Obesity Care A Quality Improvement Initiative Involving Pediatrics, Family Medicine, and Internal Medicine

Abstract

Background

The prevalence of obesity is increasing among all population groups.

Primary risk factors are poor dietary habits and inadequate physical activity. Physicians can influence this trend by identifying and counseling those patients who are already obese or at risk for developing obesity.

Objective

To develop a quality improvement initiative to address physician identification and counseling of obese and overweight patients among practices in three primary care disciplines.

Design/Methods

Physicians in the Michigan State University Primary Care Faculty Development Fellowship Program 2004-2005 discussed the care of obese patients and determined variables to measure for a practice audit.  Each physician audited charts of five obese patients and comparisons were made using the determined variables.

Results

Body mass index (BMI) was recorded in 72% of patients; mean BMI was 35.  Readiness for change was documented in 63% with goals for change set in 38%.  Diet counseling was provided to 71% and exercise counseling was provided to 74% without significant gender differences.  White patients were significantly less likely compared with non-white patients to be counseled for diet, 58% vs. 90% (p<.002) and were also less likely than non-white patients to be counseled for exercise, 61% vs. 93% (p<.002).

Conclusions

The findings in this study suggest that there is a disparity in counseling based on ethnicity and that primary care physicians can improve their documentation of BMI, assessment of readiness to change, and setting goals.  Physicians may need to implement specific strategies that target providers, staff, patients, and the office system to improve obesity care.

Introduction

Obesity is a major public health issue, with prevalence increasing at an alarming rate.  Nationally, over 15% of children and adolescents 6 to 19 years of age are overweight.  The rates of overweight children are even higher among minority and economically disadvantaged children.  The rate of overweight and obese children and adolescents has tripled in the past 25 years.  In 1999, an estimated 61% of U.S. adults were overweight or obese. ¹

Obesity-related illnesses cost the United States an estimated $117 billion in 2000 and accounts for approximately 300,000 deaths per year. ¹  The escalating issues of obesity have led the U.S. Department of Health and Human Services to target overweight and obesity as one of the ten Leading Health Indicators for the health of our nation in the Healthy People 2010 initiative. ²  The adverse health effects of obesity are immense.

Obesity during childhood is an important risk factor for obesity in adulthood and is associated with significant health problems in the pediatric age group.  Obesity affects multiple major organ systems, including the endocrine, cardiovascular, gastrointestinal, reproductive, skeletal, muscular, and pulmonary systems.  Co-morbidities include diabetes mellitus type 2, insulin resistance, metabolic syndrome, polycystic ovary syndrome, dyslipidemia, hypertension, nonalcoholic steatohepatitis, obstructive sleep apnea, orthopedic disorders, and mental health problems, including low self- esteem, depression, and the psychological distress of social stigmatization.

Poor dietary habits and inadequate physical activity are primary risk factors for becoming overweight.  As with other chronic diseases, primary care physicians need to identify patients at risk and counsel them in regard to behaviors that might ameliorate that risk.

The purpose of this study is use a multidisciplinary approach to develop a quality improvement initiative to address physician identification and counseling of obese and overweight patients in pediatrics, family practice, and internal medicine practices.

Design/Methods

Nineteen physician-fellows in the Michigan State University Primary Care Faculty Development Fellowship Program 2004-2005 discussed the care of obese patients and determined variables to measure for a practice audit.  These variables included patient demographics, family and personal history of major medical problems, documentation of diet and exercise counseling, goal-setting and follow-up plans.  Each physician audited charts of the last four visits of five obese patients and entered data onto a web-based form.  A faculty mentor exported and analyzed the data using Epi-info.  Fellows described the dataset using frequency statistics and comparisons were made on gender, ethnicity, and age with counseling variables using Chi-square and ANOVA.

Results

Data were collected on 94 patients, including 38 children. Thirty-one percent were African American; 12% Hispanic; 47% white.  Body mass index (BMI) was recorded in 72% of patients; mean BMI was 35.  Readiness for change was documented in 63% with goals for change set in 38%.  Diet counseling was provided to 71% and exercise counseling was provided to 74% without significant gender differences.  White patients were significantly less likely than non-white patients to be counseled for diet, 58% vs. 90% (p<.002) and were also less likely than non-white patients to be counseled for exercise, 61% vs. 93% (p<.002).

Discussion

This study of pooled data from pediatric, family medicine, and internal medicine practices reveals a disparity in the counseling of diet and exercise but in a manner not initially anticipated.  Non-white obese patients were more likely than white patients to receive recommended counseling services.  This study also suggests that physicians can improve their BMI documentation, assessment of readiness to change and goal setting.

Physicians may need to implement specific strategies that target providers, staff, patients, and the office system to improve care for overweight patients.  Following review of chart audit data and results, fellows designed quality improvement tools that focused on three aspects of intervention:

1. Patient-centered approach- Form for use by clinicians and patients focused on review of current diet and exercise habits, setting goals in regards to diet and exercise and review of barriers and strategies to manage them
2. Practice-based approach- Tools to promote BMI documentation in charts, with improved identification of overweight and obese patients to target care more effectively
3. Systems-based approach- Comprehensive patient administered questionnaire addressing exercise and diet habits, personal and family history and intervention targeted at readiness-for-change

It is rare for the three primary care disciplines to collaborate on a mutually agreeable initiative that spans all disciplines and that is generated by them.  The Michigan State University Faculty Development Fellowship includes pediatricians, family physicians, and internists, thus allowing such a collaboration to occur.  Obesity is an example of a health issue that can affect all ages.  Collaborating with our primary care colleagues may not only improve the success in improving the health of our patients; it may also serve to diminish our professional isolationism.