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Shook RP, Halpin K, Carlson JA, Davis A, Dean K, Papa A, Sherman AK, Noel-MacDonnell JR, Summar S, Krueger G, Markenson D, Hampl S. Adherence With Multiple National Healthy Lifestyle Recommendations in a Large Pediatric Center Electronic Health Record and Reduced Risk of Obesity. Mayo Clin Proc 2018; 93:1247-1255. [PMID: 30060957 DOI: 10.1016/j.mayocp.2018.04.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 03/31/2018] [Accepted: 04/19/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the utility of a routine assessment of lifestyle behaviors incorporated into the electronic health record (EHR) to quantify lifestyle practices and obesity risk at a pediatric primary care center. PATIENTS AND METHODS Participants included 24,255 patients aged 2 to 18 years whose parent/caregiver completed a self-report lifestyle assessment during a well-child examination (January 1, 2013, through June 30, 2016). Cross-sectional analyses of age, race/ethnicity, body mass index, and lifestyle assessment responses were performed. Outcome measures included prevalence of patients meeting consensus recommendations for physical activity; screen time; and dairy, water, and fruit/vegetable consumption and the odds of obesity based on reported lifestyle behaviors. RESULTS Prevalence of meeting recommendations for lifestyle behaviors was highest for physical activity (84%), followed by screen time (61%) and consumption of water (51%), dairy (27%), and fruits/vegetables (10%). Insufficient physical activity was the strongest predictor of obesity (odds ratio [OR], 1.65; 95% CI, 1.51-1.79), followed by excess screen time (OR, 1.36; 95% CI, 1.27-1.45). Disparities existed across ages, races/ethnicities, and sexes for multiple lifestyle habits. Youth who met 0 or 1 lifestyle recommendation were 1.45 to 1.71 times more likely to have obesity than those meeting all 5 recommendations. CONCLUSION Healthy behaviors vary in prevalence, as does their association with obesity. This variation is partially explained by age, sex, and race/ethnicity. Meeting national recommendations for specific behaviors is negatively associated with obesity in a dose-dependent manner. These findings support the assessment of lifestyle behaviors in primary care as one component of multilevel initiatives to prevent childhood obesity.
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Affiliation(s)
- Robin P Shook
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO; Center for Children's Healthy Lifestyles and Nutrition, Kansas City, MO.
| | - Kelsee Halpin
- Division of Pediatric Endocrinology and Diabetes, Children's Mercy Kansas City, Kansas City, MO
| | - Jordan A Carlson
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO; Center for Children's Healthy Lifestyles and Nutrition, Kansas City, MO
| | - Ann Davis
- Center for Children's Healthy Lifestyles and Nutrition, Kansas City, MO; Department of Pediatrics, University of Kansas Medical Center, Kansas City, KS
| | - Kelsey Dean
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO; Center for Children's Healthy Lifestyles and Nutrition, Kansas City, MO
| | - Amy Papa
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO; Center for Children's Healthy Lifestyles and Nutrition, Kansas City, MO
| | - Ashley K Sherman
- Department of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO
| | | | - Shelly Summar
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO; Center for Children's Healthy Lifestyles and Nutrition, Kansas City, MO
| | - Gary Krueger
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO
| | - Deborah Markenson
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO; Center for Children's Healthy Lifestyles and Nutrition, Kansas City, MO
| | - Sarah Hampl
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO; Center for Children's Healthy Lifestyles and Nutrition, Kansas City, MO
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Dietz WH, Baur LA, Hall K, Puhl RM, Taveras EM, Uauy R, Kopelman P. Management of obesity: improvement of health-care training and systems for prevention and care. Lancet 2015; 385:2521-33. [PMID: 25703112 DOI: 10.1016/s0140-6736(14)61748-7] [Citation(s) in RCA: 261] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Although the caloric deficits achieved by increased awareness, policy, and environmental approaches have begun to achieve reductions in the prevalence of obesity in some countries, these approaches are insufficient to achieve weight loss in patients with severe obesity. Because the prevalence of obesity poses an enormous clinical burden, innovative treatment and care-delivery strategies are needed. Nonetheless, health professionals are poorly prepared to address obesity. In addition to biases and unfounded assumptions about patients with obesity, absence of training in behaviour-change strategies and scarce experience working within interprofessional teams impairs care of patients with obesity. Modalities available for the treatment of adult obesity include clinical counselling focused on diet, physical activity, and behaviour change, pharmacotherapy, and bariatric surgery. Few options, few published reports of treatment, and no large randomised trials are available for paediatric patients. Improved care for patients with obesity will need alignment of the intensity of therapy with the severity of disease and integration of therapy with environmental changes that reinforce clinical strategies. New treatment strategies, such as the use of technology and innovative means of health-care delivery that rely on health professionals other than physicians, represent promising options, particularly for patients with overweight and patients with mild to moderate obesity. The co-occurrence of undernutrition and obesity in low-income and middle-income countries poses unique challenges that might not be amenable to the same strategies as those that can be used in high-income countries.
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Affiliation(s)
- William H Dietz
- Sumner M Redstone Global Center for Prevention and Wellness, George Washington University, Washington, DC, USA.
| | - Louise A Baur
- Weight Management Services, The Children's Hospital at Westmead Clinical School, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Kevin Hall
- Laboratory of Biological Modeling, Diabetes Endocrinology and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Rebecca M Puhl
- Rudd Centre for Food Policy & Obesity, Yale University, New Haven, CT, USA
| | - Elsie M Taveras
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Harvard Medical School, Boston, MA, USA
| | - Ricardo Uauy
- Universidad Católica de Chile, División de Pediatría, Escuela de Medicina, Santiago, Chile
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Price-Haywood EG. Clinical Comparative Effectiveness Research Through the Lens of Healthcare Decisionmakers. Ochsner J 2015; 15:154-161. [PMID: 26130978 PMCID: PMC4482557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Healthcare expenditures in the United States exceed the healthcare expenditures of other countries, yet relatively unfavorable health outcomes persist. Despite the emergence of numerous evidence-based interventions, wide variations in clinical care have caused disparities in quality of care and cost. Comparative effectiveness and cost effectiveness research may better guide healthcare decisionmakers in determining which interventions work best, for which populations, under which conditions, and at what cost. METHODS This article reviews national health policies that promote comparative effectiveness research (CER), healthcare decisionmaker roles in CER, methodological approaches to CER, and future implications of CER. RESULTS This article provides a brief summary of CER health policy up to the Patient Protection and Affordable Care Act and its establishment of the Patient-Centered Outcomes Research Institute (PCORI). Through PCORI, participatory methods for engaging healthcare decisionmakers in the entire CER process have gained momentum as a strategy for improving the relevance of research and expediting the translation of research into practice. Well-designed, methodologically rigorous observational studies and randomized trials conducted in real-world settings have the potential to improve the quality, generalizability, and transferability of study findings. CONCLUSION Learning health systems and practice-based research networks provide the infrastructure for advancing CER methods, generating local solutions to high-quality cost-effective care, and transitioning research into implementation and dissemination science-all of which will ultimately guide health policy on clinical care, payment for care, and population health.
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Affiliation(s)
- Eboni G. Price-Haywood
- Departments of Internal Medicine and Research, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
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Taveras EM, Marshall R, Horan CM, Gillman MW, Hacker K, Kleinman KP, Koziol R, Price S, Rifas-Shiman SL, Simon SR. Improving children's obesity-related health care quality: process outcomes of a cluster-randomized controlled trial. Obesity (Silver Spring) 2014; 22:27-31. [PMID: 23983130 DOI: 10.1002/oby.20612] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 08/09/2013] [Accepted: 08/16/2013] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To examine the extent to which an intervention using electronic decision support delivered to pediatricians at the point-of-care of obese children, with or without direct-to-parent outreach, improved health care quality measures for child obesity. DESIGN AND METHODS Process outcomes from a three-arm, cluster-randomized trial from 14 pediatric practices in Massachusetts were reported. Participants were 549 children aged 6-12 years with body mass index (BMI) ≥ 95th percentile. In five practices (Intervention-1), pediatricians receive electronic decision support at the point-of-care. In five other practices (Intervention-2), pediatricians receive point-of-care decision support and parents receive information about their child's prior BMI before their scheduled visit. Four practices receive usual care. The main outcomes were Healthcare Effectiveness Data and Information Set (HEDIS) performance measures for child obesity: documentation of BMI percentile and use of counseling codes for nutrition or physical activity. RESULTS Compared to the usual care condition, participants in Intervention-2, but not Intervention-1, had substantially higher odds of use of HEDIS codes for BMI percentile documentation (adjusted OR: 3.97; 95% CI: 1.92, 8.23) and higher prevalence of use of HEDIS codes for counseling for nutrition or physical activity (adjusted predicted prevalence 20.3% [95% CI 8.5, 41.2] for Intervention -2 vs. 0.0% [0.0, 2.0] for usual care). CONCLUSION An intervention that included both decision support for clinicians and outreach to parents resulted in improved health care quality measures for child obesity.
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Affiliation(s)
- Elsie M Taveras
- Division of General Pediatrics, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, Massachusetts, USA; Obesity Prevention Program, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
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Cardiovascular and economic outcomes after initiation of atorvastatin versus simvastatin in an employed population stratified by cardiovascular risk. Am J Ther 2013; 18:436-48. [PMID: 20802306 DOI: 10.1097/mjt.0b013e3181e4de68] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The relative effects of atorvastatin and simvastatin among higher- and lower-risk patients are not well characterized. This study compared cardiovascular (CV) risk and direct and indirect costs among higher- and lower-risk employees initiating atorvastatin vs. simvastatin. Using a large employer claims database (1999-2006), employees were stratified as 1) high-risk employees with prior CV events, diabetes, or renal disorders; and 2) low- to intermediate-risk employees without these conditions. Propensity score matching was used, and 2-year outcomes were compared between matched cohorts. Indirect costs included disability payments and medically related absenteeism. Drug costs were imputed with recent prices to account for availability of generic simvastatin. Among 4167 matched pairs of high-risk employees, atorvastatin use was associated with a numerically lower risk of CV events (17.6 versus 18.4%, P = 0.37), higher direct medical costs ($17,590 versus $17,377, P = 0.002), numerically lower indirect costs ($4830 versus $4989, P = 0.29), and higher total costs by $54 ($22,420 versus $22,366, P = 0.034). The majority of high-risk employees (62%) received low initial statin doses (atorvastatin = 10 mg or simvastatin = 20 mg). Among 9326 matched pairs of low- to intermediate-risk employees, atorvastatin use was associated with a lower risk of CV events (3.1% versus 3.7%, P = 0.030), lower direct medical costs ($8400 versus $8436, P < 0.001), numerically lower indirect costs ($2781 versus $2807; P = 0.12), and lower total costs by $61 ($11,181 versus $11,243, P < 0.001). These results suggest that formulary policies reserving atorvastatin for higher-risk patients may not be cost-saving from the employer perspective.
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Taveras EM, Marshall R, Horan CM, Gillman MW, Hacker K, Kleinman KP, Koziol R, Price S, Simon SR. Rationale and design of the STAR randomized controlled trial to accelerate adoption of childhood obesity comparative effectiveness research. Contemp Clin Trials 2012; 34:101-8. [PMID: 23099100 DOI: 10.1016/j.cct.2012.10.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 10/15/2012] [Accepted: 10/16/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Comparative effectiveness research (CER) evidence on childhood obesity provides the basis for effective screening and management strategies in pediatric primary care. The uses of health information technology including decision support tools in the electronic health records (EHRs), as well as remote and mobile support to families, offer the potential to accelerate the adoption of childhood obesity CER evidence. METHODS/DESIGN The Study of Technology to Accelerate Research (STAR) is a three-arm, cluster-randomized controlled trial being conducted in 14 pediatric offices in Massachusetts designed to enroll 800, 6 to 12 year old children with a body mass index (BMI)≥ 95th percentile seen in primary care at those practices. We will examine the extent to which computerized decision support tools in the EHR delivered to primary care providers at the point of care, with or without direct-to-parent support and coaching, will increase adoption of CER evidence for management of obese children. Direct-to-parent intervention components include telephone coaching and twice-weekly text messages. Point-of-care outcomes include obesity diagnosis, nutrition and physical activity counseling, and referral to weight management. One-year child-level outcomes include changes in BMI and improvements in diet, physical activity, screen time, and sleep behaviors, as well as cost and cost-effectiveness. CONCLUSIONS STAR will determine the extent to which decision support tools in EHRs with or without direct-to-parent support will increase adoption of evidence-based obesity management strategies in pediatric practice and improve childhood obesity-related outcomes.
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Affiliation(s)
- Elsie M Taveras
- Obesity Prevention Program, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, United States.
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Dryden EM, Hardin J, McDonald J, Taveras EM, Hacker K. Provider perspectives on electronic decision supports for obesity prevention. Clin Pediatr (Phila) 2012; 51:490-7. [PMID: 22330047 DOI: 10.1177/0009922812436549] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Despite the availability of national evidenced-based guidelines related to pediatric obesity screening and prevention, multiple studies have shown that primary care physicians find it difficult to adhere to them or are unfamiliar with them altogether. This article presents physicians' perspectives on the use of electronic decision support tools, an alert and Smart Set, to accelerate the adoption of obesity-related recommendations into their practice. The authors interviewed providers using a test encounter walk-through technique that revealed a number of barriers to using electronic decision supports for obesity care in primary care settings. Providers' suggestions for improving their use of obesity-related decision supports are presented. Careful consideration must be given to both the development of electronic decision support tools and a multilayered educational outreach strategy if providers are going to be persuaded to use such supports to help them implement pediatric obesity prevention and management best practices.
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Affiliation(s)
- Eileen M Dryden
- Department of Medicine, Cambridge Health Alliance, Institute for Community Health, 163 Gore St, Cambridge, MA 02141, USA.
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McDonald J, Goldman RE, O'Brien A, Ayash C, Mitchell K, Marshall R, Simon SR, Taveras EM. Health information technology to guide pediatric obesity management. Clin Pediatr (Phila) 2011; 50:543-9. [PMID: 21565885 DOI: 10.1177/0009922810395131] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this study was to examine pediatricians' familiarity with expert committee recommendations on the management of childhood obesity and their use of health information technology for obesity-related care. The authors interviewed 35 pediatricians from 17 primary care practices using an electronic health record; immersion crystallization facilitated analysis of the qualitative data. Nearly all pediatricians were unfamiliar with expert recommendations; however, all participants reported using growth charts and providing nutrition and physical activity counseling. Most participants wanted easy access to educational materials they could print for patients. The majority of participants were in favor of an electronic alert to identify obese patients, remind clinicians of current guidelines, and facilitate ordering, believing it would help standardize care. Concerns included "alert fatigue," distraction, and disruption of workflow. Suggestions for future electronic functions included tailored educational materials and physical activity resources customized by patient address.
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Affiliation(s)
- Julia McDonald
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 133 Brookline Avenue, 3rd Floor, Boston, MA 02215, USA.
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