VA has struggled to implement a systemwide weight-reduction program to combat obesity rates among veterans receiving care. More than one-third of veterans receiving care qualified as obese in 2006, and VA believed that lowering obesity also would lower weight-related illness, including diabetes, cardiovascular disease, osteoarthritis and hypertension — all of which occur in high rates among VA’s population. 1
A recent evaluation of VA’s efforts shows only modest effects. However, that may be due to a number of institutional barriers that have made implementation move slowly in most VA medical centers (VAMCs).
VA designed the evidence-based weight-management program (MOVE) and began rolling it out in 2007. By 2009, nearly all of the 155 VAMCs reported having MOVE programs in place. A recent evaluation of the program by the division of VA that created it — the National Center for Health Promotion and Disease Prevention (NCP) — found only modest weight loss after six months of use and implementation coming in fits and starts at many VAMCs.
NCP researchers looked at 10 medical facilities with MOVE programs in place. They discovered barriers that differed from facility to facility.
All facilities either had an existing weight-management program or had participated in the pilot phase of MOVE before issuance of VA policy. According to the researchers, all of the facilities knew that the VA central office soon would hold them accountable for their obesity-screening rates — a key factor leading to increased demand for MOVE treatment.
However, pre-existing weight-management programs at three facilities provided limited preparation for MOVE, because they focused primarily on healthful eating and offered only group education. In one facility, previous programs were perceived as failures, which undermined organizational readiness. Even with pilot-phase experience, two facilities struggled to offer the full range of tiered-treatment options.
Delaying accountability for obesity screening gave facilities time to implement MOVE. However, the delay had the unintended effect of reducing the sense of urgency during the interim period, leading to slower than desired MOVE implementation at at least two facilities.
At two facilities, obesity-screening rates were added to an already long list of performance indicators, which may have diluted the motivational effect of such accountability.
Support among senior management was not consistent, researchers found. In some facilities, management did not begin allocating new resources to the MOVE program until the facility had to become accountable for their obesity-screening rates.
Support among service-line chiefs also was sporadic. According to VA staff interviewed, the attitude of service-line chiefs ranged from support to passive acceptance to skepticism.
All 10 facilities attempted to tailor MOVE to better fit their organization. These modifications included adding or removing clinical reminders for obesity screening, tailoring procedures for enrolling patients and offering various levels of the MOVE program at a facility. Eight facilities noted that primary-care nurses and physicians felt that tasks associated with MOVE, such as the clinical reminder to screen for obesity or attending multidisciplinary meetings, were time consuming and burdensome to already heavy workloads. Two facilities decided to remove the clinical reminder altogether.
The NCP researchers concluded that organizational readiness for change and having a champion for innovation were the two factors most consistent with the success of MOVE implementation. However, they noted that 10 cases do not prove for a strong database.
They suggest two directions for future research. Research needs to be done on the multilayered complexities of management support and how it impacts change at facilities, and how informal innovation champions — those who step outside of their organizationally prescribed roles — help make innovations successful.
MOVE Program Testimonial:
1.Kuwait LC, Lewis MA, Kane H, Williams PA, Nerz P, Jones KR, Lance TX, Vaisey S, Kinsinger LS. Best practices in the Veterans Health Administration’s MOVE! Weight management program. Am J Prev Med. 2011 Nov;41(5):457-64. PubMed PMID: 22011415.Institutional Barriers Seen in VA MOVE Program Rollout
Researchers Look at GFR Patterns In Kidney Failure
While the course of patients on dialysis have been extensively documented, little is known about patterns of kidney function decline leading to the initiation of long-term dialysis. A recent study at the VA Pugent Sound Healthcare System has sought to fill in that knowledge gap.1
Researchers looked at 5,606 VA patients who initiated long-term dialysis between 2001 and 2003. The patients looked at the trajectory of estimated glomerular filtration rate (eGFR) during the two years prior to dialysis. Testing eGFR is currently the measure of kidney function and a patient’s stage of kidney disease.
The study identified four distinct trajectories of eGFR during that two-year period: 62.8% of patients had persistently low level, 24.6% had progressive loss of eGFR, 9.5% had accelerated loss of eGFR, and 3.1% experienced catastrophic loss of eGFR within six months or less.
Patients with steeper eGFR trajectories were more likely to have been hospitalized and have an inpatient diagnosis of acute kidney injury but less likely to have received recommended predialysis care and had a higher risk of death in the first year after dialysis initiation.
According to the researchers, these findings suggest a substantial heterogeneity in patterns of kidney-function loss, which might call for a more flexible approach when preparing patients for end-stage renal disease.
1.O’Hare AM, Batten A, Burrows NR, Pavlov ME, Taylor L, Gupta I, Todd-Stenberg J, Maynard C, Rodriguez RA, Murtagh FE, Larson EB, Williams DE. Trajectories of Kidney Function Decline in the 2 Years Before Initiation of Long-term Dialysis. Am J Kidney Dis. 2012 Feb 3. [Epub ahead of print] PubMed PMID: 22305760.
Age Not a Factor in Relationship Between GFR and Metabolic Problems
Are elderly adults with a low glomerular filtration rate (GFR) at an increased risk for anemia, hyperkalemia, acidosis and hyperphosphatemia? According to research conducted by VA, they are, although age does not modify the relationship between GFR and development of metabolic complications. 1
A study conducted by researchers at the Louis Stokes Cleveland VA Medical Center looked at 13,874 veterans age 65 and older with chronic kidney disease and a GFR between 15 and 60 mL/min per 1.73 m(2).
Researchers looked at levels of anemia, hyperkalemia, acidosis and hyperphosphatemia, examining the effect low GFR had on metabolic complications.
The study showed that 3.1% of patients had anemia, 2.5% had hyperkalemia, 2.3% had acidosis and 4.4% had hyperphosphatemia. Lower GFR was associated with higher levels of metabolic complications across all age groups, and there was no significant interaction between age and GFR.
According to the study, all elderly adults with chronic kidney disease are at a risk for these metabolic complications, regardless of their age. Elderly adults with low GFR also should be monitored for these complications, the authors said.
1.Drawz PE, Babineau DC, Rahman M. Metabolic Complications in Elderly Adults with Chronic Kidney Disease. J Am Geriatr Soc. 2012 Jan 27. doi: 10.1111/j.1532-5415.2011.03818.x. [Epub ahead of print] PubMed PMID: 22283563.
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