Obesity Prevention and Treatment Program Primer

Transcription

1 Obesity Prevention and Treatment Program Primer The following document is a resource guide for practice Quality Champions. Practice Quality Champions are asked to communicate the program recommendations, requirements and tools with their peers and staff. Practice Quality Champions are expected to lead the implementation process in the practice setting. Start Date: March 1, 2016 Program Objectives: The objectives of The Children s Care Network Obesity Prevention and Treatment program are: Encourage wellness and healthy habits for diet and exercise in all children Document BMI percentage, height, weight, and blood pressure at all well visits Incorporate obesity prevention messaging and wellness goal setting at all well child visits Collect and document overweight and obesity-related labs at well child visits, including lipid panels (cholesterol), and liver enzymes and blood glucose for all patients with a BMI greater than the 85% percentile at well visits Background: The TCCN Obesity Prevention and Treatment Program involves three basic elements: evaluation; treatment; and education. These elements are key features of well child visits and, as such, are available to all children in the network. Evaluation and treatment protocols were developed through collaborative efforts of Children s Healthcare of Atlanta, Georgia Pediatric Subspecialists (GPS), Kids Health First(KHF), The Children s Healthcare Network (TCCN), and private practice primary care physicians and subspecialists. These protocols are in accordance with the American Academy of Pediatrics (AAP) guidelines for physical exams at well child visits. All patients should receive counseling on obesity prevention messaging including the following healthy habits which will be provided at each well child visit for children ages Eat more fruits and vegetables Limit eating out Drink more water and limit sweetened drinks Encourage more active play Limit screen time All patients regardless of BMI will be encouraged to establish a wellness goal. Documentation of BMI percentile and/or plotting BMI on a growth chart will be completed at each well child visit as well as documentation of height, weight, and blood pressure for children over the age of three. In addition, a lipid panel (fasting, if possible) shall be done for all patients 9-11 years of age, regardless of BMI. The Children s Care Network advocates for the incorporation of all recommendations into the care of all well patients.

2 Our initial intervention and network requirement for 2016 is: Appropriate coding for Body Mass Index percentile for all patients 2-17 years of age Body Mass Index (BMI) Body Mass Index (BMI) is a person s weight in kilograms (kg) divided by his or her height in meters squared. The NHI now defines normal weight (5-85%), overweight (85-95%), and obesity (>95%) according to BMI rather than traditional height/weight charts. Coding for BMI using the ICD-10-CM codes (listed below) will populate the Mckesson Population Health Management tool which will determine the rate of coding by practice and provider, using the operational definition below. This will eliminate the need for time-consuming chart audits. In addition, it is a reporting requirement for Georgia Medicaid CMOs. This process improvement will allow TCCN the ability to identify patients who meet the BMI criteria for prevention and intervention strategies, as well as track the effectiveness of these programs over time. SMART Aim (Specific, Measurable, Attainable, Relevant/Realistic, Time-Bound) o The Children s Care Network baseline measurement for coding of Body Mass Index Percentile was 25% in December, o The Children s Care Network will improve the BMI coding rate from 25% to 51% by December 31, Body Mass Index (BMI) coding rate will be defined as: Numerator: Number of children (aged 2-17 years) with a well check visit and BMI percentile coding in the past 12 months Denominator: Number of children (aged 2-17 years) with a preventative/well check visit at office in the past 12 months Key Drivers: The following key drivers have been identified by TCCN pilot practices participating in the Obesity Foundational Workgroup as essential elements that must be present in order to meet the network s stated Aim: 1. Provider acceptance of the necessity for documentation and coding of Body Mass Index (BMI) percentile 2. Appropriate and simple coding mechanisms for administrative capture of BMI percentile 3. Clean claim generation with no delays or denial of payment by contracted payors Sample Interventions: 1. Provider acceptance of the necessity for documentation and coding of Body Mass Index (BMI) percentile The Children s Care Network advocates the adoption of evidence-based protocols. References will be provided with the supporting evidence for the initiatives adopted (see supporting evidence). Specifically, please share the information below with the providers in your setting regarding the documentation of Body Mass Index Percentile (BMI%) from the CDC.

3 2. Appropriate and simple coding mechanisms for administrative capture of BMI percentile Many practices have already incorporated documentation and utilization of BMI percentile into their patient care and lack only a mechanism for coding. The McKesson tool will determine BMI% documentation rate using the operational definition above. The tool is populated using un-adjudicated claims data. BMI% will need to be billed in the practice management system using the ICD-10 below: BMI <5% for age Z68.51 BMI 5-85% for age Z68.52 BMI 85-<95% for age Z68.53 BMI >95% for age Z68.54 This coding will allow administrative review and avoid the need for time-consuming chart audits. Pilot practices have demonstrated that coding results in appropriate capture into the population health management tool. This information was correlated with data from TCCN payor partners. We recommend discussion with your individual practice management system and/or EHR vendor for inclusion of the codes into your billing system. Use the PDSA cycles (Plan-Do-Study- Act) to track test batches of patients to verify correct capture by the McKesson tool and effective claims submission and reimbursement, before implementing for all patients. This intervention is an excellent way to familiarize your practice with this important rapid cycle improvement method. These codes may be: 1. Coded by the provider at the point of care 2. Added by Medical Assistants or RNs/LVNs at the time of documentation of vitals with review by the physician. 3. Incorporated directly into the record when calculated by some EHR systems with review by the physician. 3. Clean claim generation with no delays or denial of payment by contracted payors These codes have been used in some pay for performance HEDIS based incentive programs by local payors. They are configured to recognize and accommodate them in adjudicating claims. In addition, pilot practices have included the code at preventative care visits for both private and Medicaid/CMO payors with no delay or interruption in claims payment. Again, we recommend testing small batches of claims, including the codes with a variety of representative payors, to ensure that there are no delays or denials associated with the inclusion of these codes into your particular billing submission format. Next Steps:

4 Prevention (Strong4Life) Children s Healthcare of Atlanta developed the Strong4Life Provider Training Program to improve healthcare providers ability to influence patients and families to choose healthy lifestyles in an effort to prevent and reduce childhood obesity. The program includes a live training, including role play videos and interactive practice sessions centered around the 5 A s of counseling (assess, advise, agree, assist and arrange). The live training equips providers with evidence-based obesity prevention counseling and goal setting techniques that can be used across the spectrum of care from prevention counseling in healthy children to treatment for children in crisis. To facilitate consistency in Healthy Habits counseling, a toolkit of materials was developed. The toolkit includes a color-coded BMI poster, Healthy Habits Assessment forms, Healthy Habits patient handouts, and a Healthy Habits Goal Sheet. These tools are designed to help providers identify high-yield health habits and assess the patients willingness to change. The BMI posters provide an avenue for demonstrating where each individual child falls on the BMI chart, regardless of weight status. The goal setting sheet allows the provider to support the patient in setting a goal, based on the focus area they want to improve. The Healthy Habits handout for parents is included to provide simple suggestions to jumpstart healthy habits at home. The Healthy Habits Assessment helps providers target those behaviors families are most willing to change, making the time spent with the patient more meaningful and productive. Obesity prevention counseling and Healthy Habits tools are utilized for all children, regardless of weight status, as all kids need a healthy habit. This is key for obesity prevention. Intervention The following protocols relate specifically to patients defined as Overweight (85 95% BMI) and Obese (>95% BMI) respectively. Both classifications have four assessments; blood pressure, lipid panels (cholesterol), liver enzymes and blood glucose2. The results of these evaluations determine subsequent treatment paths in a stepwise fashion. Additionally, there are key components provided for all network patients, including counseling and goal setting, treatment, and referrals. Typically, primary care providers first provide counseling using motivational interview techniques. Then, they retest parameters to assess whether lifestyle changes and behavior modification have been adopted and effective; more intensive treatment measures are pursued, if needed. Overweight (85-95% BMI) Testing fasting glucose is strongly recommended, as it is typically the first indication of an abnormality. It should be noted that these protocols are recommendations, and the patient s care is ultimately at the discretion of his or her physician. For those patients with a BMI between the 85th and 94th percentile, counseling and goal setting will be provided regardless of the age of the patient. Assessments: Blood pressure will be assessed and recorded for patients three years of age or older AST, ALT for patients 9 years of age or older Lipid panel (fasting, if possible) for patients 9 years of age or older Glucose (fasting, if possible) for those patients 9 years of age or older For patients 9 years of age or older, the physician should consider testing Hgb A1C if family history or symptoms are present; the physician should consider TSH, freet4 if hypothyroidism is suspected and consider fasting insulin if evidence of acanthosis nigricans is present Obese (>95% BMI) For those patients who have a BMI at or above the 95th percentile, counseling and goal setting will be provided regardless of the patient s age. Assessments: Blood pressure will be assessed and recorded for patients three years of age or older

5 AST, ALT for patients for patients 9 years of age or older Lipid panel (fasting, if possible) for patients 9 years of age or older Glucose (fasting, if possible) for patients 9 years of age or older Consider fasting (if possible) CMP Consider fasting insulin if evidence of hyperinsulinemia, such as acanthosis nigricans is present Consider Hgb A1C Consider TSH, Free T4 Supporting Evidence: 1. Recommendations for Treatment of the Child and Adolescent Overweight and Obesity; Pediatrics 2007; 120;S254. Abstract In this article, we review evidence about the treatment of obesity that may have applications in primary care, community, and tertiary care settings. We examine current information about eating behaviors, physical activity behaviors, and sedentary behaviors that may affect weight in children and adolescents. We also review studies of multidisciplinary behavior-based obesity treatment programs and information about more aggressive forms of treatment. The writing group has drawn from the available evidence to propose a comprehensive 4-step or staged-care approach for weight management that includes the following stages: (1) Prevention Plus; (2) Structured Weight Management; (3) Comprehensive Multidisciplinary Intervention; and (4) Tertiary Care Intervention. We suggest that providers encourage healthy behaviors while using techniques to motivate patients and families, and interventions should be tailored to the individual child and family. Although more intense treatment stages will generally occur outside the typical office setting, offices can implement less intense intervention strategies. We not only address specific patient behavior goals but also encourage practices to modify office systems to streamline office-based care and to prepare to coordinate with professionals and programs outside the office for more intensive interventions. 2. Expert Committee Recommendations Regarding the Prevention, Assessment and Treatment of the Child and Adolescent Overweight and Obesity: Summary Report; Pediatrics 2007; 120; S164 Abstract To revise 1998 recommendations on childhood obesity, an Expert Committee, comprised of representatives from 15 professional organizations, appointed experienced scientists and clinicians to 3 writing groups to review the literature and recommend approaches to prevention, assessment, and treatment. Because effective strategies remain poorly defined, the writing groups used both available evidence and expert opinion to develop the recommendations. Primary care providers should universally assess children for obesity risk to improve early identification of elevated BMI, medical risks, and unhealthy eating and physical activity habits. Providers can provide obesity prevention messages for most children and suggest weight control interventions for those with excess weight. The writing groups also recommend changing office systems so that they support efforts to address the problem. BMI should be calculated and plotted at least annually, and the classification should be integrated with other information such as growth pattern, familial obesity, and medical risks to assess the child s obesity risk. For prevention, the recommendations include both specific eating and physical activity behaviors, which are likely to promote maintenance of healthy weight, but also the use of patient-centered counseling techniques such as motivational interviewing, which helps families identify their own motivation for making change. For assessment, the recommendations include methods to screen for current medical conditions and for future risks, and methods to assess diet and physical activity behaviors. For treatment, the recommendations propose 4 stages of obesity care; the first is brief counseling that can be delivered in a health care office, and subsequent stages require more time and resources. The appropriateness of higher stages is influenced by a patient's age and degree of excess weight. These recommendations recognize the importance of social and environmental change to reduce the obesity epidemic but also identify ways healthcare providers and health care systems can be part of broader efforts. 3. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report; Pediatrics 2011; 128;S213

6 Introduction Atherosclerotic cardiovascular disease (CVD) remains the leading cause of death in North Americans, but manifest disease in childhood and adolescence is rare. By contrast, risk factors and risk behaviors that accelerate the development of atherosclerosis begin in childhood, and there is increasing evidence that risk reduction delays progression toward clinical disease. In response, the former director of the National Heart, Lung, and Blood Institute (NHLBI), Dr. Elizabeth Nabel, initiated development of cardiovascular health guidelines for pediatric care providers based on a formal evidence review of the science with an integrated format addressing all the major cardiovascular risk factors simultaneously. An expert panel was appointed to develop the guidelines in the fall of The goal of the expert panel was to develop comprehensive evidence-based guidelines that address the known risk factors for CVD (Table 1-1) to assist all primary pediatric care providers in both the promotion of cardiovascular health and the identification and management of specific risk factors from infancy into young adult life. An innovative approach was needed, because a focus on cardiovascular risk reduction in children and adolescents addresses a disease process (atherosclerosis) in which the clinical end point of manifest CVD is remote. The recommendations, therefore, need to address 2 different goals: the prevention of risk-factor development (primordial prevention) and the prevention of future CVD by effective management of identified risk factors (primary prevention). 4. John Hopkins: The Harriet Lane Handbook: A Manual for Pediatric House Officers, 17th ed., c 2005 Mosby 5. The Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood Pressure in Children and Adolescents; Pediatrics 2004; 114; 555. Introduction Considerable advances have been made in detection, evaluation, and management of high blood pressure (BP), or hypertension, in children and adolescents. Because of the development of a large national database on normative BP levels throughout childhood, the ability to identify children who have abnormally elevated BP has improved. On the basis of developing evidence, it is now apparent that primary hypertension is detectable in the young and occurs commonly. The long-term health risks for hypertensive children and adolescents can be substantial; therefore, it is important that clinical measures be taken to reduce these risks and optimize health outcomes. The purpose of this report is to update clinicians on the latest scientific evidence regarding BP in children and to provide recommendations for diagnosis, evaluation, and treatment of hypertension based on available evidence and consensus expert opinion of the working group when evidence was lacking. This publication is the fourth report from the National High Blood Pressure Education Program (NHBPEP) Working Group on Children and Adolescents and updates the previous 1996 publication, Update on the 1987 Task Force Report on High Blood Pressure in Children and Adolescents. 1 New data from the National Health and Nutrition Examination Survey (NHANES) have been added to the childhood BP database, and the BP data have been reexamined. The revised BP tables now include the 50th, 90th, 95th, and 99th percentiles by gender, age, and height. Hypertension in children and adolescents continues to be defined as systolic BP (SBP) and/or diastolic BP (DBP), that is, on repeated measurement, 95th percentile. BP between the 90th and 95th percentile in childhood had been designated high normal. To be consistent with the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), this level of BP will now be termed prehypertensive and is an indication for lifestyle modifications. The evidence of early target-organ damage in children and adolescents with hypertension is evaluated, and the rationale for early identification and treatment is provided. Based on recent studies, revised recommendations for use of antihypertensive drug therapy are provided. Treatment recommendations include updated evaluation of non-pharmacologic therapies to reduce additional cardiovascular risk factors. Information is included on the identification of hypertensive children who need additional evaluation for sleep disorders.

7 6. Patel SR, Hu FB. Short sleep duration and weight gain: a systematic review; Obesity (Silver Spring) 2008; 16: Abstract Objective: The recent obesity epidemic has been accompanied by a parallel growth in chronic sleep deprivation. Physiologic studies suggest sleep deprivation may influence weight through effects on appetite, physical activity, and/or thermoregulation. This work reviews the literature regarding short sleep duration as an independent risk factor for obesity and weight gain. Methods and Procedures: A literature search was conducted for all articles published between 1966 and January 2007 using the search "sleep" and ("duration" or "hour" or "hours") and ("obesity" or "weight") in the MEDLINE database. Additional references were identified by reviewing bibliographies and contacting experts in the field. Studies reporting the association between sleep duration and at least one measure of weight were included. Results: Thirty-six publications (31 cross-sectional, 5 prospective, and 0 experimental) were identified. Findings in both cross-sectional and cohort studies of children suggested short sleep duration is strongly and consistently associated with concurrent and future obesity. Results from adult cross-sectional analyses were more mixed with 17 of 23 studies supporting an independent association between short sleep duration and increased weight. In contrast, all three longitudinal studies in adults found a positive association between short sleep duration and future weight. This relationship appeared to wane with age. Discussion: Short sleep duration appears independently associated with weight gain, particularly in younger age groups. However, major study design limitations preclude definitive conclusions. Further research with objective measures of sleep duration, repeated assessments of both sleep and weight, and experimental study designs that manipulate sleep are needed to better define the causal relationship of sleep deprivation on obesity. 7. Reilly JJ, Armstrong J, Dorosty AR, et al. Early life risk factors for obesity in childhood: cohort study. BMJ. 2005; 330:1357. Abstract Objective: To identify risk factors in early life (up to 3 years of age) for obesity in children in the United Kingdom. Design: Prospective cohort study. SETTING. Avon longitudinal study of parents and children, United Kingdom. PARTICIPANTS children in cohort aged 7 years and a subsample of 909 children (children in focus) with data on additional early growth related risk factors for obesity. Main Outcome Measures: Obesity at age 7 years, defined as a body mass index 3 95th centile relative to reference data for the UK population in Results: Eight of 25 putative risk factors were associated with a risk of obesity in the final models: parental obesity (both parents: adjusted odds ratio, 10.44, 95% confidence interval 5.11 to 21.32), very early (by 43 months) body mass index or adiposity rebound (15.00, 5.32 to 42.30), more than eight hours spent watching television per week at age 3 years (1.55, 1.13 to 2.12), catch-up growth (2.60, 1.09 to 6.16), standard deviation score for weight at age 8 months (3.13, 1.43 to 6.85) and 18 months (2.65, 1.25 to 5.59); weight gain in first year (1.06, 1.02 to 1.10 per 100 g increase); birth weight, per 100 g (1.05, 1.03 to 1.07); and short (< 10.5 hours) sleep duration at age 3 years (1.45, 1.10 to 1.89). Conclusion: Eight factors in early life are associated with an increased risk of obesity in childhood. 8. Landhuis CE, Poulton R, Welch D, Hancox RJ. Childhood sleep time and long-term risk for obesity: a 32-year prospective birth cohort study. Pediatrics. 2008; 122: Abstract Objective: Associations between short sleep duration and increased BMI have been found in children and adults. However, it is not known whether short sleep time during childhood has long-term consequences. We assessed the association between sleep time in childhood and adult BMI in a birth cohort. Methods: Study members were a general-population birth cohort of 1037 participants (502 female) who were born in Dunedin, New Zealand, between April 1972 and March Parental reports of bedtimes and rising times collected at ages 5, 7, 9, and 11 years were used to estimate childhood sleep time.

8 Linear regression analysis was used to analyze the association between childhood sleep time and BMI measured at 32 years of age. Results: Shorter childhood sleep times were significantly associated with higher adult BMI values. This association remained after adjustment for adult sleep time and the potential confounding effects of early childhood BMI, childhood socioeconomic status, parental BMIs, child and adult television viewing, adult physical activity, and adult smoking. In logistic regression analyses, more sleep time during childhood was associated with lower odds of obesity at 32 years of age. This association was significant after adjustment for multiple potential confounding factors. Conclusions: These findings suggest that sleep restriction in childhood increases the long-term risk for obesity. Ensuring that children get adequate sleep may be a useful strategy for stemming the current obesity epidemic Compilation of The Children s Care Network, Inc. Obesity Clinical Program