The purpose of this project was to explore a new model of community-based care in which obesity medicine-trained primary care physicians provide comprehensive obesity care to better meet the needs of most patients, with specialist care being reserved only for complex cases. To our knowledge, there are few publications describing weight management programs in community-based primary care settings with consistent design and adherence to current obesity treatment guidelines. Specifically, there is a sparsity of effectiveness data using anti-obesity medication in primary care practices serving resource-limited populations.
As evidenced by this project, having a community-based model for a chronic, widely prevalent, clinically important disease like obesity is a valuable addition to any healthcare system, even in the presence of a specialty care model. Through implementation of the model, 53.1% of patients achieved at least 5% total body weight loss after attending four or more visits, losing an average of 5.83% total body weight. Twenty percent of our patients achieved greater than 10% total body weight loss, an average of 11 kgs, suggesting that durable weight loss is achievable in a primary care setting. The results are promising as the Diabetes Prevention Program and DiRECT study showed that even modest weight loss with nutrition and lifestyle intervention in the community setting has significant health benefits, including diabetes prevention and remission.[9, 23] Long-term follow-up of community-based medical weight-loss interventions to assess for longitudinal health benefits and cost-effectiveness is needed.
The primary benefit of community-based clinics is decreasing the many barriers to evidence-based obesity care. The financial burden was one of the top barriers identified by primary care patients who had visited specialty weight management clinics. Accordingly, patients were only responsible for primary care copays and minimal out-of-pocket costs for prescribed medications. Compared to primarily lifestyle-based studies, our pilot model had fewer visits and fewer copays. Facility fees charged at specialty clinics were also eliminated by providing services in a community-based, primary care setting. Medication cost and insurance coverage limited the use of FDA-approved drugs, both of which are common barriers in community-based care, reflected in the absence of efficacy data on anti-obesity medication in community settings. Despite these limitations, the model replicated weight loss achieved in larger, randomized clinical trials. Physicians strategically prescribed generic medications in combination as alternatives to expensive brand name medications. For example, generic phentermine and topiramate were prescribed as an alternative to Qsymia. Additionally, embedding weight management services within three different central North Carolina communities decreased geographic barriers to care, which was important for reaching the primarily suburban and rural populations of the payor mix.
While more physician-centric than traditional lifestyle-focused programs, this model also provided more personalized patient-centered care and quicker utilization of anti-obesity medications for patients with established obesity. The patient-centered approach paired with adjuvant pharmacotherapy was essential for our patients’ success, whose average BMI was 40.0 (Table 1). Among our patients who attended four or more visits, over three-quarters of patients (78%) utilized pharmacotherapy in addition to TLC. Research has shown that in patients with severe obesity (BMI > 40), intensive lifestyle intervention alone usually does not sustain weight loss, and in the absence of a desire to proceed to bariatric surgery, earlier initiation of anti-obesity medication may help.
Lack of training and time have also been documented in the literature as barriers for primary care practitioners to providing evidence-based obesity care.[10–12] Accordingly, this model utilizes a decentralized approach, embedding obesity medicine-trained primary care providers in community settings. Although the model does require additional obesity medicine training for physicians, training can be obtained through continuing medical education pathways resulting in minimal disruption to the practice.
Another significant challenge in providing obesity care in the community setting addressed by the model is financial sustainability. The program remained financially stable using time-based CPT codes allowing all providers to meet their work rVUs goals at the 55th percentile of MGMA median for the specialty. The multidisciplinary team was comprised through the utilization of existing resources at the primary care clinics, such as RDs and LCSWs, eliminating the need for additional hiring.
Midway through the study period, the COVID-19 pandemic required an immediate transition to virtual care. The clinic successfully transitioned to a virtual model, providing care both in-person and virtually, which further reduced patients' geographic barriers. In our experience, virtual care increased convenience and served to retain patients who may have otherwise been lost to follow up and enhanced continued participation for sustained weight loss. Virtual care will likely further extend the reach and accessibility of obesity care for patients within and outside of our area. The urgency to prioritize equitable access to comprehensive obesity care in our communities continues to be underscored by the consistently higher hospitalization rates and mortality from COVID-19 infection among patients with obesity.
This study has several limitations. First, this was a pilot pre-post interventional study involving a relatively small number of patients with limited follow-up. Among the 550 patients, 158 did not have enough time to complete four visits by October 31, 2020, due to the timing of their initial visit, although some of them may have been seen after that date. These patients (n = 188) were considered lost to follow-up and therefore not included in the final analysis. Future achievement of adequate program participation (four or more visits) by these patients will allow for more robust weight and outcome analyses. Second, certain demographics were not well represented, including males and patients of Hispanic and Latino ethnicity. However, patients of color that are traditionally underrepresented in research studies were well-represented. Third, some anti-obesity medications were not used due to financial constraints and may have limited weight-loss outcomes.
Our next steps include wider implementation of this model with training more primary care providers in obesity medicine within our healthcare system. This training will increase the number of community-based weight management clinics across the state. We will continue to collect data in our Weight Management Registry to analyze secondary outcomes, including changes in comorbidities.
To our knowledge, this is the first study to demonstrate that a community-based weight management program using pharmacotherapy and adhering to current guidelines by primary care clinicians produces clinically significant weight loss. Our approach represents a promising and scalable model for expanding access to comprehensive obesity treatment for the general population.