Computerized Weight Loss Intervention Optimizes Staff Time: The Clinical and Cost Results of a Controlled Clinical Trial Conducted in a Managed Care Setting

OBJECTIVE: To evaluate the costs and effects of incremental components of a weight-loss program. DESIGN: A 3-arm, 12-month randomized controlled clinical trial to evaluate 3 incremental levels of intervention intensity. SUBJECTS/SETTING: The study included 588 individuals (BMI > 25 kg/m2) in a freestanding health maintenance organizalion and achieved an 81% completion rate. INTERVENTION: Using a cognitive behavioral approach for tailoring lifestyle modification goals, the incremental levels of intervention included a) a workbook alone, b) the addition of computerized tailoring using onsite computer kiosks with touch screen monitors, and c) the addition of both computers and staff consultation. MAIN OUTCOME MEASURES: Endpoints included weight parameters, lipid profile, plasma glucose, blood pressure, intervention costs, dietary intake, and physical activity. STATISTICAL ANALYSIS PERFORMED: Study endpoints were analyzed using analysis of variance for normally distributed variables and analysis of covariance to control for any baseline differences. Regression and correlation analysis assessed the relationship between weight loss and other variables. RESULTS: For the increasing levels of intervention intensity, the mean 12-month weight losses were 2.2, 4.7, and 7.4 pounds, with the respective cost per participant being $12.33, $41.99, and $133.74. The decreases in mean BMIs for these respective intervelation levels were 0.4, 0.9 and 1.2. All groups reported a decrease in energy and fat intake and an increase in blocks walked (P<.01). Intervention variables that correlated with weight loss included more computer log-ons, achieving computer-selected goals, more self-monitoring, increased walking, and decreased energy and fat intake, as well as higher attendance in staff consultation group sessions for that treatment condition. Weight loss correlated with decreases in fasting glucose and blood pressure. APPLICATIONS/CONCLUSIONS: In a weight-loss program, computers can facilitate selecting behavioral change goals. More frequent usage resulted in greater weight loss. Staff counseling to augment the computer intervention achieved the most weight loss.     

An evidence-based evaluation of intradialytic parenteral nutrition

Malnutrition is a well-recognized comorbid condition in dialysis patients that contributes to the increased mortality seen in these patients. Multiple interventions have been tried in an effort to decrease mortality. The most controversial of these is intradialytic parenteral nutrition. In an era of high costs and shrinking budgets, it is important to critically examine published data to determine the quality of the data and to determine whether the reported results are valid and clinically applicable. Using an evidence-based approach, all published literature concerning intradialytic parenteral nutrition was reviewed, quality of the data determined, number needed to treat (NNT) calculated, and potential costs of treatment determined. Twenty-four studies that met the search criteria were identified. Only three studies were randomized; one of these was a feasibility study, and the other two were only of level B quality. The remaining studies were either case reports or observational studies of level C quality. The absolute risk reduction in mortality with intradialytic parenteral nutrition (IDPN) usage ranged from 0.12 to 0.65; relative risk reduction ranged from 0.48 to 0.74; NNT ranged from 2 to 17; cost ranged from $150,000,000 to $877,500,000; and 588 to 9,750 patients might be expected to experience a decrease in mortality. The results of this review indicate that the data supporting the use of IDPN are weak and a clear recommendation cannot be made. IDPN use in hemodialysis patients seems to be associated with decreased mortality. IDPN should be available for use in patients who meet previously published guidelines and who are not normoalbuminemic.