The prevalence of overweight and obesity is higher in the veteran population than the US population as a whole.1 In FY2000, the prevalence of overweight was 73% and the prevalence of obesity was 33%.2 Consequently, the burden of obesity-related chronic illness in the veteran population is high.3, 4 On March 27, 2006, the VA Under Secretary for Health signed VHA Handbook 1101.1, Managing Overweight/Obesity for Veterans Everywhere (MOVE!), which directs all VAMC facilities to offer comprehensive, evidence-based, tiered, patient-centered weight management programs. The Handbook details the core components of MOVE!, which were developed by the VA National Center for Health Promotion and Disease Prevention (NCP) based on the NIH Guidelines for the Identification and Treatment of Overweight and Obesity in Adults.5 MOVE! was launched nationally in January 2006 to help overweight and obese veterans reduce weight and prevent obesity-associated morbidity and mortality. Measuring the degree of MOVE! uptake across the VA over time is important so that changes in weight and BMI can be adjusted by the degree of implementation by facilities to more accurately assess the program's effectiveness and to inform implementation studies to improve MOVE!.
The rate at which MOVE! is being implemented varies widely across the VA with some sites enrolling zero patients, while others have enrolled over 1,600 unique patients since the start of the program. While the NCP has collected some crude quantitative measures and some anecdotal evidence of barriers to implementation, there is little in-depth understanding of why some sites appear to have success implementing the program while others have barely started. It is also unclear whether different modes of MOVE! implementation (i.e., greater reliance on group visits versus individual counseling) have implications for program uptake. Currently, NCP lacks a means to measure and track the degree of implementation attainment (uptake) of MOVE! in the VA over time. Furthermore, a clearer understanding of the variation in MOVE! implementation between sites is necessary to inform the development and dissemination of intervention strategies that are reduce delivery costs while enhancing intervention effectiveness (e.g., using home-based messaging and monitoring devices, web-based interactive formats, enhanced pedometer programs). Greater understanding of the implementation processes affecting MOVE-related clinical activity improves patient health outcomes by enabling VA researchers to identify opportunities for process improvement that assure program generalizability and success.
We are partnering with the NCP to better understand barriers and facilitators for implementing MOVE! with the intent to improve implementation of the current program and as pre-implementation work for a future enhanced MOVE! implementation study. We plan to examine the experience of a small purposive sample of VA sites. Specifically, the study aims are to: 1) understand the wide variability in uptake of MOVE!; 2) assess gaps in the current structure of MOVE! in a small sample of diverse sites which will help strengthen the design of an enhanced MOVE! implementation study in the future; and 3) begin developing measures of implementation attainment that NCP can use to more accurately reflect uptake of MOVE! over time.
Given the limited timeframe available (5-6 months), we believe it is feasible to conduct this study at five sites. We have tentatively selected sites using a purposive sample approach. These sites vary by degree of program uptake, delivery strategies, and the age ranges of patient populations. The sites are spread across multiple VISNs to maximize administrative variability. The Table lists key characteristics of each site for the proposed study. One site has an above average proportion of patients who are under 35 years old.We intentionally included this site to maximize our ability to understand potentially unique needs of the OEF/OIF veterans who may be participating in MOVE! (or who are eligible for MOVE!), as understood by stakeholders at that site.
The primary aim of this study is to conduct an implementation and progress-focused formative evaluation6 using a qualitative study design to explain the wide variability in uptake of the MOVE! program. NCP has very little information with which to understand why some sites are reporting no or very few visits and why other sites have successfully engaged large numbers of patients. We plan to conduct semi-structured interviews of 3 key stakeholders at each site: 1) VISN MOVE! coordinator; 2) site MOVE! coordinator; and 3) MOVE! physician champion for MOVE! at each site. Interviews will be conducted over the phone. We have spoken with the VISN MOVE! Coordinators, who have informally agreed to participate in the study and help recruit the site coordinator and physician champion for the site in their VISN. We will use data from these interviews to explore the relationship between organizational and external contextual factors and explore the interface of MOVE! core components with those contextual factors to better explain variability in the degree of uptake for the MOVE! program. We will identify barriers, facilitators, and other contextual factors, using the QUERI-DM Implementation Framework that is in development. This framework incorporates components from many other existing implementation and innovation research.7-9 We will also find the degree to which components of MOVE! are being used and how they are being adapted for the sites in our study; and whether sites are using components that are not described in MOVE! program materials. Concurrent to this, we will also find out how sites are reporting MOVE! workload. NCP relies on the number of unique patients and visits reported through MOVE! DSS Identifiers (stop-codes), summarized from administrative data within the VHA Service Support Center (VSSC)-hosted MOVE! Visits Proclarity data cube. Based on data collected from facilities as part of an annual MOVE! Program Status Report and anecdotal evidence, NCP believes that sites use MOVE! stop-codes in very different ways resulting in under- or over-estimates of MOVE!-related clinical activity. Future evaluations and all research studies related to MOVE! that rely on administrative data will need to understand these limitations.
A secondary aim will be to collect information about barriers and facilitators to implementing MOVE! that will be used to assess gaps in the current MOVE! program structure. This information will then be used to inform a large-scale implementation study to enhance MOVE!. For example, if we find that providers are not able to commit enough time to adequately foster patients' self-management activities, MOVE! could be enhanced by adding a web-based mediated intervention that promotes physical activity and healthy eating for weight loss by helping patients set individualized physical activity and dietary goals, providing motivational feedback, and offering links to relevant and credible Internet resources. Providers would be able to focus their limited time on patients who are in need of personalized face-to-face support. This kind of implementation study can take into account, specific organizational and external contextual factors that may be impeding progress; factors identified in this proposed study.
This study will serve as the first step in developing an implementation attainment measurement instrument. Utilizing the qualitative findings achieved by Aim 1, our third aim will be to generate the items and preliminary taxonomy from which to develop quantitative measures that more accurately and completely capture MOVE! implementation status. This is an instrument that NCP and future researchers can use in a cost-effective way to more accurately assess the scope and nature of MOVE! implementation at VA sites.
4 of 5 medical centers experienced significantly constrained resources for implementing MOVE!. However, both quantitative and qualitative data revealed significant differences in key factors that influenced implementation effectiveness. We found that, unlike low-uptake sites, high-uptake sites had: strong belief in the evidence, stronger focus on patient needs, effective team-building, positive implementation climate, high readiness for implementation, and effective implementation processes. Quantitative data confirmed these findings. High-uptake VAMCs averaged 4.4 (using a 1-5 agreement scale) for management support, 4.4 for communications, and 4.5 for priority compared to 2.8, 3.2, and 3.1 for low-uptake facilities (p-values<.02). At all but one site, MOVE! coordinators were significant facilitators; they went above and beyond expectations to implement MOVE! - even in the face of daunting organizational challenges.
Even in an environment of pervasive constrained resources, interventions to modify key organizational factors may help accelerate uptake of MOVE! in VHA.
We recommend that VHA/HSR&D explore options for phone-based self-management as an adjunct to the on-site programs. Continue to place high priority on MOVE! by having clear performance indicators to measure viability of MOVE! at local facilities. Preparation of manuscripts for publication is underway.
External Links for this Project
None at this time.