QUALITY IMPROVEMENT REPORT

Translation of clinical practice guidelines for childhood obesity prevention in primary care mobilizes a rural Midwest community S. Jo Gibson, DNP, RN, CNP (Clinical Assistant Professor) College of Nursing, South Dakota State University, Brookings, South Dakota

Keywords Pediatric; obesity; prevention; clinical practice guidelines; primary care; rural. Correspondence S. Jo Gibson, DNP, RN, CNP, College of Nursing, South Dakota State University, Brookings, SD 57007. Tel: 605-688-4897 (office), 605-691-5821 (cell); Fax: 605-688-5827; E-mail: jo.gibson@ sdstate.edu, [email protected] Received: 16 June 2014; accepted: 22 December 2014 doi: 10.1002/2327-6924.12239

Abstract Purpose: The purpose of this project was to implement clinic system changes that support evidence-based guidelines for childhood obesity prevention. Adherence rates for prevention and screening of children in a rural Midwest primary care setting were used to measure the success of the program. Data sources: Retrospective chart reviews reflected gaps in current practice and documentation. An evidence-based toolkit for childhood obesity prevention was used to implement clinic system changes for the identified gaps. Conclusions: The quality improvement approach proved to be effective in translating knowledge of obesity prevention guidelines into rural clinic practices with significant improvements in documentation of prevention measures that may positively impact the childhood obesity epidemic. Implications for practice: Primary care providers, including nurse practitioners (NPs), are at the forefront of diagnosing, educating, and counseling children and families on obesity prevention and need appropriate resources and tools to deliver premier care. The program successfully demonstrated how barriers to practice, even with the unique challenges in a rural setting, can be overcome. NPs fulfill a pivotal primary care role and can provide leadership that may positively impact obesity prevention in their communities.

Background Obesity rates have reached global epidemic proportions. Children in the United States are no exception and because of this are forecasted to lead less healthy lives and have shorter life spans than their parents (Olshansky et al., 2005). Obesity disproportionately affects children in the rural setting as well as minority, culturally diverse, and economically disadvantaged children, and children with less-educated parents (Griffith, 2009; Liu, Bennett, & Harun, 2007; Wang & Beydoun, 2007). An alarming 75% of the young Americans ages 17–24 cannot enlist in the military; the leading medical reason is overweight or obesity, whereby applicants are physically unfit to qualify for military service (Christeson, Taggart, & Messner-Zidell, 2010). Chronic diseases that once only affected adults, including type 2 diabetes mellitus, hypertension, lipid disorders, and psychosocial disorders, are now being diagnosed in young children who are overweight and obese (American Heart Association [AHA], 2010; Ogden, Carroll, Kit, & Flegal, 2012). The escalation of obesity with the associated

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medical and psychosocial sequelae has cost the United States a staggering $11.7 billion annually for children (Polacsek et al., 2009), $190.2 billion overall including adults, and constitutes nearly 21% of national healthcare spending (Institute of Medicine [IOM], 2012). Obesity impacts an entire generation of children and is a severe threat to the security and economic well-being of the entire nation (Christeson et al., 2010; Huang & Horlick, 2007). Primary care providers (PCPs) play a pivotal role in implementing evidence-based guidelines and can have a significant impact on childhood obesity and obesity-related health consequences. PCPs are defined for purposes of this article as physicians, nurse practitioners (NPs), and physician’s assistants working in a primary care setting. Correctly diagnosing overweight and obesity as well as providing education and counseling are critical steps in reducing childhood obesity. However, PCPs are not effectively using evidence and incorporating guidelines into clinical practice, especially in a time-restricted clinic visit. Regardless of the availability of evidence-based recommendations, multiple studies have shown that PCPs are not adhering

Journal of the American Association of Nurse Practitioners 28 (2016) 130–137  C 2015 American Association of Nurse Practitioners

Childhood obesity prevention

S. J. Gibson

Putting guidelines into practice is challenging for busy PCPs whose office visits are often too brief to allow for comprehensive assessment and prevention counseling in detail. In addition to time constraints, PCPs report unfamiliarity with billing codes, lack of reimbursement by third-party payers, lack of parent recognition and motivation, and lack of economically feasible treatment options (AAP, 2007; Ewing et al., 2009). A more recent, and often overlooked, barrier is the lack of well-developed data systems and health information technology, which could be used to simplify tracking and monitoring and improve outcomes (Dryden, Hardin, McDonald, Taveras, & Hacker, 2012). Perhaps the largest barrier is that many PCPs have not had adequate training, are unfamiliar with evidencebased practice guidelines, and are perplexed with how to diagnose, educate, and counsel children and families on obesity prevention (Ewing et al., 2009; Hearn, Miller, & Campbell-Pope, 2008).

lations of body mass index (BMI) and BMI percentile (Barlow & Expert Committee, 2007). PCPs are also urged to assess key dietary habits (e.g., consumption of sugarsweetened beverages, fruits, and vegetables), physical activity habits, readiness to change lifestyle habits, and family history of obesity and obesity-related illnesses (Barlow & Expert Committee, 2007). PCPs should then educate parents about their child’s BMI percentile, diet, physical activity, and sedentary behaviors (Barlow & Expert Committee, 2007). Children should also be educated using language that is age and developmentally appropriate. The literature review revealed several practice guidelines with a variety of strategies to reflect the evidence-based recommendations. The author noted the detail and complexity of many of the practice guideline programs as a limitation for adoption in the often time-sensitive clinic setting. Also, the resources required for some programs were either cost prohibitive, not feasible for rural practices, or unavailable to the general practitioner. Therefore, the primary goal was to identify an existing program that was affordable, practical, and utilized a short, simple, and feasible training and intervention approach that is ideal for busy PCPs (Stahl, Necheles, Mayefsky, Wright, & Rankin, 2011). Based on these criteria, the author selected the Let’s Go! 5210 (2012) program and found the consistent health messaging to be indisputable. Derived from 10 evidencebased strategies, the program is a nationally recognized childhood obesity prevention program designed to increase healthy eating and active living in children from birth to 18 (Polacsek et al., 2009). The behavioral goals are based on the “5210” philosophy of encouraging at least five servings of fruit and vegetables daily, limiting screen time unrelated to school (television, computer games, other sedentary media activities) to two hours or less each day, at least one hour of physical activity daily, and avoiding (i.e., consuming zero) fruit drinks, soda pop, and any sugarsweetened beverage and replacing these with water or low-fat milk. Because the focus is on prevention and not just treatment, the science-based interventions are universally appropriate for all children and not just those who are overweight or obese (Polacsek et al., 2009).

Evidence-based clinical practice guidelines

Conceptual framework

Evidence-based recommendations for childhood obesity prevention were released in 2007 by an expert panel and endorsed by 15 prestigious and reputable professional organizations (Barlow & Expert Committee, 2007). The panel of experts recommended that PCPs address the issue of weight with all children at least once a year including measurements of height and weight and calcu-

The Chronic Care Model, developed by Wagner (1998) and modified for the primary care management of children and families (National Initiative for Children’s Healthcare Quality [NICHQ], 2011), provided the framework for the project. Wagner (1998) describes the model as a synthesis of evidence-based system changes that healthcare systems can use to guide quality improvement activities. The

to obesity prevention guidelines or are unfamiliar with the guidelines altogether (American Academy of Pediatrics [AAP], 2007; Benson, Baer, & Kaelber, 2009; Klein et al., 2010; Perrin, Flower, Garrett, & Ammerman, 2005; Small, Anderson, Sidora-Arcoleo, & Gance-Cleveland, 2009). In fact, rates of weight loss counseling by PCPs decreased by 41% from 2007 to 2008, with less than 30% of obese patients receiving counseling, despite the substantial increase in the rates of overweight and obesity (Kraschnewski et al., 2012). The higher prevalence of obesity in rural areas and the relatively lower access to prevention resources and specialty care creates unique challenges (Liu et al., 2007).

Purpose The purpose of this project was to implement clinic system and provider practice changes that support evidencebased guidelines for childhood obesity prevention. The specific aim was to improve adherence to obesity prevention and screening of children in a rural Midwest primary care setting.

Barriers to practice

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Childhood obesity prevention

model depicts that improvements in functional and clinical outcomes are the result of productive interactions between “a prepared, proactive team of healthcare professionals and an informed, activated patient” (NICHQ, 2011, p. 1). Quality improvement healthcare teams working with this model focus their efforts and interventions on the four areas contained in the health system: family and self-management support, delivery system design, decision support, and clinical information systems (NICHQ, 2011; Wagner, 1998).

Methods Setting and sample The project involved two rural health clinics that are part of a Midwest healthcare system and included the clinic’s PCPs and front-line staff.

Design Preintervention data were retrieved from retrospective chart reviews of well-child visits. Postintervention chart reviews were completed to evaluate changes in clinic and PCP behaviors and documentation of childhood obesity screening and prevention measures. The project was designed to evaluate the effectiveness of using an evidencebased childhood obesity prevention toolkit and determined the program’s feasibility and acceptability in the rural Midwest primary care practice setting.

Procedures The quality improvement design of this project was considered exempt by the Human Subjects Committee and followed the guidelines established by the healthcare system. The Let’s Go! 5210 (2012) program for health care, Childhood Obesity Prevention Resources Toolkit for Healthcare Professionals, was used to establish a protocol for the identified gaps in the current practice patterns and in the clinic’s documentation system. Staff education was essential and encompassed the following: (a) accuracy with anthropometric measures to facilitate correct diagnosis of overweight and obesity, (b) assessment and evaluation of the child’s lifestyle behaviors through use of a questionnaire, (c) consistent health messaging related to nutrition and physical activity, and (d) use of motivational interviewing to guide a mutually established action plan. The newly establish protocol incorporated the following “5210” components. ■

Office tools included “5210” posters and drink comparison displays. The posters were hung at each clinic in the waiting rooms, exam rooms, and the patient bathrooms.

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The drink comparison display was prepared by the registered dietitian (RD) and set up by the medical receptionist in the waiting rooms at each clinic. ■ Children who had scheduled appointments at the clinic were given the 5210 Healthy Habits Questionnaire at the time of registration and either the child (for 10- to 18year-olds) or child’s parent (for 2- to 9-year-olds) completed the form in the waiting room. ■ The nurse or medical assistant weighed and measured the height of the child, calculated the BMI and BMI percentile, and plotted the findings on the Centers for Disease Control and Prevention (CDC) BMI-for-Age Growth Charts for Boy and Girls (CDC, 2009). ■ The PCP evaluated the child’s height, weight, BMI and BMI percentile, growth charts, and blood pressure in association with the findings of the physical exam. The PCP also evaluated the child/parent responses to the 5210 Healthy Habits Questionnaire and utilized motivational interviewing skills to facilitate an action plan. The PCP used references from the toolkit, including motivational interviewing guidelines for approaching parents and children with healthy eating and active living. Appropriate educational brochures were given and reviewed with the child/family along with a 4-week tracker for the selected “5210” challenge. Documentation reflected the “5210” education and action plan with follow-up if indicated.

Data collection The author performed manual chart reviews and collected data for the previous calendar year preintervention and for the 6-week period postintervention. A data collection sheet was used to extract the following variables: age, gender, race/ethnicity, payor source, height, weight, BMI and BMI percentile, plotting on the CDC growth chart, weight classification, diagnosis of overweight or obesity, blood pressure, and documentation of education and counseling. Data were entered into SPSS software, version 19 and reviewed manually for entry accuracy.

Results Clinic population profile Chart review data (Table 1) for a total of 74 charts preintervention were compared to the 60 charts of children who were involved in the “5210” study group. The mean age for the prestudy population was older at 13.1 years compared to the “5210” study group at 11.0 years (p < .05). The two groups of children were similar in demographic characteristics including gender, race/ethnicity, and payor source. Weight classifications for the two groups were categorized based on the child’s BMI percentile

Childhood obesity prevention

S. J. Gibson

Table 1 Study population characteristics before and with 5210 education, N = 134 (preintervention n = 74; postintervention n = 60)

Child characteristics Mean age (in years) Gender (male) Race/ethnicity Caucasian Hispanic American Indian Visit type Well exam Acute episode 5210 screen Payor source Private insurance Medicaid Self-pay Weight classification Underweight Healthy weight Overweight Obese Elevated blood pressure

Before 5210 % (n)

With 5210 % (n)

p-Value

13.1 ± 3.8 (74) 54 (40)

11.0 ± 4.7 (60) 53 (32)