Facility-level program components leading to population impact: a coincidence analysis of obesity treatment options within the Veterans Health Administration

Obesity is a well-established risk factor for increased morbidity and mortality. Comprehensive lifestyle interventions, pharmacotherapy, and bariatric surgery are three effective treatment approaches for obesity. The Veterans Health Administration (VHA) offers all three domains but in different configurations across medical facilities. Study aim was to explore the relationship between configurations of three types of obesity treatments, context, and population impact across VHA using coincidence analysis. This was a cross-sectional analysis of survey data describing weight management treatment components linked with administrative data to compute population impact for each facility. Coincidence analysis was used to identify combinations of treatment components that led to higher population impact. Facilities with higher impact were in the top two quintiles for (1) reach to eligible patients and (2) weight outcomes. Sixty-nine facilities were included in the analyses. The final model explained 88% (29/33) of the higher-impact facilities with 91% consistency (29/32) and was comprised of five distinct pathways. Each of the five pathways depended on facility complexity-level plus factors from one or more of the three domains of weight management: comprehensive lifestyle interventions, pharmacotherapy, and/or bariatric surgery. Three pathways include components from multiple treatment domains. Combinations of conditions formed "recipes" that lead to higher population impact. Our coincidence analyses highlighted both the importance of local context and how combinations of specific conditions consistently and uniquely distinguished higher impact facilities from lower impact facilities for weight management. Configurations of obesity treatment options leading to higher positive population impact within the Veterans Health Administration's (VHA) network of medical centers were identified using coincidence analysis methods. Optimal configurations varied based on context, including the size and complexity of the medical center. Lay Summary Obesity can contribute to increased rates of ill health and earlier death. Proven treatments for obesity include programs that help people improve lifestyle behaviors (e.g., being physically active), medications, and/or bariatric surgery. In the Veterans Health Administration (VHA), all three types of treatments are offered, but not at every medical center-in practice, individual medical centers offer different combinations of treatment options to their patients. VHA medical centers also have a wide range of population impact. We identified high-impact medical centers (centers with the most patients participating in obesity treatment who would benefit from treatment AND that reported the most weight loss for their patients) and examined which treatment configurations led to better population-level outcomes (i.e., higher population impact). We used a novel analysis approach that allows us to compare combinations of treatment components, instead of analyzing them one-by-one. We found that optimal combinations are context-sensitive and depend on the type of center (e.g., large centers affiliated with a university vs. smaller rural centers). We list five different "recipes" of treatment combinations leading to higher population-level impact. This information can be used by clinical leaders to design treatment programs to maximize benefits for their patients.