Accuracy of Parental Report and Electronic Health Record Documentation as Measures of Diet and Physical Activity Counseling

Abstract

Objective To determine whether parental reports and electronic health record documentation of physician counseling on nutrition and physical activity reflect actual counseling provided. Methods Participants were parents of 198 children 2–12 years of age seen in a primary care pediatric clinic at an academic medical center for well child care and their 38 physicians. Parents completed a post-visit questionnaire to reported discussions on weight, nutrition and physical activity that occurred during the visit. Electronic health records were reviewed to measure documentation of these topics during the visit. Parental reports and records were compared to actual discussions based on coded audiotapes. Counseling was coded as having occurred if specific topics were mentioned during the encounter, however brief this mention was. Results Children were 48% female with a mean age of 5.4 years; 28% were overweight or obese. Sensitivity of parental report was high (70%–96%), but specificity was low (43%–78%), due to parents’ tendency to over-report counseling. Sensitivity of electronic health record documentation was generally low (40–53%) except for discussion of screen time (92%) and physical activity (88%); the specificity of this data source was also poor (42% and 21% respectively). Conclusions Electronic health record documentation may not be the most valid method of measuring physician counseling on weight, nutrition, and physical activity in pediatric primary care. Parental report using a questionnaire administered immediately after the visit is a better alternative in quality improvement or research studies when resources do not allow for direct observation, with the caveat that parents may over-report whether counseling was provided.

Impact of Electronic Health Record Clinical Decision Support on the Management of Pediatric Obesity

“…The study team's previous research demonstrates that assessing clinician documentation may underestimate the true frequency of these behaviors, particularly for outcomes related to discussion. 29 The team also was unable to classify risk factor assessment and counseling for visits during which risk factor assessment occurred but the presence of a risk factor was unclear and counseling was not delivered, although this accounted for a very small number of observations-specifically, 5 for nutrition, 15 for physical activity, and 15 for screen time. Although the study team accounted for correlation related to clustering by physician, the team was unable to account for varying depth of relationship between parents and providers.…”

Anticipatory Guidance about Child Diet and Physical Activity for Latino Farmworker Mothers

“…Recall accuracy and bias, particularly for questions about issues generally believed to reflect good parenting, may affect the results. However, the questionnaire items used to construct measures of anticipatory guidance were adapted from an existing instrument, 27 and the consistent differences between mothers of children with obesity versus mothers of children with healthy weight and overweight indicates that recall bias could not be account for the results.…”

“…Anticipatory guidance measures were adapted from Shaikh et al 27 These measures included recalling if the health care provider discussed child’s weight; food related issues of what the mother should feed her child, feeding children fruits and vegetables, limiting outside food from restaurants, eating breakfast, having family meals together, and not serving soda and sweetened beverages; and activity related issues of time watching television and videos, playing video games or using computer, and amount of physical activity or exercise. A total food guidance measure was based on the total number of food-related issues the mother recalled (0–6); a total activity guidance measure was based on the total number of activity related issues the mother recalled (0–3).…”

Parental report of receipt of adolescent preventive health counseling services from pediatric providers

“…We used parental report of provider counseling behaviors rather than directly measuring counseling behaviors. Though parental report of provider behavior has been shown to be a valid proxy 17 , recall bias may still have affected the results, resulting in underreporting by some participants, overreporting by other participants, or variable reporting of different topics. We assessed counts of prevention-focused conversations.…”

“…Studies employing parental report vary depending on the length of time since the clinic visit, visit type, and the child's age 16 . Despite these limitations of using parental report, a recent study demonstrated that parental recall is a time- efficient and cost-effective method with higher sensitivity than medical record review and good convergent validity with audio-recorded visits 17 .…”