PATHWEIGH: pragmatic weight management in primary care

项目总结/摘要 肥胖--及其许多共病状况--现在已经超过吸烟，成为可预防的疾病的主要原因。 死亡在美国。尽管肥胖是可以治疗和预防的， 合并症而不是肥胖本身仍然是治疗的主要对象。重要的是，肥胖正在 越来越多的人认识到，这不仅是疾病的一个危险因素，而且本身就是一种疾病。尽管如此，<1%的 任何程度的超重或肥胖的人除了生活方式的建议之外，什么都没有得到。原因 缺乏重量管理优先化是广泛和复杂。实际上，主要利益攸关方， 包括肥胖症患者，他们的临床医生和保险公司，已经屈服于这一流行病。因此，有一个 迫切需要以务实的方法和证据系统地解决这些不同的障碍， 有助于体重管理的实践。为了解决这一差距，科罗拉多大学健康家庭 位于科罗拉多威斯敏斯特的一家医学诊所开发了PATHWEIGH。PATHWEIGH优先考虑重量 通过以下方式在初级保健中进行管理：1）使用EPIC中内置的指定的、时间效率高的流程图（ 在美国广泛使用的电子病历（EMR）系统）引导并捕捉历史 体重增加和减肥建议，以及与诊断和计费相关的实际问题， 和2）临床医生和团队培训a）使用PATHWEIGH作为工具，和B）教育当前有效的 体重管理的实践。我们的试点研究表明， PATHWEIGH在初级保健诊所的应用，显著改善了18岁以上患者的体重减轻 个月拟议工作的总体目标是测试PATHWEIGH与 在57个初级保健诊所提供护理，这些诊所涵盖不同的环境、患者人群和社区环境， 以检查优化执行的方法。我们的具体目标包括：1）评估执行情况 PATHWEIGH，并确定其有效性与对照诊所使用标准治疗（SOC）的患者 6个月时的体重减轻（主要）以及12和18个月时的体重减轻维持（次要）， 在初级保健中优先就诊，2）确定患者体重减轻和体重减轻维持的预测因素 使用中介者和调节者分析，包括相关患者、提供者和临床水平变量，以及3） 检查影响PATHWEIGH采用、实施和可持续性的环境因素， 实用、稳健、实施和可持续发展模式（PRISM）。为了实现这些目标，我们将 采用阶梯式楔形分组随机试验。数据收集和分析方法包括临床数据， 使用统计、定性和混合方法进行调查、观察和访谈。PATHWEIGH拥有 有可能成为一种可扩展的，低成本的，务实的肥胖方法。建议的基本原理 研究表明，PATHWEIGH的最终成功依赖于了解如何实施证据- 基于体重管理干预措施，并使其最有效，使用和保持在实践中。

Project Summary/Abstract Obesity – with its many comorbid conditions – has now surpassed smoking as the leading cause of preventable death in the United States. Despite the fact that obesity is both treatable and preventable, treating the comorbidities, rather than obesity per se remains the mainstay of therapy. Importantly, obesity is being increasingly recognized not only as a risk factor for disease, but a disease unto itself. Despite this fact, <1% of people with any degree of overweight or obesity are offered anything other than lifestyle advice. Reasons for lack of weight management prioritization are extensive and complex. Effectively, the major stakeholders, including people with obesity, their clinicians and insurers, have yielded to the epidemic. Thus, there is a critical need to systematically address these diverse barriers with pragmatic approaches and evidence that facilitates the practice of weight management. To address this gap, the University of Colorado Health Family Medicine clinic in Westminster, Colorado developed PATHWEIGH. PATHWEIGH prioritizes weight management in primary care by: 1) using a designated, time-efficient flowsheet built into EPIC (the most widely utilized electronic medical record (EMR) system in the U.S.) that guides and captures history around weight gain and recommendations for weight loss, as well as practical issues related to diagnosis and billing, and 2) clinician and team training on a) use of PATHWEIGH as a tool, and b) education on current effective practices for weight management. Our pilot study demonstrated the ability to effectively implement PATHWEIGH in a primary care clinic that lead to significant improvement in patient weight loss over 18 months. The overall objective for the proposed work is to test the effectiveness of PATHWEIGH vs. standard of care in 57 primary care clinics that span diverse settings, patient populations and community contexts, as well as to examine methods to optimize implementation. Our specific aims include: 1) Evaluate the implementation of PATHWEIGH and determine its effectiveness versus control clinics using standard of care (SOC) on patient weight loss at 6 months (primary) and weight loss maintenance at 12 and 18 months (secondary) for weight- prioritized visits in primary care, 2) Identify predictors of patient weight loss and weight loss maintenance using mediator and moderator analysis, including relevant patient, provider and clinic-level variables, and 3) Examine contextual factors affecting the adoption, implementation and sustainability of PATHWEIGH using the Practical, Robust, Implementation and Sustainability Model (PRISM). To complete these aims, we will utilize a stepped wedge cluster randomized trial. Data collection and analysis methods include clinical data, surveys, observations and interviews using statistical, qualitative and mixed methods. PATHWEIGH has the potential to be a scalable, low-cost, pragmatic approach to obesity. The rationale that underlies the proposed research is that the ultimate success of PATHWEIGH relies on understanding how to implement evidence- based weight management interventions and make them most effective, used and maintained in practice.