Association between shared medical appointments and weight loss outcomes and anti‐obesity medication use in patients with obesity

Summary Objective In shared medical appointments (SMAs), multiple patients with a similar clinical diagnosis are seen by a multidisciplinary team for interactive group sessions. Very few studies have specifically studied SMAs and weight loss in patients with obesity. This study compared weight loss outcomes and anti‐obesity medication (AOM) access between patients with obesity managed through (SMAs) versus individual appointments. Methods Retrospective study of adults seen for obesity between September 2014 and February 2017 at Cleveland Clinic Institute of Endocrinology and Metabolism. Percent weight loss from baseline was compared between two propensity score‐matched populations: patients who attended ≥1 SMA and patients managed with individual medical appointments. Results From all eligible patients identified (n=310 SMA, n=1,993 non‐SMA), 301 matched pairs were evaluated for weight loss. The SMA group (n=301) lost a mean of 4.2%, 5.2% and 3.8% of baseline weight over 6, 12 and 24 months; the non‐SMA group (n=301) lost significantly less weight (1.5%, 1.8% and 1.6%, respectively) (paired t‐test, P<.05). All patients were eligible for US Food and Drug Administration‐approved AOMs based on obesity diagnosis; however, 49.8% (150/301) of matched SMA patients were prescribed an AOM versus 12.3% (37/301) of matched non‐SMA patients. Conclusion This study suggests that SMAs may offer a promising alterative for obesity management and one that may facilitate greater utilization of AOMs. In propensity score‐matched cohorts, SMAs were associated with greater weight loss outcomes when compared to usual care facilitated through individual medical appointments alone.


| INTRODUCTION
The recognition of obesity as a chronic disease by the American Medical Association in 2013 1 encourages physicians to be on the forefront of not only treating obesity-related comorbidities but also the primary problem of weight management. However, due to limitations in time and resources, physicians often focus on the consequences of obesity, rather than the primary problem of obesity itself. Patients may be prescribed antihypertensives or diabetes medications, but typically only receive brief advice on weight management. 2 Additionally, antiobesity medications (AOMs) are prescribed to <2% of patients who are eligible. 3 These current methods of obesity treatment do not provide patients with the intensive interventions needed for long-term weight loss success. 4 Shared medical appointments (SMAs) may be one method to deliver effective and efficient obesity treatment. 5 SMAs are group medical visits where multiple patients with a similar clinical diagnosis are seen by a multidisciplinary team for interactive group sessions that typically last 60 to 90 min each. 6 Theorized beneficial aspects of SMAs include fostering patient-patient and patientcaregiver relationships, co-learning from others with the same condition, gaining inspiration from others' successes, better understanding of patients' needs by providers, greater provider-patient interaction time and improved patient trust in providers. 7 Patients experience the support of other patients and often learn more than during a traditional appointment as a result of the longer sessions and from questions and comments shared by other SMA participants. 8 Data on the use of SMAs continue to accumulate, particularly in the field of diabetes. [9][10][11][12][13][14][15][16] Reviews of such research have concluded that while there are indications of improved outcomes in patients managed with SMAs, the small size and heterogeneity of studies thus far does not allow for conclusions to be drawn from the collective body of research. 16,17 Very few studies have specifically studied SMAs as a weight loss strategy in patients with obesity. [18][19][20] This study examines the hypothesis that patients involved in weight loss-focused SMAs would experience greater weight loss over a 2-year period compared to patients who received standard obesity management through individual medical appointments alone.

| Obesity shared medical appointments
The process and structure of SMAs provided through the Cleveland Clinic Department of Endocrinology are illustrated in Figure 1.
Patients with obesity were referred for an obesity SMA through selfreferral or referral from their primary care provider or endocrinologist.
Patients who present with the primary intent of weight loss are generally good candidates for SMAs. In general, referral suitability was a judgment call on the part of the clinician based on a sense of whether the patient would benefit from the socialization aspect and/or accountability structure of SMAs. Once a patient was referred, the first step was an individual encounter with an obesity specialist (physician or nurse practitioner). This initial meeting entailed an overview of F I G U R E 1 Shared medical appointments (SMAs) at the Cleveland Clinic Department of Endocrinology-Process and structure. AOMs: anti-obesity medications; Endo: endocrinologist; PC: primary care; P-S: protein-sparing; SMA: shared medical appointment [Colour figure can be viewed at wileyonlinelibrary.com] the expectations and goals of the SMAs and evaluation of the patient for possible stress/psychological disorders, sleep disorders and risk stratification to help guide an exercise intervention strategy. At this visit, patients selected a nutrition plan from one of three options: Mediterranean, protein-sparing modified fast or meal replacement.
The meal replacement plan was based on a recommendation of 500 to 700 calories per meal; meal replacements could be bars/shakes/snacks meeting the following specifications: 200 to 300 calories, no more than 30 g of carbohydrates and 10 to 30 g of protein.
Patients were provided examples of commercially available meal replacement products (bars and shakes) that fit the criteria as part of their educational materials, as well as recipes for bars and shakes for patients who preferred to make their own.
Based on their nutrition plan selection, patients attended a shared nutrition appointment in a group of 8 to 10 patients, led by a regis-

| Usual care individual medical appointments
This reference group included all patients with an ICD-9 encounter diagnosis of obesity or morbid obesity during the study period who had been seen in the Department of Endocrinology by a general practicing endocrinologist who did not conduct SMAs. While it is presumed that obesity was addressed in the appointment, it may not have been the primary focus. The intensity and frequency of obesity treatment provided to these patients were at the discretion of the provider.

| Measures
The primary outcome of this study was percent weight loss from baseline weight. Baseline weight was defined as the recorded weight at the enrolment of the SMA program for the SMA group or the recorded weight at the first individual appointment during the study period for the non-SMA group. Outcome weight was defined by the weight measured at the nearest outpatient visit, as recorded in the EMR, at 6 months (±30 d), 1 year (±30 d) and 2 years (±60 d). Other variables collected from the EMR included age at enrollment, gender, race, marital status, insurance type, median household income

| Statistical analysis
Descriptive and outcome data were analyzed using chi-square for categorical variables and t test for continuous variables for unmatched comparisons. Prior to propensity matching, weight loss was compared between SMA and non-SMA groups while stratified by use of an AOM. To account for differences in baseline characteristics, a logistic regression model including age, gender, race, marital status, insurance type, median household income, baseline weight (kg) and diagnosis of T2D at baseline was used to generate a propensity score for attending an SMA. Patients in the SMA group were matched 1:1 with patients who did not attend an SMA (non-SMA group) using a caliper width of 0.2. Patients with missing weight values were excluded from that specific analysis. Post-match analyses were performed using paired t test.
Statistical analysis was performed using R statistical software.

| Population description after propensity matching
Propensity matching identified 301 matched pairs that were wellmatched on all measured baseline variables ( Table 3

| Weight loss outcomes after propensity matching
Patients in the SMA group lost more weight at 6 months, 1 year and 2 years compared to the matched non-SMA group ( Table 4). The average weight loss at 1 year was 5.2% in the SMA group, compared to 1.8% in the non-SMA group (P<.001). At 1 year, the proportions of patients who lost >5% and 10 to 15% of their baseline weight were higher in the SMA group as compared to the non-SMA group ( Figure 2).

| DISCUSSION
In this longitudinal retrospective cohort study, patients enrolled in the SMA program had superior weight loss outcomes compared with a matched cohort of patients who had obesity addressed in individual medical appointments of usual care alone. In propensity-  an average increase of 0.8% of baseline weight. 18 In a noncontrolled study of 222 patients who attended at least one SMA for weight loss over a 9-month period, 41% of patients achieved a 5% weight loss. 20 Prior evidence has shown that weight loss in the range of 3 to 5% of body weight can be associated with clinical health benefits such as improved glycaemic control 22 ; the mean weight loss in the SMA group have been reported to lose 3 to 8% of initial body weight. [23][24][25][26] Participants in SMAs may gain additional benefits from being seen by obesity-focused medical providers, such as prescription of AOMs, identification of medications that promote weight gain and management of obesity-related comorbidities. SMAs also provide opportunity for comprehensive medical care of obesity, such as addressing nutrition, exercise, sleep and stress management. Patients in SMAs can learn from their peers' experiences to gain a better understanding of their obesity treatment options. 5 However, like longitudinal studies of weight loss, our data show that weight loss maintenance over 2 years was a challenge. In the SMA group, patients lost 5.2% of body weight at 1 year, but at 2 years, median weight loss was 3.8%. This may be due to inconsistent SMA attendance, patient dropout from SMAs or the use of phentermine, an AOM approved only for short-term use. In other studies, only 20% of patients were able to maintain their weight loss 1 year after treatment end. 27,28 Weight loss maintenance is difficult due to the emergence of a hormone profile and physiologic adaptations that promote weight regain. 29 These data highlight the need for chronic obesity management. In order to adequately treat patients, medical management needs to be continued long term, and there is a need for continual patient engagement in obesity treatment. Prior research has identified factors such as follow-up visit frequency 30,31 and interdisciplinary intervention 32 as contributing positively to weight loss over periods of 1 to 2 years, both of which are characteristics of the SMA approach.
All the patients in our study were eligible to take a Food and Drug Administration-approved AOM due to their diagnosis of obesity. However, AOM prescriptions varied markedly between the SMA group (49.8% of patients prescribed an AOM) and the matched non-SMA group (12.3% of patients prescribed an AOM), possibly due to differences in provider experience in prescribing AOMs In addition, the use of coding to identify patients with obesity in the non-SMA group has limitations; in that, it cannot be confirmed with absolute certainty that robust discussions around weight management occurred between providers and these patients. However, given evidence that in the United States, only 28% of patients with a BMI≥30 kg m −2 are coded for obesity, 34 it is clear that this is not a common practice and thus, is likely to indicate, that some level of focused discussion about weight management did occur at that visit.
Finally, it is possible that referral to any type of weight management counselling outside of a patient's primary care provider leads to better weight loss, whether as a group or individual. For example, data from the POWER-UP trial 35 found that patients who participated in regular weight counselling activities by a medical assistant in addition to ongoing visits with their primary care physician (PCP) lost more weight than did those who received only counselling from the PCP.

DATA AVAILABILITY STATEMENT
Restrictions apply to the availability of data generated or analyzed during this study to preserve patient confidentiality or because the data were used under license. The corresponding author will on request detail the restrictions and any conditions under which access to some data may be provided.