1. The Impact of and Management of Obesity At Kaiser Permanente Academy Health National Health Policy Conference February 4-5, 2008 Washington, D.C. Francis J. Crosson, MD Senior Medical Director

2. 2 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

3. 3 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

4. 4 We have been at this a long time! … It is Our Heritage

5. 5 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)

6. 6 Adult BMI Measurement: Northwest Region BMI measured in 70.5% of Adult Members  70% Overweight/Obese  38% Obese  7% Extreme Obesity

7. 7 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

8. 8 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

9. 9 KPNW 2004 Diabetes and Prediabetes

10. 10 Comparison to BMI 20-25 BMI 30-3525% Increase BMI > 3544% Increase BMI > 4078% 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

11. 11 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

12. 12 Incremental Costs in Chronic Conditions CAD + Obesity CAD DM + Obesity CHF + Obesity DM CHF Note: Analysis is based on utilization and standardized unit costs. CMI 2003

13. 13 Increased Work Loss Employer Costs – Work Loss KP Data: HealthMedia Succeed Participants

14. 14 Multifaceted Public Health Approach to the Prevention and Treatment of Obesity Research network Legislation/ public policy Successful practice dissemination Clinical management Community partnerships Kaiser Permanente’s Strategic Approach

15. 15 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

16. 16 Risk Stratification KP Interventions BMI Risk StrataProposed Interventions NormalAdvice: “Maintain, Don’t Gain,” BMI 18 - 24.9 Prevention, 10,000 steps ® OverweightBalance TM, 10,000 Steps ®, BMI 25 - 29.9 Weight Watchers ® Local KP Program, Nourish TM, Relax TM Obese IBalance TM, 10,000 Steps ®, BMI 30 - 34.9 Weight Watchers ® Local KP Program, Nourish TM, Relax TM Obese IIBariatric Surgery, BMI 35 - 35.9 Local KP programs Obese IIIBariatric Surgery, Regional Medical BMI > 40 Weight Management Program

17. 17 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

18. 18 Decision Support – KP HealthConnect

19. 19 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 11 28 43 62 66 74 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

20. 20 Balance ® Online Weight Management Program

21. 21 180 Days post-program completion % Weight Loss in Balance by BMI

22. 22 Time Average # outpatient visits over previous six months MANOVA repeated measures test, F=4.1; p<.05; n=478 (6.5) (5.4) Balance ® RCT: Outpatient Visits

23. 23 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

24. 24 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

25. 25 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

26. 26 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 Diabetes84%91% OSA87%95% HTN75%87% Buchwald H JAMA 2004

27. 27 Farmers’ Markets Promote Environmental Change

28. 28 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

29. 29 When We Arrive…

30. 30 Contact Information If you have questions about Kaiser Permanente’s Weight Management Initiative, please contact: Trina Histon, PhD Kaiser Permanente Care Management Institute One Kaiser Plaza, 16L Oakland, CA 94612 trina.histon@kp.org (510) 271-2667

31. 31 Thank You