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Improving the Prevention, Early Recognition, and Treatment of Pediatric Obesity by Primary Care Physicians Paul C. Young, Sandra DeBry, W. Daniel Jackson, Julie Metos, Elizabeth Joy, Mark Templeman and Chuck Norlin CLIN PEDIATR 2010 49: 964 DOI: 10.1177/0009922810370056 The online version of this article can be found at: http://cpj.sagepub.com/content/49/10/964

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Improving the Prevention, Early Recognition, and Treatment of Pediatric Obesity by Primary Care Physicians

Clinical Pediatrics 49(10) 964–969 © The Author(s) 2010 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922810370056 http://clp.sagepub.com

Paul C. Young, MD1,2, Sandra DeBry, MBA2, W. Daniel Jackson, MD1, Julie Metos, MPH, RD, CD3, Elizabeth Joy, MD, MPH1,2, Mark Templeman, MD1,4, and Chuck Norlin, MD1,2

Abstract To determine if participation in a learning collaborative (LC) would improve care processes for prevention, early recognition, and treatment of childhood obesity by primary care physicians (PCP), the authors conducted pre-post evaluations of the use of obesity related care processes by 18 primary care practices following participation in a 9-month LC based on the Model for Improvement. Prior to the LC, chart audits revealed that 55% of patients had a BMI recorded; this rose to 97% of patients at its conclusion. Following the LC, 11 practices had implemented systematic prevention advice to parents of infants compared with 3 prior to the LC. All practices developed plans for evaluation and management of children with an elevated BMI. Participation in an LC increased the number of primary care practices that provided anticipatory guidance regarding obesity prevention and that identified and treated overweight or obese children. Keywords prevention and treating pediatric obesity

Introduction Since the 1970s, childhood and adolescent obesity has increased 3- to 6-fold. Approximately 12% to 18% of 2- to 19-year-old children and adolescents are obese (defined as having an age- and gender-specific BMI ≥95th percentile).1 Primary care pediatricians and other clinicians who provide health care to children (primary care physicians [PCPs]) have a crucial role to play in confronting this increasing prevalence of obesity among children and adolescents. Although the ultimate solution to the problem of childhood obesity requires changes in families, schools, community environments, and national policies, the short- and long-term adverse health consequences for children places a significant responsibility on the health care system, especially those who practice primary care pediatrics. PCPs have substantial opportunities to provide primary prevention of obesity anticipatory guidance during well-child care beginning in early infancy. PCPs can, for example, encourage exclusive breast-feeding for 6 months because there is substantial

evidence that this practice is associated with a reduced risk of obesity.2 In addition, though evidence of benefit is not as strong, PCPs can recommend fruits and vegetables rather than cereal as the first solid foods and can educate parents that fruit juice is high in sugar and that infants do not need beverages other than milk and water. As children age, PCPs can advise parents to limit their children’s TV watching, encourage active play, and restrict intake of sugar-sweetened beverages.3 In addition to primary prevention, PCPs have opportunities to identify children who appear to be at higher-thanaverage risk of becoming obese because of their family 1

The University of Utah School of Medicine, Salt Lake City, UT, USA The Utah Pediatric Partnership for Healthcare Quality, Salt Lake City, UT, USA 3 University of Utah, Salt Lake City, UT, USA 4 Intermountain Hillcrest Pediatrics, Murray, UT, USA 2

Corresponding Author: Paul C. Young, Department of Pediatrics, University of Utah School of Medicine, PO Box 581289, Salt Lake City, UT 84158, USA Email: [email protected]


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Young et al. history or rapid early weight gain and provide secondary prevention through more intensive education and follow-up to them.3 Finally, by systematically monitoring their patients’ BMIs, PCPs can recognize children who are overweight or obese, address potential comorbidities, and provide treatment and/or referral to community resources such as dieticians, exercise programs, childhood obesity specialists, and comprehensive treatment programs.4,5 However, studies suggest that many PCPs do not use effective care process models for preventing, recognizing, or treating obesity.6 Several studies have found, for example, that only about half of pediatricians systematically determine BMI of their patients.7,8 Other reports suggest that few PCPs provide primary or secondary prevention interventions; also, PCPs do not identify comorbidities such as elevated blood pressure or dyslipidemia in obese children and do not initiate appropriate treatment, referral, and follow-up for children who are overweight or obese.6,9 Multiple factors are likely to be associated with the failure of PCPs to provide appropriate prevention, early recognition, and treatment services to their patients. These may include lack of awareness regarding evidence-based and expert recommendations,3 skepticism that interventions will be successful, lack of time, poor or no reimbursement by insurance companies, and barriers to changing usual office procedures and practices.6,9-13 A learning collaborative (LC) is a quality improvement (QI) method that provides physicians and others with tools to make changes in their office approaches and procedures in order to successfully accomplish their goals and aims with regard to specific clinical problems such as immunization delivery, asthma management, developmental screening, providing a medical home, autism, ADHD, and preventive services.14-17 The Utah Pediatric Partnership for Improving Healthcare Quality (UPIQ) has conducted LCs addressing these and other issues. We have previously reported the successful results of a LC designed to improve the delivery of preventive services.15 UPIQ LCs typically involve 10 to 20 practice teams; teams generally include a physician, a nurse or medical assistant, and an administrative person. The teams come together for an initial half-day workshop that includes the evidence regarding the particular topic, an introduction to practice-based QI, and the development of specific plans for change and appropriate measures to ensure that the plans have resulted in the desired outcome. Following the workshop, practices participate in monthly conference calls, sight visits, and chart audits. LCs last 6 to 12 months. In this article, we report the results of a UPIQ LC designed to improve the

prevention, recognition, and treatment of pediatric obesity by PCPs. We hypothesized that participating practices would improve one or more aspects of their care processes related to childhood obesity.

Methods The Learning Collaborative The LC began in April of 2008 and concluded in January of 2009. A total of 20 practice teams participated in the initial workshop; 18 remained active in the LC for the entire period. Two half-day workshops were held at the conference center of a local community college. At the first workshop, participants were presented with didactic sessions regarding evidencebased and expert opinion recommendations for prevention, recognition, and management of overweight children by 2 general pediatricians.3 The “5,2,1,0” slogan (5 servings per day of fruits and vegetables, less than 2 hours of TV or screen time per day, more than 1 hour of daily exercise, and 0 sweetened beverages) and its rationale was presented and emphasized. 3,18 A dietician provided additional advice regarding dietary recommendations, and a family physician with sports medicine expertise described approaches to assessing and increasing physical activity; a child psychiatrist provided a short introduction to motivational interviewing.19 The UPIQ QI specialist described the Model for Improvement and the use of PDSA (plan, do, study, act) cycles.20 Each team then developed specific aims regarding what they wanted to accomplish, plans for change in order to achieve the aims and measurement tools, and methods for determining if the desired improvements had occurred. The UPIQ QI specialist visited each practice during the subsequent month to reinforce the need for team meetings, for using PDSA cycles, and to assist with overcoming barriers that the practices were facing. At the second workshop, one session focused on management of those in the overweight category; another described treatment options for children who were in the obese and morbidly obese categories. The child psychiatrist reviewed elements of motivational interviewing and addressing resistance. Teams then refined their plans and, in some cases, developed additional plans. Participating teams were invited to participate in monthly conference calls on a variety of obesity and QI-related topics. Each practice performed monthly chart audits related to the measures that they had established as part of their plans. The UPIQ QI specialist conducted several site visits with each of the practices.


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Practice Name: _______________________________________________ We are looking forward to your practice team’s participation in the upcoming UPIQ Learning Collaborative, Preventing, Recognizing, and Treating Childhood Obesity. In order for us to help your practice team maximize the benefits of participation, we would like to obtain some information about your practice’s current approach and what areas you are most interested in improving. Please take a few minutes to answer the following questions: 1. Does your practice routinely determine and plot BMI’s on children over 2 at their well child visits? No Yes 2. Do you routinely evaluate… a. physical activity? b. physical inactivity? c. screen time?

No No No

Yes Yes Yes

3. D o you regularly provide an obesity prevention message at well child visits? (If yes, please note what your typical prevention message is for each age group or if you focus on a particular topic, such as nutrition, physical activity, behavior change, etc.) Prevention Message or Topic Focus: a. during infancy? No Yes _______________________________________ b. during childhood? No Yes _______________________________________ c. during adolescence? No Yes _______________________________________ 4. D o you make an attempt to identify children who may be at higher than average risk to become obese because of family history, rapid weight gain or some other factor? (If “yes,” what do you do when you identify such an infant or child? No Yes____________________________________________________ 5. D oes your practice identify children with “obesity” or “overweight” on a problem list or similar method for children who are overweight/obese? No Yes 6. If you do identify a child as obese, what do you typically do? a. initiate a plan to treat the child in my office. If so, do you typically schedule follow-up visits specifically for management of this problem? __No __Yes Are you typically reimbursed for these follow-up visits? __No __Yes __Not sure b. refer elsewhere (please note where: ________________________ ) c. other: ________________________________________________

Figure 1. Participant questionnaire

Evaluation Practice teams were invited to participate in the evaluation of the LC. Although participation as research subjects for the evaluation component was not required for participating in the LC, all participants agreed to do so and provided informed consent. The University of Utah Health Science Center institutional review board approved the evaluation component of the project. Prior to the first workshop, the physicians completed a questionnaire inquiring about their current obesity related procedures (Figure 1). Following the first workshop, each practice audited 5 charts from the month prior to the collaborative using the measures that they

had developed for their new aims and plans. Practice teams that proposed to measure and plot BMIs of all patients were required to audit 10 charts from the previous month. Practice teams conducted monthly audits of the measures that they had defined as elements of their plans. At the completion of the LC, participants completed a follow up questionnaire that was identical to the initial one. Comparisons between the initial and followup questionnaires were made using McNemar’s test for significance of change. In addition, the results of each month’s audits were tabulated. These results were provided to the practice teams as linear graphs. Comparisons between the proportions of charts reflecting adherence to plans at the initial and final audits were assessed


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Young et al. Table 1. Types of Plans Categories of Plans Prevention 5,2,1,0 At all well-child visits Posters in exam rooms No juice for infants Recognition BMI at all well-child visits BMI at some or all sick visits BMI results to parents Always Only if above 85th percentile Treatment of overweight (BMI 85th to 95th percentile) In-office treatment Refer to dietician Refer to specialist Treatment of obesity (BMI > 95th percentile) In-office treatment Refer to dietician Refer to specialist

Number of Practices Adopting the Plan 14 9 13 3 18 18 7 16 14 2 18 18 13 4 18 17 9 9

using the c2 test. Comparisons were performed using Stata/IC for Macintosh (Stata Corporation, College Station, TX).

Results Of the 20 practice teams that registered for the LC and attended the initial workshop, 18 participated fully by completing pre-LC and post-LC questionnaires, submitting 90% of the monthly audits and joining at least 50% of the conference calls. The teams developed a wide variety of aims and plans for improvement. We categorized these as prevention, recognition, and treatment aims, with the latter being divided into treatment of overweight and treatment of obesity. Table 1 lists the different types of plans and the number of practice teams that adopted each one. Practice teams typically chose 3 aims and change plans. Every practice team indicated that they would measure BMI at every well-child visit and engage in some type of intervention for children who were overweight and/or obese. In all, 14 practices adopted strategies that fell into the prevention category, including 9 that planned to provide a 5,2,1,0 message as part of anticipatory guidance during well-child visits for children and adolescents and to advise “no juice” when counseling parents regarding infant feeding. Table 2 shows the changes that the practices reported based on the prequestionnaire and postquestionnaire regarding 11 obesity-related practices. Significant increases were reported primarily in areas related to

Table 2. Number of Practices Reporting Performing 11 Obesity-Related Activities Before and After the LC

Measure/assess BMI Assess: physical activity Physical inactivity Screen time Prevention message during infancy Prevention message during childhood Prevention message during adolescence Identify high risk for obesity Overweight/obesity on problem list Treat overweight or obese children in office Refer obese children elsewhere

Before

After

Significancea

17 13 13 9 3

18 18 15 15 11

NS NS NS .01 .005

11

18

.008

14

16

NS

14 5

15 11

NS .05

11

15

NS

9

11

NS

Abbreviations: LC, learning collaborative; NS, not significant. a McNemar test for significance of change.

prevention such as routinely assessing screen time or including prevention advice as part of anticipatory guidance. Table 3 provides the results of the monthly audits for the 16 practices that indicated that they would obtain a BMI at all well-child visits. Interestingly, 17 of the 18 practices reported on the pre-LC questionnaire that they already measured BMI; however, chart audits performed in the month prior to the first workshop showed that only 55% of the charts actually had a BMI recorded. In the final audit, conducted in month 9, 97% of the 92 charts had a BMI determined and plotted on a growth chart.

Discussion Practice teams participating in a LC were able to set goals, develop plans for changing their office systems, and demonstrate, through chart audits, that they could make substantial changes in the way they approached various aspects of childhood obesity. Practice teams chose their own goals for change and developed specific plans for prevention, recognition, and intervention. We found that practices were very receptive to the information that was presented at the workshops and were able to use this information to develop plans for change. Most of the practices were less comfortable identifying the specific measures that would allow them to determine if the change plan was accomplishing the aim. The importance of measurement was highlighted by the contrast between the global impression of practices


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Table 3. Results of Monthly Chart Audits for Practices With a Plan to Measure and Plot BMI at Well-Child Visits Month 0 1 2 3 4 5 6 7 8 9

Number of Charts

Number with BMI

Percentage

174 93 90 99 78 85 106 96 101 92

96 84 82 71 74 81 101 94 96 89

55 90 91 72 95 95 95 98 95 97a

a P = .000 (c2 comparing audit results at month 9 with month 0, ie, before the learning collaborative).

regarding whether they were routinely assessing BMI before the LC and what the chart audit actually revealed. In the pre-LC questionnaire, 94% (17/18) of practices indicated that this was their routine practice, but when chart audits were performed, only 55% of the charts actually had a BMI recorded. Primary prevention activities showed the largest increase. Prior to the LC, few practices were routinely providing anticipatory guidance to parents of all infants and children (of whatever weight category) directed at obesity prevention. Primary prevention activities were also the easiest to measure by chart audit because an indication that prevention advice was provided should have been present on all the charts of infants or children in the age groups that the practices targeted. In contrast, practices that decided to implement a plan for children whose BMI was above the 85th percentile had to have a method of identifying which children in the past month had fallen into this category in order to have an appropriate denominator. As the LC progressed, the QI specialist assisted teams to create appropriate registries so that the team could measure whether their plans had actually been implemented. Unlike a traditional continuing medical education presentation, a LC requires that practice teams develop a plan for changing an aspect of their care process based on the content of the presentations. UPIQ LC participants spend a substantial portion of the initial session developing their improvement plans based on the Model for Improvement.20 To develop their plans, teams had to address 3 questions: (1) What do we want to accomplish? (the aim); (2) what do we need to do to achieve our aim? (the plan); and (3) how would we know that the plan for change had worked (achieved our aim)? (the measures). Teams were introduced to the concept of rapid cycles of change known as PDSA cycles.19 UPIQ staff emphasized that it was likely that the initial plan would not achieve the desired aim at its first

implementation (the “do” phase) as would be revealed during the “study” phase. As the team recognized this, they would need to modify the initial plan, the “act” phase, and initiate another rapid cycle. LCs, based on the Model for Improvement, have been used by several QI organizations. The Vermont Child Health Improvement Program has conducted more than 25 QI projects on a wide variety of pediatric and perinatal topics.16,20 Several investigators have described efforts to improve how PCPs approach the problem of pediatric obesity. Dorsey and colleagues9 recently described an improvement project at a clinic in New Haven, CT. They found that “clinicians were willing and able to use clinical tools, delivery, and information systems to improve their weight management practices.” However, they noted that there was a decline in the improvement efforts over time and suggested that the decline resulted from the presence of “persistent barriers such as lack of sufficient time, discomfort with repeated conversations regarding weight, lack of reimbursement for services, and continued skepticism regarding the efficacy of these efforts.”9 Although we were able to accomplish our goal of assisting practices to improve their processes related to prevention, recognition, and treatment of pediatric overweight and obesity, we do not know if improving their care processes will reduce the prevalence of obesity among their patients. There is some evidence suggesting that implementing these procedures will or may result in success, but it is limited and controversial.21,22 However, the procedures that we encouraged practices to consider may help primary care clinicians care for overweight and obese children and are unlikely to cause harm; therefore, we believe that they should be implemented.22 Our goal was to assist clinicians to use the Model for Improvement19 as a strategy to implement the recommendations that made sense to them in the context of their practices; in this, we believe that we were successful. In addition to not knowing whether changes in the process of care will result in improved outcomes, there are other limitations to our study. The primary care practices that participated in the LC were self-selected, based on their interest in the topic, and therefore, they may have been more highly motivated to make changes than other practices would be. In addition, because they paid a fee to participate, their motivation to follow through may have been relatively high. Of the participating pediatricians, 11 did so, at least in part, to obtain part 4 credit as part of the American Board of Pediatrics Maintenance of Certification Program.23 Ongoing participation and chart audit requirements were somewhat more stringent for these clinicians, which probably resulted in better data collection. Our results were dependent on the practices auditing their own charts, and we did not perform any independent validation of these audits; thus,


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Young et al. the quality of the data may be imperfect. The majority of participating practitioners were pediatricians in private practice, and they may not be representative of primary care clinicians practicing in other settings. However, our participants included family physicians, midlevel providers, and a team from a federally qualified community health center. In conclusion, we believe that primary care clinicians have an important role to play in preventing, recognizing, and managing children who are at risk to become or who are already overweight or obese. For most clinicians, implementing evidence-based or informed procedures requires changing their office systems in one way or another and using appropriate measurement tools to ensure that the changes they make lead to the improvements they desire. A LC using the approaches that we describe is one way of assisting practices to achieve these outcomes. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the authorship and/or publication of this article. Funding The author(s) received no financial support for the research and/or authorship of this article. References 1. Ogden CL, Carroll MD, Flegal KM. High body mass index for age among US children and adolescents, 2003–2006. JAMA. 2008;299:2401-2405. 2. Owen CG, Martin RM, Whincup PH, Smith GD, Cook DG. Effect of infant feeding on the risk of obesity across the life course: a quantitative review of published evidence. Pediatrics. 2005;115:1367-1377. 3. Barlow SE; Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120:S164-S192. 4. US Preventive Services Task Force. Screening for obesity in children and adolescents: US preventive services task force recommendation statement. Pediatrics. 2010; 125:361-367. 5. Hassink SG. Evidence for effective obesity treatment: pediatricians on the right track! Pediatrics. 2010;125:387-388. 6. Rhodes ET, Ebbeling CB, Meyers AF, et al. Pediatric obesity management: variation by specialty and awareness of guidelines. Clin Pediatr (Phila). 2007;46:491-505. 7. Flower K, Perrin EM, Viadro CI, Ammerman AS. Using body mass index to identify overweight children: barriers and facilitators in primary care. Ambul Pediatr. 2007;7:38-44. 8. Klein JD, Sesselberg TS, Johnson MS, et al. Adoption of body mass index guidelines for screening and counseling in pediatric practice. Pediatrics. 2010;125:265-272.

9. Dorsey KB, Mauldon M, Magraw R, Valka J, Yu S, Krumholz HM. Applying practice recommendations for the prevention and treatment of obesity in children and adolescents. Clin Pediatr (Phila). 2010;49:137-145. 10. Walker O, Strong M, Atchinson R, Saunders J, Abbot J. A qualitative study of primary care clinicians’ views of treating childhood obesity. BMC Fam Pract. 2007; 8:50. 11. Barlow SE, Dietz WH, Klish WJ, Trowbridge FL. Medical evaluation of overweight children and adolescents: reports from pediatricians, pediatric nurse practitioners, and registered dietitians. Pediatrics. 2002;110:222-228. 12. Barlow SE, Trowbridge FL, Klish WJ, Dietz WH. Treatment of child and adolescent obesity: reports from pediatricians, pediatric nurse practitioners, and registered dietitians [comment]. Pediatrics. 2002;110:229-235. 13. Cabana MD, Rand CS, Powe NR, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282:1458-1465. 14. Homer CJ, Forbes P, Horvitz L, Peterson LE, Wypij D, Heinrich P. Impact of a quality improvement program on care and outcomes for children with asthma. Arch Pediatr Adolesc Med. 2005;159:464-469. 15. Young PC, Glade GB, Stoddard GJ, Norlin C. Evaluation of a learning collaborative to improve the delivery of preventive services by pediatric practices. Pediatrics. 2006;117:1469-1476. 16. Lannon CM, Flower K, Duncan P, Moore KS, Stewart J, Bassewitz J. The bright futures training intervention project: implementing systems to support preventive and developmental services in practice. Pediatrics. 2008;122: e163-e171. 17. Shaw JS, Wasserman RC, Barry S, et al. Statewide quality improvement outreach improves preventive services for young children. Pediatrics. 2007;120:481-488. 18. Maine Center for Public Health. Keep me healthy. http:// www.mcph.org/Major_Activities/KeepMEHealthy.htm. Accessed August 10, 2009. 19. Davis MM, Gance-Cleveland B, Hassink S, Johnson R, Paradis G, Resnicow K. Recommendations for prevention of childhood obesity. Pediatrics. 2007;120:S229-S253. 20. IHI.org. How to improve. http://www.ihi.org/IHI/Topics/ Improvement/ImprovementMethods/HowToImprove/. Accessed July 9, 2009. 21. University of Vermont. Vermont child health improvement program. https://www.med.uvm.edu/VCHIP/HPDEPT.ASP?SiteAreaID=513. Accessed August 18, 2010. 22. Laven GT. Insufficient evidence for committee recommendations on obesity. Pediatrics. 2008;121:1077-1078. 22. Barlow SE, Resnicow K, Krebs NF, Spear BA. Insufficient evidence for committee recommendations on obesity [in reply]. Pediatrics. 2008;121:1078-1079. 23. American Board of Pediatrics. Certification matters. https:// www.abp.org/ABPWebStatic/. Accessed July 9, 2009.
