Previously submitted to: JMIR Formative Research (no longer under consideration since Jul 24, 2025)
Date Submitted: Sep 6, 2023
Warning: This is an author submission that is not peer-reviewed or edited. Preprints - unless they show as "accepted" - should not be relied on to guide clinical practice or health-related behavior and should not be reported in news media as established information.
"Combining Effectiveness, Reach, and Cost of a Scalable, Digitally Delivered Weight Loss Program Delivered Through Rural Primary Care: A Hybrid Type-III Effectiveness-Dissemination Trial
ABSTRACT
Background:
To address the public health crisis of obesity, healthcare recommendations include referring patients to evidence-based programming. In rural areas where resources are scant, how best to identify and engage patients in weight management programming has yet to be determined.
Objective:
The purpose of this Hybrid Type-III effectiveness-dissemination trial was to report outcomes of different physician referral strategies for improving reach (i.e., number, proportion, and representativeness of participants), retention, and effectiveness of an evidence-based, digitally delivered, 12-month weight loss program in a rural region. Program implementation costs were also examined as a secondary purpose based on cost per participant and cost per participant achieving a 3% or 5% weight loss.
Methods:
Five primary care physicians were randomly assigned to a sequence of four referral strategies: point of care (POC) with active telephone follow-up (ATF); POC, no ATF; population health registry-derived letter with ATF; and letter, no ATF. Proportions of eligible participants that were referred, screened, enrolled, and engaged with the intervention were tracked for each strategy. Eligible and enrolled patients received a Bluetooth-enabled home scale, which provided data to document intervention effectiveness. Implementation costs were based on cost per participant and cost per participant achieving 3% or 5% weight loss.
Results:
Of a potential 991 referrals, 573 were made by the physicians over 16 weeks. Ninety-eight patients (60% female; 94% Caucasian—representative of the region) enrolled in the program. Letter referrals reached a significantly higher proportion of patients than POC (100% vs 17%) and yielded more participants (12% vs 8%, p<.05). Patients receiving ATF were significantly more likely to be screened (47% vs 7%; p<.05) and enroll (15% vs 7%, p<.05) compared to those without ATF. Total recruitment costs were $6,192; cost per enrolled patient was highest for letter with ATF ($89) but was similar for the other referral conditions (range $43-$50). Retention and weight loss did not significantly differ among referral strategies. Mean weight loss was 6.9±10.5lbs. with 42/98 and 29/98 of participants losing 3% and 5% or more of their initial body weight, respectively. Intervention implementation costs were $29,500.
Conclusions:
Population health management approaches with active follow-up may not be cost-efficient for clinical settings. Digital weight-loss programs, when delivered in rural settings without a large population to benefit from scalability, may be as costly as intensive, in-person programs. Clinical Trial: ClinicalTrials.gov NCT03690557; 01/10/2018. http://clinicaltrials.gov/ct2/show/NCT03690557
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