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The American Journal of Managed Care February 2014
Physician Financial Incentives and Care for the Underserved in the United States
Alyna T. Chien, MD, MS; Marshall H. Chin, MD, MPH; G. Caleb Alexander, MD, MS; Hui Tang, MS; and Monica E. Peek, MD, MPH
Connecting the Dots: Examining the Link Between Workforce Health and Business Performance
Bruce W. Sherman, MD; and Wendy D. Lynch, PhD
Patient Attitudes About Specialty Follow-up Care by Telephone
Jessica A. Eng, MD; Cecily J. Hunter, BA; Margaret A. Handley, PhD; Christy K. Boscardin, PhD; Ralph Gonzales, MD; and Sara L. Ackerman, PhD
The Impact of Patient Assistance Programs and the 340B Drug Pricing Program on Medication Cost
Yelba M. Castellon, MD; Shahrzad Bazargan-Hejazi, PhD; Miles Masatsugu, MD; and Roberto Contreras, MD
Complying With State and Federal Regulations on Essential Drug Benefits: Implementing the Affordable Care Act
Joshua P. Cohen, PhD; Abigail Felix, BA; and Magdalini Vasiadi, PhD
Trends in the Financial Burden of Medical Care for Nonelderly Adults with Diabetes, 2001 to 2009
Peter Cunningham, PhD; and Emily Carrier, MD
Formulary Restrictions on Atypical Antipsychotics: Impact on Costs for Patients With Schizophrenia and Bipolar Disorder in Medicaid
Seth A. Seabury, PhD; Dana P. Goldman, PhD; Iftekhar Kalsekar, PhD; John J. Sheehan, PhD; Kimberly Laubmeier, PhD; and Darius N. Lakdawalla, PhD
Impact of a Medicare MTM Program: Evaluating Clinical and Economic Outcomes
Rita L. Hui, PharmD, MS; Brian D. Yamada, PharmD; Michele M. Spence, PhD; Erwin W. Jeong, PharmD; and James Chan, PharmD, PhD
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Dialing In: Effect of Telephonic Wellness Coaching on Weight Loss
Min Tao, PhD; Krishna Rangarajan, MS; Michael L. Paustian, PhD, MS; Elizabeth A. Wasilevich, PhD, MPH; and Darline K. El Reda, DrPH, MPH

Dialing In: Effect of Telephonic Wellness Coaching on Weight Loss

Min Tao, PhD; Krishna Rangarajan, MS; Michael L. Paustian, PhD, MS; Elizabeth A. Wasilevich, PhD, MPH; and Darline K. El Reda, DrPH, MPH
Small weight loss was reported by overweight/obese individuals targeted for telephonic wellness coaching in this large retrospective study using pre-post design.
Objective: To estimate the effect of telephonic wellness coaching on weight loss in a commercially insured population.

Study Design: Pre-post evaluation design.

Methods: Self-reported weight was obtained from 2 annual health assessment questionnaires administered during 2008 and 2010. Baseline (T1) information from these questionnaires was used to identify overweight/obese individuals and to determine targets for a 4-call wellness coaching program. Overweight/obese individuals identified at T1 were classified into following groups: (1) targeted for wellness coaching (N = 1448, including 1050 participants and 398 nonparticipants); (2) not targeted for wellness coaching, but targeted for other telephonic wellness care management (WCM) programs (N = 1270); (3) not targeted for any WCM programs (N = 7586). Weight reported on questionnaires a year later (T2) was used to calculate weight change between T1 and T2. Paired t-tests were used to detect significant weight changes over time. Multivariable linear regressions were used to compare weight changes between the groups. Stratified analysis was conducted to determine the effectiveness of telephonic wellness coaching for subgroups based on participants’ selected health goals, intensity of the intervention received and initial stage of change.

Results: The group targeted for wellness coaching reported an average weight change of –0.44 kg (95% confidence interval [CI], –0.76 to –0.16) at T2, significantly more weight loss than reported by the group not targeted for any WCM programs. Participants who started in preparation stage and completed the program reported weight change of –1.43 kg (95% CI, –2.17 to –0.68), highest among program participants.

Conclusions: Small weight loss was observed for obese/individuals targeted for telephonic wellness coaching.

Am J Manag Care. 2014;20(2):e35-e42
Telephonic wellness coaching programs are popular interventions for a large population because of their versatility and convenience.
  • This large retrospective study observed small weight loss among telephonic wellness coaching participants more than 6 months after they finished the program.

  • It evaluated factors that impact weight loss among wellness coaching participants, including participants’ initial stage of change, motivation level, and intensity of coaching received. This information can assist decision making of whether to offer telephonic wellness coaching programs to a population. The analysis on successful elements of wellness coaching programs can help compare telephonic wellness coaching programs or improve program design.
Obesity poses a substantial threat to the US health and healthcare system.1 Among adults, higher morbidity in association with being overweight or obese has been observed for hypertension,2-4 type 2 diabetes,5-8 coronary heart disease, stroke, respiratory problems, and some types of cancers.9-16 Epidemiologic studies have shown that mortality increases with body mass index (BMI) values above 30.17-19 Consequently, obesity has conferred a significant economic burden for the nation.20 A wide variety of programs have been developed to address the obesity issue in the United States, including wellness coaching programs.

In wellness coaching programs, wellness coaches assist individuals to establish and work toward health-promoting goals using techniques such as motivational interviewing.21 Telephonic wellness coaching offers the personalized focus and discussion, while avoiding common barriers for on-site consultations such as inadequate transportation or lack of childcare. Telephonic coaching programs have been used to address a variety of health behaviors including smoking, nutrition, and weight.22-25

Evidence for the effectiveness of telephonic coaching on weight loss is limited, with only a few studies having demonstrated a small but positive effect.24,26,27 Previous published studies have largely not provided details on participant or intervention factors that may mediate the outcomes of such coaching programs. The goals of this study are to estimate the effect of telephonic coaching on weight loss in a large, commercially insured population and to evaluate how a participant’s initial stage of change, motivation level, and intensity of coaching program received impact weight loss among wellness coaching participants.


Telephonic Wellness Coaching Program

This study assesses a health plan-administered telephonic wellness coaching program that consists of 4 telephone calls designed to help participants reduce risk factors through health education and behaviorchange counseling. During the initial telephone contact, health coaches review the top 3 risk factors identified on each participant's health assessment questionnaire. Health coaches also assess each participant's readiness to change, level of motivation to change, and perceived barriers to adopt healthy lifestyle behaviors.

Initial stage of change is determined by asking participants how ready they are to make changes to improve their health on a scale of 1 to 10. If participants respond with a score between 1 and 4 and show characteristics of not considering change, feeling no control, or believing consequences not to be serious, the health coach will classify them as precontemplation. If participants respond with a score between 5 and 7 and have considered the benefits and costs of their health behaviors as well as proposed changes in behaviors, the health coach will classify them as contemplation. For participants who respond with a score between 8 and 10, having experimented with small changes will lead to classification as being in the preparation stage; having demonstrated definitive actions to change will lead to classification as being in the action stage; and having definitive actions over an extended time period will lead to classification as being in the maintenance stage.

After the assessment, health coaches work with each participant to create an action plan that includes personalized health-related goals, actions the person will take, strategies for coping with perceived barriers, and identification of who might support them with their efforts. The action plan is mailed to the program participants. During subsequent calls, the health coach discusses progress, barriers and action items with the participant. The length of each phone call ranges between 10 and 20 minutes.

The health coaches that deliver the intervention can be registered nurses, registered dietitians, exercise physiologists or health educators. Several approaches are taken to ensure quality and consistency of interventions being delivered. First, health coaches are required to have a bachelor's or master's degree with additional training in motivational interviewing and certification such as Chronic Condition Professionals from the Health Sciences Institute. Second, health coaches receive ongoing trainings which utilize cognitive behavioral therapy modules. The trainings include classroom training, 1-on-1 instruction, and mentoring by an established coach. Third, fidelity to the program is assessed through randomly recorded phone conversations between health coaches and participants to ensure that the delivery of the program is consistent across health coaches and follows established policies and procedures.

Program Participants

Employers purchase the wellness coaching program benefit for their employees from the health plan. The eligible employees are required to complete an annual health assessment questionnaire at the beginning of each benefit year in order to receive program-related incentives provided by employer groups. The incentives vary across employers from lower office visit and prescription co-pays to gift cards. Health assessment questionnaire respondents are first prioritized for case management or disease management. Disease management is a nurse-administered, telephonic program that targets patients with 1 of 5 chronic diseases: asthma, ischemic heart disease, chronic obstructive pulmonary disease, diabetes, or chronic heart failure, and focuses on chronic disease selfmanagement. Case management is a nurse-administered, telephonic program that targets patients with complex medical needs and focuses on coordination of care. The prioritizing processes for disease management and case management are separate from the health assessment. For respondents who neither need disease management nor case management but have 3 or more risk factors identified via questionnaire, these respondents will receive outbound calls from an engagement specialist to enroll them in the wellness coaching intervention. Individuals who have few risk factors identified via questionnaire do not receive outreach to participate in the wellness coaching program, but are encouraged to use the health plan’s online health tools to maintain good health.

Health Assessment Questionnaires

During the course of the study period, there was a change in the health risk assessment questionnaire administered by the health plan. The University of Michigan Health Risk Appraisal (HRA) was used through May 200928; afterward the StayWell Health Media Health Assessment (HA) was used.29 This change in health assessment questionnaires reflects a business decision of the health plan and not of the authors, who conducted the evaluation retrospectively. The HRA consists of 47 questions while the HA consists of 150 questions. Common health risks assessed by the 2 questionnaires include body weight, existing medical conditions, physical activity, nutrition, alcohol, smoking, stress, safety belt use, skin protection, absenteeism at work, perceived health, and overall life satisfaction. On each instrument, respondents also report their race/ethnicity, gender, level of education, and motivation to lose weight. Although both questionnaires assess similar health risks, the wording of the questions and answers differ markedly. For example, the HRA asks “Do you have heart problems? (Never/Have Currently/In the Past)” while the corresponding HA question is worded as “Have you been diagnosed with coronary heart disease? (Yes/No).” For this evaluation, we only used questions from the 2 questionnaires that could be reconciled to allow consistent measurement over time.


As shown in the Figure, 40,222 individuals responded to 2 questionnaires at least 6 months apart from 2008 to 2010 for our pre-post evaluation. The average time between baseline (T1) and follow-up (T2) questionnaires was 385 days (approximately 1.05 years) with a standard deviation of 70 days. BMI was calculated from responses to height and weight questions on these surveys. Overweight was defined as a BMI between 25 kg/m2 and 29.9 kg/m2 and obesity was defined as a BMI of 30 kg/m2 or greater. Among respondents, 16,178 (40%) were considered overweight or obese at baseline. Of the overweight and obese respondents, 5653 (35%) were referred for a wellness care management (WCM) program during the study period between baseline and follow-up; 8922 (55%) did not receive any referral during the study period, and 1603 (10%) received a referral, but outside of the period, and thus were excluded from the analysis. Two percent (2%) of the adults who reported a more than 2-inch difference in their height across the 2 time periods were excluded from study population due to potential data quality concern. Respondents with complete data on weight, height, age, gender, race/ethnicity, level of education, motivation to lose weight, smoking status, and comorbidities were used for the analysis. The final study population was divided into 3 groups. The intervention group consisted of obese or overweight respondents targeted for the telephonic wellness coaching program (N = 1448, including 1050 participants and 398 nonparticipants). The 2 comparison groups were overweight or obese respondents: (1) not targeted for any telephonic WCM program (N = 7586) and (2) not targeted for telephonic wellness coaching, but targeted for other WCM programs, primarily disease management (N = 1270).

Statistical Analysis

Differences in the distribution of demographic characteristics, self-reported chronic disease status, smoking status, and motivation to lose weight at baseline among the study groups were tested using c2 test, while differences in baseline BMI among the groups were tested using ANOVA. Paired t-tests were used to detect whether significant weight changes were reported for each group between baseline and follow-up.

To illustrate the impact of outliers, we reported the 1-year weight change for each group after removing outliers in 2 ways: a) statistically, by calculating upper and lower fences based on mean and standard deviation of the weight changes between T1 and T2 using “outer fence” formula (mean + 4.72* standard deviation),30 and b) by removing 4% of the study population that had more than an 18-kg (40-lb) difference (increase or decrease) in self-reported weight based on health coach suggestions of what constituted a substantial weight change.

The association between self-reported weight change and the wellness coaching program was determined using multivariable linear regression, adjusted for sex, race, education, motivation to lose weight, and comorbidities. P values less than .05 were considered statistically significant. Analyses were performed in SAS 9.2.31

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