Leila Kahwati - Academia.edu (original) (raw)

Papers by Leila Kahwati

Systematic reviews, Jan 4, 2016

Interventions to improve medication adherence are diverse and complex. Consequently, synthesizing... more Interventions to improve medication adherence are diverse and complex. Consequently, synthesizing this evidence is challenging. We aimed to extend the results from an existing systematic review of interventions to improve medication adherence by using qualitative comparative analysis (QCA) to identify necessary or sufficient configurations of behavior change techniques among effective interventions. We used data from 60 studies in a completed systematic review to examine the combinations of nine behavior change techniques (increasing knowledge, increasing awareness, changing attitude, increasing self-efficacy, increasing intention formation, increasing action control, facilitation, increasing maintenance support, and motivational interviewing) among studies demonstrating improvements in adherence. Among the 60 studies, 34 demonstrated improved medication adherence. Among effective studies, increasing patient knowledge was a necessary but not sufficient technique. We identified seven...

Systematic reviews, Jan 4, 2016

Systematic reviews evaluating complex interventions often encounter substantial clinical heteroge... more Systematic reviews evaluating complex interventions often encounter substantial clinical heterogeneity in intervention components and implementation features making synthesis challenging. Qualitative comparative analysis (QCA) is a non-probabilistic method that uses mathematical set theory to study complex phenomena; it has been proposed as a potential method to complement traditional evidence synthesis in reviews of complex interventions to identify key intervention components or implementation features that might explain effectiveness or ineffectiveness. The objective of this study was to describe our approach in detail and examine the suitability of using QCA within the context of a systematic review. We used data from a completed systematic review of behavioral interventions to improve medication adherence to conduct two substantive analyses using QCA. The first analysis sought to identify combinations of nine behavior change techniques/components (BCTs) found among effective in...

Military Medicine, Jun 1, 2008

Overweight and obesity are increasingly contributing to disease burden among military populations... more Overweight and obesity are increasingly contributing to disease burden among military populations. The purpose of this study was to calculate and examine the prevalence of overweight and obesity among the veteran population. Data were obtained from the 2004 Behavioral Risk Factor Surveillance System. Overweight (body mass index > or = 25 kg/m2) prevalence in veterans was 73.3% (SE, 0.4%) for males and 53.6% (SE 1.7%) for females. Obesity (body mass index > or = 30 kg/m2) prevalence in veterans was 25.3% (SE, 0.4%) for males and 21.2% (SE, 1.4%) for females. After adjusting for sociodemographics and health status, veterans were no more likely to be overweight (odds ratio, 1.05; 95% confidence interval, 0.99-1.11) or obese (odds ratio 0.99; confidence interval, 0.93-1.05) than nonveterans. Despite previous participation in a culture and environment that selects for and enforces body weight standards, veterans have a high prevalence of overweight and obesity that is similar to general population estimates.

Family Medicine, Feb 1, 2006

Although the vast majority of health care is rendered in primary care practices, 1 most research ... more Although the vast majority of health care is rendered in primary care practices, 1 most research is carried out in subspecialty settings, largely in tertiary care centers. To help alleviate this disparity between research and practice settings, it has been increasingly recommended that "various types of practice laboratories, or centers of excellence" in primary care research be established. To date, efforts to develop a primary care research infrastructure have largely focused on establishing practice-based research networks (PBRNs)-groups of practices that affiliate to carry out practice-relevant research.

Military Medicine, Jun 1, 2008

Overweight and obesity are increasingly contributing to disease burden among military populations... more Overweight and obesity are increasingly contributing to disease burden among military populations. The purpose of this study was to calculate and examine the prevalence of overweight and obesity among the veteran population. Data were obtained from the 2004 Behavioral Risk Factor Surveillance System. Overweight (body mass index > or = 25 kg/m2) prevalence in veterans was 73.3% (SE, 0.4%) for males and 53.6% (SE 1.7%) for females. Obesity (body mass index > or = 30 kg/m2) prevalence in veterans was 25.3% (SE, 0.4%) for males and 21.2% (SE, 1.4%) for females. After adjusting for sociodemographics and health status, veterans were no more likely to be overweight (odds ratio, 1.05; 95% confidence interval, 0.99-1.11) or obese (odds ratio 0.99; confidence interval, 0.93-1.05) than nonveterans. Despite previous participation in a culture and environment that selects for and enforces body weight standards, veterans have a high prevalence of overweight and obesity that is similar to general population estimates.

American Journal of Preventive Medicine, 2016

Sedentary time spent with screen media is associated with obesity among children and adults. Obes... more Sedentary time spent with screen media is associated with obesity among children and adults. Obesity has potentially serious health consequences, such as heart disease and diabetes. This Community Guide systematic review examined the effectiveness and economic efficiency of behavioral interventions aimed at reducing recreational (i.e., neither school- nor work-related) sedentary screen time, as measured by screen time, physical activity, diet, and weight-related outcomes. For this review, an earlier ("original") review (search period, 1966 through July 2007) was combined with updated evidence (search period, April 2007 through June 2013) to assess effectiveness of behavioral interventions aimed at reducing recreational sedentary screen time. Existing Community Guide systematic review methods were used. Analyses were conducted in 2013-2014. The review included 49 studies. Two types of behavioral interventions were evaluated that either (1) focus on reducing recreational sedentary screen time only (12 studies); or (2) focus equally on reducing recreational sedentary screen time and improving physical activity or diet (37 studies). Most studies targeted children aged ≤13 years. Children's composite screen time (TV viewing plus other forms of recreational sedentary screen time) decreased 26.4 (interquartile interval= -74.4, -12.0) minutes/day and obesity prevalence decreased 2.3 (interquartile interval= -4.5, -1.2) percentage points versus a comparison group. Improvements in physical activity and diet were reported. Three study arms among adults found composite screen time decreased by 130.2 minutes/day. Among children, these interventions demonstrated reduced screen time, increased physical activity, and improved diet- and weight-related outcomes. More research is needed among adolescents and adults.

Preventing Chronic Disease, 2012

One-third of US veterans receiving care at Veterans Health Administration (VHA) medical facilitie... more One-third of US veterans receiving care at Veterans Health Administration (VHA) medical facilities are obese and, therefore, at higher risk for developing multiple chronic diseases. To address this problem, the VHA designed and nationally disseminated an evidence-based weight-management program (MOVE!). The objective of this study was to examine the organizational factors that aided or inhibited the implementation of MOVE! in 10 VHA medical facilities.

North Carolina Medical Journal, 2004

The Journal of family practice

Family medicine, 2006

Efforts to develop "laboratories" for primary care research have largely focused on the... more Efforts to develop "laboratories" for primary care research have largely focused on the development of networks that recruit subjects on a project-specific basis. We sought to develop an alternative model--a representative cohort of adult primary care patients maintained for use in multiple projects. In 2001, research assistants in waiting areas of a representative sample of 16 family medicine practices in North Carolina approached all adult patients during a 4-week period. Follow-up has been maintained for 3 years. In 2004 and 2005, the cohort was refreshed by adding eight new practices. Each consenting subject was administered a four-page self report questionnaire that included items on demographics, risk factors, health status, and quality of life. Of 10,649 eligible patients approached in 2001, 6,811 (64%) completed the enrollment questionnaire, of whom 5,575 (81.9%) consented to be included in the cohort. African Americans, Latinos, and older persons were enrolled at ...

North Carolina medical journal

JAMA Internal Medicine, 2015

IMPORTANCE Medication therapy management (MTM) services (also called clinical pharmacy services) ... more IMPORTANCE Medication therapy management (MTM) services (also called clinical pharmacy services) aim to reduce medication-related problems and their downstream outcomes. OBJECTIVE To assess the effect of MTM interventions among outpatients with chronic illnesses. DATA SOURCES MEDLINE, Cochrane Library, and International Pharmaceutical Abstracts through January 9, 2014. STUDY SELECTION Two reviewers selected studies with comparators and eligible outcomes of ambulatory adults.

Preventing chronic disease, 2009

Practitioners in the Veterans Health Administration (VHA) identified comprehensive weight managem... more Practitioners in the Veterans Health Administration (VHA) identified comprehensive weight management as a high priority in early 2001. The MOVE! Weight-Management Program for Veterans was developed on the basis of published guidelines from the National Institutes of Health and other organizations. Testing of program feasibility occurred at 17 VHA sites, and the program was refined during early implementation throughout 2005. MOVE! was disseminated nationally in January 2006. Local program coordinators and physician champions were named, and toolkits, online training, marketing materials, and ongoing field support were provided. MOVE! has been implemented at nearly all VHA medical centers. By June 2008, more than 100,000 patients had participated in MOVE! during more than 500,000 visits. An evaluation based on an established framework is under way. MOVE! is an example of the large-scale translation of research into practice. It has the potential to reduce the burden of disease from o...

Translational Behavioral Medicine, 2011

Over one-third of patients treated in the Veterans Health Administration (VHA) are obese. VHA int... more Over one-third of patients treated in the Veterans Health Administration (VHA) are obese. VHA introduced the MOVE! Weight Management Program for Veterans in 2006 to provide comprehensive weight management services. An evolving, periodic evaluation using the RE-AIM framework (reach, effectiveness, adoption, implementation, and maintenance) has been conducted to gauge success and opportunities for improvement. Key metrics were identified in each Implications Practice: Weight management treatment can be delivered at VHA medical centers and community-based outpatient clinics with modest but positive impact on short-term weight loss outcomes. Intensity and span of treatment are key drivers of clinical success.

Surgery for Obesity and Related Diseases, 2010

Bariatric surgery has largely been performed on middle-age female populations and been associated... more Bariatric surgery has largely been performed on middle-age female populations and been associated with significant medication discontinuation; however, it is unknown whether similar medication discontinuation rates could be achieved in men. The purpose of the present analysis was to examine the discontinuation rate of diabetes or lipid-lowering medications and the patient factors associated with medication discontinuation among veterans undergoing bariatric surgery. We identified the demographic and health status information for 284 veterans with diabetes and 298 veterans with hyperlipidemia who had undergone bariatric surgery at 1 of 12 Veterans Affairs bariatric centers in 2000 to 2006 from the Veterans Affairs National Surgical Quality Improvement Program data. We also identified the medications that had been prescribed and discontinued using the Veterans Affairs administrative data. Medication discontinuation was estimated using a logistic regression model. Of the 284 veterans with diabetes and 298 with hyperlipidemia, 52% and 40% had discontinued their medications at 1 year, respectively. The veterans with diabetes were more likely to discontinue medication if they had been taking oral hypoglycemic agents alone (odds ratio 2.77, P <.001) than were those taking insulin or oral hypoglycemic agents and insulin. The veterans with hyperlipidemia were more likely to discontinue medication if they had only been taking fibrates (odds ratio 6.15, P <.01) than were those veterans taking statins and fibrates. Bariatric surgery led to significant medication discontinuation within 1 year for high-risk veterans with diabetes or hyperlipidemia.

Military Medicine, 2008

Overweight and obesity are increasingly contributing to disease burden among military populations... more Overweight and obesity are increasingly contributing to disease burden among military populations. The purpose of this study was to calculate and examine the prevalence of overweight and obesity among the veteran population. Data were obtained from the 2004 Behavioral Risk Factor Surveillance System. Overweight (body mass index > or = 25 kg/m2) prevalence in veterans was 73.3% (SE, 0.4%) for males and 53.6% (SE 1.7%) for females. Obesity (body mass index > or = 30 kg/m2) prevalence in veterans was 25.3% (SE, 0.4%) for males and 21.2% (SE, 1.4%) for females. After adjusting for sociodemographics and health status, veterans were no more likely to be overweight (odds ratio, 1.05; 95% confidence interval, 0.99-1.11) or obese (odds ratio 0.99; confidence interval, 0.93-1.05) than nonveterans. Despite previous participation in a culture and environment that selects for and enforces body weight standards, veterans have a high prevalence of overweight and obesity that is similar to general population estimates.

Implementation science : IS, 2014

Implementation of practice change is difficult and large scale implementation is particularly dif... more Implementation of practice change is difficult and large scale implementation is particularly difficult. Among the challenges facing the healthcare system in general and healthcare organizations is the overuse of low value care. Improving medication safety also constitutes an attempt to reduce low value or potentially harmful care. Critical issues of overuse of low value practices and medication safety intersect in overtreatment of diabetes. Specifically, (over)intensive glycemic control increases hypoglycemia risk and morbidity without providing meaningful benefit. Our work indicates that among patients with diabetes who are at high risk for hypoglycemia, potential overtreatment is common. The Choosing Wisely Initiative to reduce low value care led by the American Board of Internal Medicine Foundation recommends not to treat most persons over 65 years of age with medications to reduce the A1c<7.5%. For most physicians this involves a change in practice. We will study the impleme...

Translational Behavioral Medicine, 2014

Understanding the factors that facilitate implementation of behavioral medicine programs into pra... more Understanding the factors that facilitate implementation of behavioral medicine programs into practice can advance translational science. Often, translation or implementation studies use case study methods with small sample sizes. Methodological approaches that systematize findings from these types of studies are needed to improve rigor and advance the field. Qualitative comparative analysis (QCA) is a method and analytical approach that can advance implementation science. QCA offers an approach for rigorously conducting translational and implementation research limited by a small number of cases. We describe the methodological and analytic approach for using QCA and provide examples of its use in the health and health services literature. QCA brings together qualitative or quantitative data derived from cases to identify necessary and sufficient conditions for an outcome. QCA offers advantages for researchers interested in analyzing complex programs and for practitioners interested in developing programs that achieve successful health outcomes.

Preventing Chronic Disease, 2013

The Veterans Health Administration (VHA) has implemented MOVE!, a weight-management program for v... more The Veterans Health Administration (VHA) has implemented MOVE!, a weight-management program for veterans designed to address the increasing proportion of overweight and obese veterans. The objective of our study was to determine whether peer support employing motivational interviewing (MI) could positively influence lifestyle changes, thus expanding the reach of the MOVE! program. We describe the initial evaluation of the peer training program. We developed an MI peer ounselor training program for volunteer veterans, the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;Buddies&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; program, to provide one-on-one telephone support for veterans enrolled in MOVE!. Buddies were recruited at 5 VHA sites and trained to provide peer support for the 6-month MOVE! intervention. We used a DVD to teach MI skills and followed with 2 to 3 booster sessions. We observed training, conducted pre- and posttraining surveys, and debriefed focus groups to assess training feasibility. Fifty-six Buddies were trained. Results indicate positive receipt of the program (89% reported learning about peer counseling and 87% reported learning communication skills). Buddies showed a small improvement in MI self-efficacy on posttraining surveys. We also identified key challenges to learning MI and training implementation. MI training is feasible to implement and acceptable to volunteer Buddies. Trainers must assess how effectively volunteers learn MI skills in order to enhance its effective use in health promotion.

Systematic reviews, Jan 4, 2016

Interventions to improve medication adherence are diverse and complex. Consequently, synthesizing... more Interventions to improve medication adherence are diverse and complex. Consequently, synthesizing this evidence is challenging. We aimed to extend the results from an existing systematic review of interventions to improve medication adherence by using qualitative comparative analysis (QCA) to identify necessary or sufficient configurations of behavior change techniques among effective interventions. We used data from 60 studies in a completed systematic review to examine the combinations of nine behavior change techniques (increasing knowledge, increasing awareness, changing attitude, increasing self-efficacy, increasing intention formation, increasing action control, facilitation, increasing maintenance support, and motivational interviewing) among studies demonstrating improvements in adherence. Among the 60 studies, 34 demonstrated improved medication adherence. Among effective studies, increasing patient knowledge was a necessary but not sufficient technique. We identified seven...

Systematic reviews, Jan 4, 2016

Systematic reviews evaluating complex interventions often encounter substantial clinical heteroge... more Systematic reviews evaluating complex interventions often encounter substantial clinical heterogeneity in intervention components and implementation features making synthesis challenging. Qualitative comparative analysis (QCA) is a non-probabilistic method that uses mathematical set theory to study complex phenomena; it has been proposed as a potential method to complement traditional evidence synthesis in reviews of complex interventions to identify key intervention components or implementation features that might explain effectiveness or ineffectiveness. The objective of this study was to describe our approach in detail and examine the suitability of using QCA within the context of a systematic review. We used data from a completed systematic review of behavioral interventions to improve medication adherence to conduct two substantive analyses using QCA. The first analysis sought to identify combinations of nine behavior change techniques/components (BCTs) found among effective in...

Military Medicine, Jun 1, 2008

Overweight and obesity are increasingly contributing to disease burden among military populations... more Overweight and obesity are increasingly contributing to disease burden among military populations. The purpose of this study was to calculate and examine the prevalence of overweight and obesity among the veteran population. Data were obtained from the 2004 Behavioral Risk Factor Surveillance System. Overweight (body mass index &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; or = 25 kg/m2) prevalence in veterans was 73.3% (SE, 0.4%) for males and 53.6% (SE 1.7%) for females. Obesity (body mass index &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; or = 30 kg/m2) prevalence in veterans was 25.3% (SE, 0.4%) for males and 21.2% (SE, 1.4%) for females. After adjusting for sociodemographics and health status, veterans were no more likely to be overweight (odds ratio, 1.05; 95% confidence interval, 0.99-1.11) or obese (odds ratio 0.99; confidence interval, 0.93-1.05) than nonveterans. Despite previous participation in a culture and environment that selects for and enforces body weight standards, veterans have a high prevalence of overweight and obesity that is similar to general population estimates.

Family Medicine, Feb 1, 2006

Although the vast majority of health care is rendered in primary care practices, 1 most research ... more Although the vast majority of health care is rendered in primary care practices, 1 most research is carried out in subspecialty settings, largely in tertiary care centers. To help alleviate this disparity between research and practice settings, it has been increasingly recommended that "various types of practice laboratories, or centers of excellence" in primary care research be established. To date, efforts to develop a primary care research infrastructure have largely focused on establishing practice-based research networks (PBRNs)-groups of practices that affiliate to carry out practice-relevant research.

Military Medicine, Jun 1, 2008

Overweight and obesity are increasingly contributing to disease burden among military populations... more Overweight and obesity are increasingly contributing to disease burden among military populations. The purpose of this study was to calculate and examine the prevalence of overweight and obesity among the veteran population. Data were obtained from the 2004 Behavioral Risk Factor Surveillance System. Overweight (body mass index > or = 25 kg/m2) prevalence in veterans was 73.3% (SE, 0.4%) for males and 53.6% (SE 1.7%) for females. Obesity (body mass index > or = 30 kg/m2) prevalence in veterans was 25.3% (SE, 0.4%) for males and 21.2% (SE, 1.4%) for females. After adjusting for sociodemographics and health status, veterans were no more likely to be overweight (odds ratio, 1.05; 95% confidence interval, 0.99-1.11) or obese (odds ratio 0.99; confidence interval, 0.93-1.05) than nonveterans. Despite previous participation in a culture and environment that selects for and enforces body weight standards, veterans have a high prevalence of overweight and obesity that is similar to general population estimates.

American Journal of Preventive Medicine, 2016

Sedentary time spent with screen media is associated with obesity among children and adults. Obes... more Sedentary time spent with screen media is associated with obesity among children and adults. Obesity has potentially serious health consequences, such as heart disease and diabetes. This Community Guide systematic review examined the effectiveness and economic efficiency of behavioral interventions aimed at reducing recreational (i.e., neither school- nor work-related) sedentary screen time, as measured by screen time, physical activity, diet, and weight-related outcomes. For this review, an earlier (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;original&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;) review (search period, 1966 through July 2007) was combined with updated evidence (search period, April 2007 through June 2013) to assess effectiveness of behavioral interventions aimed at reducing recreational sedentary screen time. Existing Community Guide systematic review methods were used. Analyses were conducted in 2013-2014. The review included 49 studies. Two types of behavioral interventions were evaluated that either (1) focus on reducing recreational sedentary screen time only (12 studies); or (2) focus equally on reducing recreational sedentary screen time and improving physical activity or diet (37 studies). Most studies targeted children aged ≤13 years. Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s composite screen time (TV viewing plus other forms of recreational sedentary screen time) decreased 26.4 (interquartile interval= -74.4, -12.0) minutes/day and obesity prevalence decreased 2.3 (interquartile interval= -4.5, -1.2) percentage points versus a comparison group. Improvements in physical activity and diet were reported. Three study arms among adults found composite screen time decreased by 130.2 minutes/day. Among children, these interventions demonstrated reduced screen time, increased physical activity, and improved diet- and weight-related outcomes. More research is needed among adolescents and adults.

Preventing Chronic Disease, 2012

One-third of US veterans receiving care at Veterans Health Administration (VHA) medical facilitie... more One-third of US veterans receiving care at Veterans Health Administration (VHA) medical facilities are obese and, therefore, at higher risk for developing multiple chronic diseases. To address this problem, the VHA designed and nationally disseminated an evidence-based weight-management program (MOVE!). The objective of this study was to examine the organizational factors that aided or inhibited the implementation of MOVE! in 10 VHA medical facilities.

North Carolina Medical Journal, 2004

The Journal of family practice

Family medicine, 2006

Efforts to develop "laboratories" for primary care research have largely focused on the... more Efforts to develop "laboratories" for primary care research have largely focused on the development of networks that recruit subjects on a project-specific basis. We sought to develop an alternative model--a representative cohort of adult primary care patients maintained for use in multiple projects. In 2001, research assistants in waiting areas of a representative sample of 16 family medicine practices in North Carolina approached all adult patients during a 4-week period. Follow-up has been maintained for 3 years. In 2004 and 2005, the cohort was refreshed by adding eight new practices. Each consenting subject was administered a four-page self report questionnaire that included items on demographics, risk factors, health status, and quality of life. Of 10,649 eligible patients approached in 2001, 6,811 (64%) completed the enrollment questionnaire, of whom 5,575 (81.9%) consented to be included in the cohort. African Americans, Latinos, and older persons were enrolled at ...

North Carolina medical journal

JAMA Internal Medicine, 2015

IMPORTANCE Medication therapy management (MTM) services (also called clinical pharmacy services) ... more IMPORTANCE Medication therapy management (MTM) services (also called clinical pharmacy services) aim to reduce medication-related problems and their downstream outcomes. OBJECTIVE To assess the effect of MTM interventions among outpatients with chronic illnesses. DATA SOURCES MEDLINE, Cochrane Library, and International Pharmaceutical Abstracts through January 9, 2014. STUDY SELECTION Two reviewers selected studies with comparators and eligible outcomes of ambulatory adults.

Preventing chronic disease, 2009

Practitioners in the Veterans Health Administration (VHA) identified comprehensive weight managem... more Practitioners in the Veterans Health Administration (VHA) identified comprehensive weight management as a high priority in early 2001. The MOVE! Weight-Management Program for Veterans was developed on the basis of published guidelines from the National Institutes of Health and other organizations. Testing of program feasibility occurred at 17 VHA sites, and the program was refined during early implementation throughout 2005. MOVE! was disseminated nationally in January 2006. Local program coordinators and physician champions were named, and toolkits, online training, marketing materials, and ongoing field support were provided. MOVE! has been implemented at nearly all VHA medical centers. By June 2008, more than 100,000 patients had participated in MOVE! during more than 500,000 visits. An evaluation based on an established framework is under way. MOVE! is an example of the large-scale translation of research into practice. It has the potential to reduce the burden of disease from o...

Translational Behavioral Medicine, 2011

Over one-third of patients treated in the Veterans Health Administration (VHA) are obese. VHA int... more Over one-third of patients treated in the Veterans Health Administration (VHA) are obese. VHA introduced the MOVE! Weight Management Program for Veterans in 2006 to provide comprehensive weight management services. An evolving, periodic evaluation using the RE-AIM framework (reach, effectiveness, adoption, implementation, and maintenance) has been conducted to gauge success and opportunities for improvement. Key metrics were identified in each Implications Practice: Weight management treatment can be delivered at VHA medical centers and community-based outpatient clinics with modest but positive impact on short-term weight loss outcomes. Intensity and span of treatment are key drivers of clinical success.

Surgery for Obesity and Related Diseases, 2010

Bariatric surgery has largely been performed on middle-age female populations and been associated... more Bariatric surgery has largely been performed on middle-age female populations and been associated with significant medication discontinuation; however, it is unknown whether similar medication discontinuation rates could be achieved in men. The purpose of the present analysis was to examine the discontinuation rate of diabetes or lipid-lowering medications and the patient factors associated with medication discontinuation among veterans undergoing bariatric surgery. We identified the demographic and health status information for 284 veterans with diabetes and 298 veterans with hyperlipidemia who had undergone bariatric surgery at 1 of 12 Veterans Affairs bariatric centers in 2000 to 2006 from the Veterans Affairs National Surgical Quality Improvement Program data. We also identified the medications that had been prescribed and discontinued using the Veterans Affairs administrative data. Medication discontinuation was estimated using a logistic regression model. Of the 284 veterans with diabetes and 298 with hyperlipidemia, 52% and 40% had discontinued their medications at 1 year, respectively. The veterans with diabetes were more likely to discontinue medication if they had been taking oral hypoglycemic agents alone (odds ratio 2.77, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.001) than were those taking insulin or oral hypoglycemic agents and insulin. The veterans with hyperlipidemia were more likely to discontinue medication if they had only been taking fibrates (odds ratio 6.15, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.01) than were those veterans taking statins and fibrates. Bariatric surgery led to significant medication discontinuation within 1 year for high-risk veterans with diabetes or hyperlipidemia.

Military Medicine, 2008

Overweight and obesity are increasingly contributing to disease burden among military populations... more Overweight and obesity are increasingly contributing to disease burden among military populations. The purpose of this study was to calculate and examine the prevalence of overweight and obesity among the veteran population. Data were obtained from the 2004 Behavioral Risk Factor Surveillance System. Overweight (body mass index &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; or = 25 kg/m2) prevalence in veterans was 73.3% (SE, 0.4%) for males and 53.6% (SE 1.7%) for females. Obesity (body mass index &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; or = 30 kg/m2) prevalence in veterans was 25.3% (SE, 0.4%) for males and 21.2% (SE, 1.4%) for females. After adjusting for sociodemographics and health status, veterans were no more likely to be overweight (odds ratio, 1.05; 95% confidence interval, 0.99-1.11) or obese (odds ratio 0.99; confidence interval, 0.93-1.05) than nonveterans. Despite previous participation in a culture and environment that selects for and enforces body weight standards, veterans have a high prevalence of overweight and obesity that is similar to general population estimates.

Implementation science : IS, 2014

Implementation of practice change is difficult and large scale implementation is particularly dif... more Implementation of practice change is difficult and large scale implementation is particularly difficult. Among the challenges facing the healthcare system in general and healthcare organizations is the overuse of low value care. Improving medication safety also constitutes an attempt to reduce low value or potentially harmful care. Critical issues of overuse of low value practices and medication safety intersect in overtreatment of diabetes. Specifically, (over)intensive glycemic control increases hypoglycemia risk and morbidity without providing meaningful benefit. Our work indicates that among patients with diabetes who are at high risk for hypoglycemia, potential overtreatment is common. The Choosing Wisely Initiative to reduce low value care led by the American Board of Internal Medicine Foundation recommends not to treat most persons over 65 years of age with medications to reduce the A1c<7.5%. For most physicians this involves a change in practice. We will study the impleme...

Translational Behavioral Medicine, 2014

Understanding the factors that facilitate implementation of behavioral medicine programs into pra... more Understanding the factors that facilitate implementation of behavioral medicine programs into practice can advance translational science. Often, translation or implementation studies use case study methods with small sample sizes. Methodological approaches that systematize findings from these types of studies are needed to improve rigor and advance the field. Qualitative comparative analysis (QCA) is a method and analytical approach that can advance implementation science. QCA offers an approach for rigorously conducting translational and implementation research limited by a small number of cases. We describe the methodological and analytic approach for using QCA and provide examples of its use in the health and health services literature. QCA brings together qualitative or quantitative data derived from cases to identify necessary and sufficient conditions for an outcome. QCA offers advantages for researchers interested in analyzing complex programs and for practitioners interested in developing programs that achieve successful health outcomes.

Preventing Chronic Disease, 2013

The Veterans Health Administration (VHA) has implemented MOVE!, a weight-management program for v... more The Veterans Health Administration (VHA) has implemented MOVE!, a weight-management program for veterans designed to address the increasing proportion of overweight and obese veterans. The objective of our study was to determine whether peer support employing motivational interviewing (MI) could positively influence lifestyle changes, thus expanding the reach of the MOVE! program. We describe the initial evaluation of the peer training program. We developed an MI peer ounselor training program for volunteer veterans, the &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;Buddies&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; program, to provide one-on-one telephone support for veterans enrolled in MOVE!. Buddies were recruited at 5 VHA sites and trained to provide peer support for the 6-month MOVE! intervention. We used a DVD to teach MI skills and followed with 2 to 3 booster sessions. We observed training, conducted pre- and posttraining surveys, and debriefed focus groups to assess training feasibility. Fifty-six Buddies were trained. Results indicate positive receipt of the program (89% reported learning about peer counseling and 87% reported learning communication skills). Buddies showed a small improvement in MI self-efficacy on posttraining surveys. We also identified key challenges to learning MI and training implementation. MI training is feasible to implement and acceptable to volunteer Buddies. Trainers must assess how effectively volunteers learn MI skills in order to enhance its effective use in health promotion.