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Original Investigation
January 26, 2021

Effect of Behavioral Therapy With In-Clinic or Telephone Group Visits vs In-Clinic Individual Visits on Weight Loss Among Patients With Obesity in Rural Clinical Practice: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Population Health, University of Kansas Medical Center, Kansas City
  • 2Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, Marshfield, Wisconsin
  • 3Division of Endocrinology, University of Nebraska Medical Center, Omaha
  • 4Department of Biostatistics, University of Kansas Medical Center, Kansas City
  • 5Department of Family Medicine and Community Health, University of Kansas Medical Center, Kansas City
  • 6College of Public Health and Health Professions, University of Florida, Gainesville
  • 7Department of Endocrinology, Marshfield Clinic Health System, Marshfield, Wisconsin
  • 8School of Public Health and Health Policy, Center for Systems and Community Design, City University of New York, New York, New York
JAMA. 2021;325(4):363-372. doi:10.1001/jama.2020.25855
Visual Abstract. Behavioral Therapy With In-Clinic Individual or Group Visits or Telephone Visits and Weight Loss in Rural Clinical Practice
Behavioral Therapy With In-Clinic Individual or Group Visits or Telephone Visits and Weight Loss in Rural Clinical Practice
Key Points

Question  Does behavioral obesity treatment delivered in rural primary care settings via in-clinic group visits or telephone group visits improve weight loss compared with the fee-for-service model with in-clinic individual visits?

Findings  In this cluster randomized trial that included 1407 participants, in-clinic group visits, compared with in-clinic individual visits, resulted in significantly greater mean weight loss at 24 months (–4.4 kg vs –2.6 kg, respectively), and the difference between telephone-based group visits and in-clinic individual visits was not significantly different (–3.9 kg vs –2.6 kg).

Meaning  In rural primary care practices, behavioral weight loss therapy delivered via in-clinic group visits resulted in statistically significantly greater weight loss than in-clinic individual visits, although the difference was small and of uncertain clinical importance.

Abstract

Importance  Rural populations have a higher prevalence of obesity and poor access to weight loss programs. Effective models for treating obesity in rural clinical practice are needed.

Objective  To compare the Medicare Intensive Behavioral Therapy for Obesity fee-for-service model with 2 alternatives: in-clinic group visits based on a patient-centered medical home model and telephone-based group visits based on a disease management model.

Design, Setting, and Participants  Cluster randomized trial conducted in 36 primary care practices in the rural Midwestern US. Inclusion criteria included age 20 to 75 years and body mass index of 30 to 45. Participants were enrolled from February 2016 to October 2017. Final follow-up occurred in December 2019.

Interventions  All participants received a lifestyle intervention focused on diet, physical activity, and behavior change strategies. In the fee-for-service intervention (n = 473), practice-employed clinicians provided 15-minute in-clinic individual visits at a frequency similar to that reimbursed by Medicare (weekly for 1 month, biweekly for 5 months, and monthly thereafter). In the in-clinic group intervention (n = 468), practice-employed clinicians delivered group visits that were weekly for 3 months, biweekly for 3 months, and monthly thereafter. In the telephone group intervention (n = 466), patients received the same intervention as the in-clinic group intervention, but sessions were delivered remotely via conference calls by centralized staff.

Main Outcomes and Measures  The primary outcome was weight change at 24 months. A minimum clinically important difference was defined as 2.75 kg.

Results  Among 1407 participants (mean age, 54.7 [SD, 11.8] years; baseline body mass index, 36.7 [SD, 4.0]; 1081 [77%] women), 1220 (87%) completed the trial. Mean weight loss at 24 months was –4.4 kg (95% CI, –5.5 to –3.4 kg) in the in-clinic group intervention, –3.9 kg (95% CI, –5.0 to –2.9 kg) in the telephone group intervention, and –2.6 kg (95% CI, –3.6 to –1.5 kg) in the in-clinic individual intervention. Compared with the in-clinic individual intervention, the mean difference in weight change was –1.9 kg (97.5% CI, –3.5 to –0.2 kg; P = .01) for the in-clinic group intervention and –1.4 kg (97.5% CI, –3.0 to 0.3 kg; P = .06) for the telephone group intervention.

Conclusions and Relevance  Among patients with obesity in rural primary care clinics, in-clinic group visits but not telephone-based group visits, compared with in-clinic individual visits, resulted in statistically significantly greater weight loss at 24 months. However, the differences were small in magnitude and of uncertain clinical importance.

Trial Registration  ClinicalTrials.gov Identifier: NCT02456636

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