Comparative Effectiveness of Childhood Obesity Interventions in Pediatric Primary Care

Abstract

IMPORTANCE Evidence of effective treatment of childhood obesity in primary care settings is limited. OBJECTIVE To examine the extent to which computerized clinical decision support (CDS) delivered to pediatric clinicians at the point of care of obese children, with or without individualized family coaching, improved body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) and quality of care. DESIGN, SETTING, AND PARTICIPANTS We conducted a cluster-randomized, 3-arm clinical trial. We enrolled 549 children aged 6 to 12 years with a BMI at the 95% percentile or higher from 14 primary care practices in Massachusetts from October 1, 2011, through June 30, 2012. Patients were followed up for 1 year (last follow-up, August 30, 2013). In intent-to-treat analyses, we used linear mixed-effects models to account for clustering by practice and within each person. INTERVENTIONS In 5 practices randomized to CDS, pediatric clinicians received decision support on obesity management, and patients and their families received an intervention for self-guided behavior change. In 5 practices randomized to CDS + coaching, decision support was augmented by individualized family coaching. The remaining 4 practices were randomized to usual care. MAIN OUTCOMES AND MEASURES Smaller age-associated change in BMI and the Healthcare Effectiveness Data and Information Set (HEDIS) performance measures for obesity during the 1-year follow-up. RESULTS At baseline, mean (SD) patient age and BMI were 9.8 (1.9) years and 25.8 (4.3), respectively. At 1 year, we obtained BMI from 518 children (94.4%) and HEDIS measures from 491 visits (89.4%). The 3 randomization arms had different effects on BMI over time (P = .04). Compared with the usual care arm, BMI increased less in children in the CDS arm during 1 year (−0.51 [95% CI, −0.91 to −0.11]). The CDS + coaching arm had a smaller magnitude of effect (−0.34 [95% CI, −0.75 to 0.07]). We found substantially greater achievement of childhood obesity HEDIS measures in the CDS arm (adjusted odds ratio, 2.28 [95% CI, 1.15-4.53]) and CDS + coaching arm (adjusted odds ratio, 2.60 [95% CI, 1.25-5.41]) and higher use of HEDIS codes for nutrition or physical activity counseling (CDS arm, 45%; CDS + coaching arm, 25%; P < .001 compared with usual care arm). CONCLUSIONS AND RELEVANCE An intervention that included computerized CDS for pediatric clinicians and support for self-guided behavior change for families resulted in improved childhood BMI. Both interventions improved the quality of care for childhood obesity. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01537510

Secular Trends of Overweight and Obesity in Young Southern Californians 2008-2013

“…29 A recent study provided evidence that the use of an electronic decision support system similar to the one used in the present study can be successful in improving BMI in children. 30 This study benefited from measured weight and height from medical office visits as opposed to self-reported weight and height. All children were members of a large prepaid managed care system, and standardized screening guidelines for weight and height in all children in the health plan were routine.…”

Connect for Health : Design of a clinical-community childhood obesity intervention testing best practices of positive outliers

“…14,22 These tools included pre-populated, standardized note templates specific for obesity that included options for: 1) documenting and coding for BMI percentile, 2) documenting and coding for nutrition and physical activity counseling, 3) placing referrals to weight management programs, 4) placing orders for laboratory studies if appropriate, and 5) printing educational materials.…”

“…These materials were based on our previous STAR trial and have been shown to be effective in improving child BMI. 14 The materials focus primarily on decreases in screen time and sugar-sweetened beverages; increases in moderate and vigorous physical activity; and improvement of sleep duration and quality. Based on our qualitative work with positive outlier families and feedback from our parent and youth advisory board, we also developed materials to promote social and emotional wellness.…”

“…Based on previous studies within this setting in which we achieved over 90% follow up at 1-year, we anticipate that 713 children will complete the study. 14,36 The key variable for sample size calculations is the naturally occurring standard deviation in the change of BMI (in kg/m 2 ) during a 12 month period. From a large population-based study the estimated standard deviation in BMI change was 0.96 for boys and 0.95 for girls.…”

“…Members of the research and clinical team have long-standing collaborative relationships developing previous obesity interventions 14 and thus, a key activity in preparation for this study was to build a strong network of cross-collaboration among stakeholders who had not yet worked with each other.…”