Assessment of Physical Health Outcomes in an Enhanced Primary Care Model:  Weight and BMI Outcomes for Patients with Severe Mental Illness at WakeBrook Primary Care Clinic
Creators: name: Garner, Kate
Publisher: name: The University of North Carolina at Chapel Hill University Libraries
Year: 2019

description: Introduction: Approximately 9.6 million people in the United States are diagnosed with Severe Mental Illness (SMI), a term applying to any diagnosable mental, behavioral, or emotional disorder resulting in substantial functional impairment, but most often used to describe persons with diagnoses of schizophrenia spectrum disorders, bipolar disorder, and recurrent major depressive disorder with psychotic features.  The average life expectancy of individuals with SMI is approximately 8-25 years shorter than is the lifespan of those without SMI.  Lack of access by persons with SMI to quality preventive and primary care services has led to disproportionately high morbidity and mortality from chronic medical conditions such as hypertension, diabetes, obesity, and cardiovascular disease.  The WakeBrook Primary Care office, a primary care clinic embedded within a mental health facility, hopes to address these health disparities through their innovative Enhanced Primary Care Model, which has already improved access to and utilization of quality primary care.  This study of changes in weight and BMI over time assesses whether WakeBrook’s model has been successful to date at improving physical health outcomes.
 Methods: In this retrospective chart review, I identified patients already participating in a SAMHSA-funded grant project and enrolled in the Enhanced Primary Care Model at the WakeBrook Primary Care Office for at least 18 months and who were currently enrolled without lapses in care as of the study censoring date (January 28, 2019).  I determined participants’ length of enrollment in the model, extracted weight and BMI data at 6-month intervals until the study censoring date (the primary outcome indicators) from their electronic medical records, and descriptive statistics, paired t-tests, and logistic regression models.
 Results: A majority of the 119 eligible WakeBrook patients were obese at the time of enrollment (59.7%), diagnosed with a schizophrenia spectrum disorder (50.4%), and prescribed at least one atypical antipsychotic (68.9%).  These patients were likely also to have hypertension (61.3%), diabetes (34.5%), and dyslipidemia (52.9%).  Mean weight and BMI significantly increased after 12 months of enrollment of +2.02 kg (95% CI 0.47 to 3.58) and +0.77 kg/m2 (0.19 to 1.36), but BMI classification and distribution changed little over time.  Logistic regression modeling showed that longer enrollment in the program (>23 months) was apparently more associated with obseity at the end of the study period (OR 2.49, 95% CI 1.06 to 5.87) than was shorter enrollment (18-22 months) after adjusting for age and diagnoses of hypertension, diabetes, and dyslipidemia.
 Discussion: The study suggests that weight gain and obesity, significant health concerns in patients with SMI, are not significantly improved by being assigned to a medical home.  This study did not collect number of visits to the practice or number of sessions with health education staff, and it cannot make inferences about the intervention beyond being assigned to a medical home.  This study emphasizes that carefully examining different components of care is essential to our understanding of obesity and weight gain in patients with SMI.  A more comprehensive study design, including carefully matched controls, is necessary to draw firm conclusions about whether structured, protocolized interventions successfully promote weight loss and maintenance.  Future research and policy recommendations should focus on the development of enhanced EMR infrastructure and better systems of measurement to allow for continuous data collection, robust analysis, and longitudinal follow-up.  In-depth interviews to assess patient perceptions of current weight loss programs would also be helpful.  This expanded research design has the potential to inform future programming decisions to improve care and health outcomes of patients diagnosed with SMI.