Integrating childhood obesity resources into the patient-centered medical home: Provider perspectives in the United States

Reliable prediction of childhood obesity using only routinely collected EHRs may be possible

Background

Early identification of children at high risk of obesity can provide clinicians with the information needed to provide targeted lifestyle counseling to high-risk children at a critical time to change the disease course.

Objectives

This study aimed to develop predictive models of childhood obesity, applying advanced machine learning methods to a large unaugmented electronic health record (EHR) dataset. This work improves on other studies that have (i) relied on data not routinely available in EHRs (like prenatal data), (ii) focused on single-age predictions, or (iii) not been rigorously validated.

Methods

A customized sequential deep-learning model to predict the development of obesity was built, using EHR data from 36,191 diverse children aged 0-10 years. The model was evaluated using extensive discrimination, calibration, and utility analysis; and was validated temporally, geographically, and across various subgroups.

Results

Our results are mostly better or comparable to similar studies. Specifically, the model achieved an AUROC above 0.8 in all cases (with most cases around 0.9) for predicting obesity within the next 3 years for children 2-7 years of age. Validation results show the model's robustness and top predictors match important risk factors of obesity.

Conclusions

Our model can predict the risk of obesity for young children at multiple time points using only routinely collected EHR data, greatly facilitating its integration into clinical care. Our model can be used as an objective screening tool to provide clinicians with insights into a patient's risk for developing obesity so that early lifestyle counseling can be provided to prevent future obesity in young children.

Empowering Families and Providers With a Lifestyle Medicine Approach to Pediatric Obesity

Pediatric overweight and obesity is a complex chronic medical condition with a multitude of contributing factors. Rates are now nearly double what they were before the COVID-19 pandemic and if the current trajectory holds it is anticipated that by 2050 one in every two US children will experience obesity before the age of thirty-five. Pediatric obesity guidelines emphasize referral to intensive health behavior and lifestyle therapy programs, but these are difficult to access. Front line providers caring for children can use a lifestyle medicine approach within the medical home to make lifestyle changes easier. Lifestyle Medicine can promote a family-oriented, weight-neutral approach by (1) Educating and equipping providers to assess readiness to change and providing high-quality motivational interviewing and lifestyle counseling, (2) Equipping patients and their families with tools involving the six lifestyle interventions to optimize health starting an early age, and (3) Offering a longitudinal uniform office approach to effectively prevent, manage and often reverse obesity and related comorbidities through healthy habit change.

Predictors of successful weight loss in children treated at a community hospital-based tertiary care pediatric weight management program

Childhood obesity is a major public health concern. However, predictors of successful outcomes for patients treated at multidisciplinary community hospital-based pediatric weight management programs remain poorly understood. We conducted a retrospective analysis to evaluate 633 pediatric patients from ages 2 to 18 at a tertiary pediatric weight management program in 2018. Predictors were evaluated in univariate comparisons, and significant variables were included in a linear regression analysis to identify factors associated with improvements in body mass index relative to the age- and sex-specific 95th percentile body mass index (%BMIp95). We found that male sex and increased number of clinical visits were independently and significantly associated with reductions in %BMIp95. Baseline %BMIp95, age, preferred language, and insurance status were not significant predictors of outcomes. A total of 398 (63%) patients experienced a decrease in %BMIp95 from baseline to follow-up. One quarter (24.8%) of patients experienced a decrease in %BMIp95 of at least 5%, a threshold associated with cardiometabolic improvements. Further, we observed significant improvements in cholesterol, triglycerides, alanine aminotransferase, aspartate aminotransferase, HbA1c, and waist circumference. These findings support a potential need for sex- and gender-tailored care as well as the benefits of increased access to pediatric weight management programs.

A Longitudinal Effectiveness Study of a Child Obesity Electronic Health Record Tool

BACKGROUND

Primary-care providers, clinic staff, and nurses play an important role in reducing child obesity; yet time restraints and clinical demands compete with effective pediatric weight management and prevention.

METHODS

To investigate the potential impact of an electronic health record (EHR) enabled tool to assist primary care teams in addressing child obesity, we conducted a controlled effectiveness study of FitTastic compared with usual care on the BMI pattern of 291 children (2 to 17 years) up to 4 years later.

RESULTS

Per χ2 analysis, a greater proportion of children with baseline overweight/obesity in the EHR tool group than the control group had a favorable BMI pattern (32% vs 13%, P = .03). In logistic regression, FitTastic children were more likely than control children to have a favorable BMI pattern at follow-up (OR 3.8, 95% CI 1.1 to 13.2), adjusted for age, gender, race, and parental education.

CONCLUSION

Study findings suggest that EHR-enabled tools to assist primary care teams in managing child obesity may be useful for helping to address the weight in children with overweight/obesity, especially in younger children (2 to 5 years). Digital and EHR-enabled technologies may prove useful for partnering health care teams and families in the important tasks of setting positive, family-centered healthy lifestyle behavioral goals and managing child overweight and obesity.

Control del sobrepeso y la obesidad en niños y adolescentes por enfermeras: un estudio de métodos mixtos

Resumen Objetivo: analizar el manejo del sobrepeso y la obesidad en niños y adolescentes por las enfermeras de la Estrategia Salud de la Familia (ESF). Método: se trata de un estudio de método mixto paralelo convergente, desarrollado en Centros de Salud (UBS) de un municipio del nordeste de Brasil En la etapa cuantitativa, los datos fueron recolectados a partir de un cuestionario aplicado a 98 enfermeras y evaluados mediante estadística descriptiva. Para la etapa cualitativa, se realizaron entrevistas semiestructuradas con siete enfermeras, interpretadas por análisis temático inductivo. Se combinaron los resultados cuantitativos y cualitativos y se mostraron a través de joint display. Resultados: la mayoría de los enfermeros raramente verificaba el perímetro de cintura (77,6%), la dislipidemia (55,7%), la glucemia (42,3%) y tampoco evaluaba la presión arterial (75,3%). En los resultados cualitativos se identificó que hay enfermeras que no clasificaban el índice de masa corporal según sexo y edad. En cuanto a la solicitación de pruebas, las peticiones se trataban principalmente sobre la rutina asociada a la puericultura. Las orientaciones con respecto a la actividad física y nutrición se efectuaban de forma básica o eran asignadas a otros profesionales, y también no se hizo un seguimiento cuando fueron direccionados a otros servicios o profesionales. Conclusión: existen deficiencias en el conocimiento y la práctica de las enfermeras de atención primaria en el control del sobrepeso y la obesidad en niños y adolescentes. Es imperativo capacitar a los enfermeros para el manejo del sobrepeso y la obesidad en la atención primaria de niños y adolescentes, con miras a la calidad de la atención para la prevención de comorbilidades.

Management of overweight and obesity in children and adolescents by nurses: a mixed-method study

Abstract Objective: to analyze the management of overweight and obesity in children and adolescents by nurses of the Family Health Strategy. Method: this is a study of convergent parallel mixed methods, developed in Health Centers of a municipality in northeastern Brazil. In the quantitative stage, data were collected from a questionnaire applied to 98 nurses and analyzed by descriptive statistics. For the qualitative stage, semi-structured interviews were conducted with seven nurses, interpreted by inductive thematic analysis. The quantitative and qualitative results were integrated and presented by a joint display. Results: most nurses rarely checked waist circumference (77.6%), dyslipidemia (55.7%), blood glucose (42.3%), and neither evaluated blood pressure (75.3%). In the qualitative results, we identified that there are nurses who did not classify body mass index according to sex and age. As for medical tests, the requests were mainly related to the routine of childcare. Guidance on physical activity and diet were given in a basic way or attributed to other professionals, and referrals to other services or professionals were not followed up. Conclusion: it is imperative to train nurses for the management of overweight and obesity in primary care for children and adolescents, with a view to quality of care for the prevention of comorbidities.

Manejo do sobrepeso e obesidade em crianças e adolescentes por enfermeiras: estudo de métodos mistos

Resumo Objetivo: analisar o manejo do sobrepeso e da obesidade de crianças e adolescentes por enfermeiras da Estratégia Saúde da Família. Método: estudo de método misto paralelo convergente, desenvolvido em Unidades Básicas de Saúde, de um município do nordeste brasileiro. Na etapa quantitativa, os dados foram coletados a partir de um questionário aplicado a 98 enfermeiras e analisados por meio de estatística descritiva. Para a etapa qualitativa, foram realizadas entrevistas semiestruturadas com sete enfermeiras, interpretadas pela análise temática indutiva. Os resultados quantitativos e qualitativos foram integrados e apresentados por meio de joint display. Resultados: a maioria dos enfermeiros raramente verificava a circunferência da cintura (77,6%), dislipidemia (55,7%), glicemia (42,3%) e nenhum avaliava a pressão arterial (75,3%). Nos resultados qualitativos, identificamos que há enfermeiros que não classificavam o índice de massa corporal segundo sexo e idade. Quanto aos exames, as solicitações estavam relacionadas principalmente à rotina de puericultura. As orientações sobre atividade física e alimentação foram dadas de forma básica ou atribuídas a outros profissionais, e os encaminhamentos para outros serviços ou profissionais sem seguimento pelos enfermeiros. Conclusão: é imperioso a capacitação dos enfermeiros para o manejo do sobrepeso e obesidade na atenção primária para crianças e adolescentes com vistas a qualidade do atendimento para a prevenção de comorbidades.

A Quality Improvement Initiative Addressing Provider Prescription of Weight Management Follow-up in Primary Care

Introduction

Few providers routinely comply with the American Academy of Pediatrics recommendations to prescribe weight management follow-up in-between well-child checks for children with obesity/overweight. This quality improvement (QI) project aimed to increase the percentage of patients prescribed weight management follow-up within three months of their well-child check.

Methods

The project took place in 1 outpatient primary care clinic at a large, free-standing children's hospital from May 2018 to April 2019. We grouped interventions in 4 Plan-Do-Study-Act ramps with the following themes: (1) provider education; (2) electronic health record note changes; (3) discharge order modifications; and (4) provider feedback. The primary outcome was the percent of patients ages 2-18 years with body mass index ≥ 85% that had an order placed to schedule a follow-up weight management appointment in primary care. We monitored attendance rates for scheduled follow-up visits as a balancing measure.

Results

Mean prescription rates increased from 32% at baseline to 58%, with special cause analysis demonstrating improvement. Of patients prescribed follow-up, 40% returned for a weight management visit, compared to 13% before the QI initiative. The no-show rate was 35%.

Conclusions

The utilization of QI methodology led to an increase in the percentage of patients appropriately prescribed weight management follow-up and a resultant increase in the number of patients seen for follow-up. The next steps include a re-examination of process failures to improve patient buy-in in follow-up prescriptions.

Association of healthy child-rearing practices and children's receipt of care in patient-centered medical homes

Efforts to improve the quality of care for children have focused on the patient-centered medical home (PCMH), defined by the National Committee for Quality Assurance (NCQA). Little research has focused on caregivers' role in choosing physicians for children. This study aims to determine whether healthy caregiving behaviors and specific behaviors are associated with children's receipt of PCMH care. Using data from the 2016-2017 National Survey of Children's Health, which includes information on child-rearing behaviors, we estimated logistic regressions, controlling for children's and caregivers' characteristics, to quantify possible associations. We found that each additional healthy child-rearing practice followed increased a child's chance of receiving PCMH care by 4.5% (p < 0.001). Being breastfed (children aged 0-5 years), sharing ideas with their caregiver (children aged 6-17 years), their caregiver ensuring homework is finished (children aged 6-17 years), and having TV time monitored (all ages), each increased the likelihood of PCMH use. These findings show that caregiving behavior is independently associated with locus of care. Future research is warranted as educating caregivers about healthy child-rearing may lead them to seek higher quality care for their children. Also, evaluating the effect of behaviors on health outcomes associated with PCMH would be valuable.

Adoption of an Electronic Medical Record Tool for Childhood Obesity by Primary Care Providers

BACKGROUND

Primary care providers are tasked with the increasingly difficult job of addressing childhood obesity during clinic visits. Electronic medical record (EMR)-enabled decision-support tools may aid providers in this task; however, information is needed regarding whether providers perceive such tools to be useful for addressing nutrition and physical activity lifestyle behaviors.

OBJECTIVES

This study aimed to evaluate the usefulness and usability of FitTastic, an EMR-enabled tool to support prevention and management of childhood obesity in primary care.

METHODS

In this mixed-method study, we implemented the FitTastic tool in two primary-care clinics, then surveyed and conducted focused interviews with providers. Validated Technology Acceptance Model perceived usefulness and National Aeronautics and Space Administration (NASA) perceived usability survey questions were e-mailed to 60 providers. In-depth provider interviews with family medicine and pediatric physicians (n = 12) were used to further probe adoption of FitTastic.

RESULTS

Surveys were completed by 73% of providers (n = 44). The mean score for FitTastic's usefulness was 3.3 (standard deviation [SD] = 0.54, scale 1-5, where 5 is strongly agree) and usability, 4.8 (SD = 0.86, scale 1-7, where 7 is strongly agree). Usefulness and usability scores were associated with intention to use FitTastic (correlation for both, p < 0.05). Data from provider interviews indicated that useful features of FitTastic included: standardizing the approach to childhood obesity, and facilitating conversations about weight management, without increasing cognitive workload. However, use of FitTastic required more time from nurses to input lifestyle data.

CONCLUSION

FitTastic is perceived as a useful and usable EMR-based lifestyle behavior tool that standardizes, facilitates, and streamlines healthy lifestyle conversations with families. Perceived usability and usefulness scores correlated with provider intention-to-use the technology. These data suggest that EMR-based child obesity prevention and management tools can be feasible to use in the clinic setting, with potential for scalability. Usefulness can be optimized by limiting amount of time needed by staff to input data.

US Pediatrician Practices and Attitudes Concerning Childhood Obesity: 2006 and 2017

OBJECTIVE

To compare primary care pediatricians' practices and attitudes regarding obesity assessment, prevention, and treatment in children 2 years and older in 2006 and 2017.

STUDY DESIGN

National, random samples of American Academy of Pediatrics members were surveyed in 2006, 2010, and 2017 on practices and attitudes regarding overweight and obesity (analytic n = 655, 592, and 558, respectively). Using logistic regression models (controlling for pediatrician and practice characteristics), we examined survey year with predicted values (PVs), including body mass index (BMI) assessment across 2006, 2010, and 2017 and practices and attitudes in 2006 and 2017.

RESULTS

Pediatrician respondents in 2017 were significantly more likely than in 2006 and 2010 to report calculating and plotting BMI at every well-child visit, with 96% of 2017 pediatricians reporting they do this. Compared with 2006, in 2017 pediatricians were more likely to discuss family behaviors related to screen time, sugar-sweetened beverages, and eating meals together, P < .001 for all. There were no observed differences in frequency of discussions on parental role modeling of nutrition and activity-related behaviors, roles in food selection, and frequency of eating fast foods or eating out. Pediatricians in 2017 were more likely to agree BMI adds new information relevant to medical care (PV = 69.8% and 78.1%), they have support staff for screening (PV = 45.3% and 60.5%), and there are effective means of treating obesity (PV = 36.3% and 56.2%), P < .001 for all.

CONCLUSIONS

Results from cross-sectional surveys in 2006 and 2017 suggest nationwide, practicing pediatricians have increased discussions with families on several behaviors and their awareness and practices around obesity care.