Lack of documentation on overweight & obese status in patients admitted to the coronary care unit: Results from the CCU study

Transcription

1 Lack of documentation on overweight & obese status in patients admitted to the coronary care unit: Results from the CCU study Meriam F. Caboral,, RN, MSN, NP-C Clinical Coordinator Heart Failure

2 Components of a nursing research article Problem/Question/Hypothesis Conceptual Framework (nursing research) Literature Review Methods Study design Statistical analysis Results Conclusion Limitations Nursing Implication Future research ideas

3 Background/Problem Obesity is a public health problem and has become epidemic worldwide. WHO 1 estimated that there will be about 2.3B overweight people aged 15 years and above and over 700 million obese people worldwide in Health care cost is substantial 1 : US total cost associate with obesity accounted for 1.2% of GDP Europe up to 10.4B Euros spent on obesity-related HC relative economic burden ranged from 0.09% to 0.61% of their national GDP. China 2.74 billion US dollars and these accounted for 3.7% of the national total medical costs Canada 6 billion US dolaars,, corresponding to 4.1& of the total national health expenditures. If comorbidities were included, the direct cost increased by 25% 1. Chan & Woo, Int J Envir Research & Public Health

4

5

6 State-specific Prevalence of Obesity* Among U.S. Adults, by Race/Ethnicity, White non-hispanic Black non- Hispanic Hispanic

7

8

9

10 It is associated with many chronic conditions 1. 1 Swinburn, Gill & Kumanyika, Obesity Review

11 It reduces length and quality of life, maybe approaching smoking as the most preventable cause of mortality 1. Guidelines recommend routine screening of obesity in adults in all clinical settings 2. Although clinical setting imply both the outpatient and inpatient areas, most obesity screening and management were in the clinic or ambulatory setting. In-hospital studies were mostly focused on length of stay, outcomes and complication. There is paucity of data of obesity assessment in the inpatient setting. 1 Swinburn, Gill & Kumanyika, Obesity Review 2.

12 Coronary care unit is the area where providers admit and treat patients who are experiencing acute symptoms of coronary events. Clinicians including physicians, nurse practitioners, physician assistant, and nurses who work in the unit are considered experienced and knowledgeable of cardiovascular conditions including risk factors and complications.

13 Question: Purpose/Hypothesis What percentage of patients who were admitted to the Coronary Care Unit had their weight status documented and addressed? HYPOTHESIS: Coronary care unit clinicians are at least 85% compliant in documenting and identifying overweight and obese status as medical/nursing problem or diagnosis in patient admitted to the unit. 85% was chosen for compliance because all core measures use this percent as determinant of good practice

14 Literature Review Various indices for assessing obesity and predicting obesity-related risk 1 BMI (body mass index) WC (waist circumference) WHR (waist-hip ratio) good predictor of health risk (indicated abdominal fat accumulation) WHtR (waist height ratio). 1. Swinburn, Gill & Kumanyika, Obesity Review

15 Diagnosing overweight and obese status can be easily done by measuring the body mass index (BMI) or weight circumference. BMI is a fast, inexpensive and objective way to identify weight status. It correlates with adult body fat. Studies concur that morbidity risk increased linearly with increased BMI.

16 Framingham study indicates that overweight is an independent predictor of cardiovascular disease Several studies have shown that weight reduction can significantly decrease these risk. Observational study of overweight individuals with diabetes showed that intentional weight loss was associated with improvement in blood pressure, lipid abnormalities, and glycemic control

17 Definitions Documentation was defined as one of the following: 1. Inclusion of the terms overweight or obese in the clinician s s notes, 2. final diagnosis of overweight or obese, 3. notation of the height, weight, and BMI (all three must be included) in the clinician s s notes. BMI was calculated using the National Heart and Lung Blood Institute (NHLBI) calculator by inputting the patient s s height and weight. Current definition of obesity is a BMI >30; overweight is BMI - >25 but <29.9

18 Classification of overweight and obesity Classifications BMI Risk of comorbidities 1 Underweight < Low Normal Average Overweight Increased Obese = >30 Obese Moderate Obese II Severe Obese III >40 - Very severe 1. Chan & Woo, Int J Envir Research & Public Health

19

20 Methods Retrospective review of 250 charts of patients admitted to the CCU of our institution between January 1, 2008 to June 30, Patients who expired, those with diminished mental capacity (dementia, Alzheimer s, organic brain disorder) that may impair judgment were excluded from the abstraction. 219 charts analyzed for the purpose of this study. The study received approval from the Institutional Review Board.

21 Data collection Statistical analysis Data were analyzed using SPSS Version 17. Descriptive Inferential

22 RESULTS Demographic characteristics N=219 Age (mean) -Male -Female Gender (%) -Male -Female Race (%) -Asian -Black/African American -White -Unknown Insurance (%) -Medicaid Medicare Private or others Self-pay Marital status (%) -Single -Married -Divorced -Widow/er -Separated Educational Background (%) - Grade school -High school -College -Advanced degree -Unknown Language spoken at home (%) -English -Spanish -French/Creole -Others 63± ± ±

23 Clinical characteristics Clinical characteristics N=219 Medical history (%) -Hypertension -DM -HF -High cholesterol -Cardiac arrhythmia -CVA -Sleep apnea -COPD/Asthma -CAD -MI -Depression Final diagnosis -MI -HF -Cardiac dysrrhythmia -CAD -Others Social history -Smoking No Current Past -Alcohol No Current Past Missing information -Substance use No Current Past Missing Ejection fraction (mean) - Systolic dysfunction (EF 40%) = Diastolic dysfunction (EF >40%) ±

24 Patient s s weight status Weight status BMI (mean) - Male - Female Body mass index distribution (%) -Underweight -Normal -Overweight ( ) -Obese (>30) Overall weight documentation -Medical Yes No NA -Nursing Yes No NA -Dietary Yes No NA 28 ± 7 27 ± 6 NS 29 ± Overall documentation (defined by our study) -Yes -No -Documentation by all clinicians - Yes - No

25 BMI distribution in male and females Male Female Underweight Normal Overweight Obese

26 Documentation of overweight and obese status by clinicians

27 Documentation by gender

28 Discussion Clinician do not regularly document the overweight or obese status of patients admitted to the CCU. This finding is consistent with the studies nationwide. Although, obesity is a billable diagnosis under the Medicare rule since July, 2004, only 1 in 5 obese patients had their weight status documented and management plans developed. Other studies on documentation of obesity by healthcare providers are few and controversial.

29 Clothier and colleagues reviewed family medicine residents charts and showed that documentation of obesity did not increase in medical chart despite inclusion of the BMI as part of the vital signs. Conversely, Burdowitz et al., evaluated documentation using automated BMI calculator in their EMR and showed improvement in documentation. However, although documentation improved, this did not translate into an improvement in the treatment of obesity.

30 Infrequent documentation of overweight and obese status in the medical charts could mainly because it is not the main presenting chief complaint of the patients. Likewise, admission to the CCU represent acute CV event that obesity becomes less important issue or problem. However, our findings were consistent with a study by Lopez-Jimenez and colleague in 2005 who reviewed charts of patients discharged after an MI.

31 Inconsistent findings were observed regarding health care providers giving weight counseling. Weight loss advice were more likely to be given in people with associated co- morbities as part of the secondary and tertiary prevention rather than primary prevention. Despite the facts that there was a positive association noted between counseling and wanting to lose weight, there was a decline in counseling obese patients by healthcare professionals.

32 Limitation(s) Data precludes generalizability Data were abstracted from one institution Data were from one unit of the institution Data from specific geographic area. Patient demographics may not be comparable with the rest of the population

33 Conclusion Our findings demonstrated that less than 85% compliance in the documentation of overweight and obese status of patients admitted to the CCU.

34 Implications to practice It can affect change in our practice to include routine identification of overweight and obese status during initial assessment process. Incorporate weight issue into nursing problem list. Develop a protocol that will include (Phase 2) Identifying and documenting weight classification of patients. Documenting plan and intervention. Developing referral system (nutritionist on D1 of admission unless contraindicated) Initiating referral to outpatient management program

35 Future research Future studies could be directed at determining barriers in addressing weight status and patient education on weight loss There is a need to determine whether documentation of weight status can improve outcomes. Likewise there is also a need to determine whether the patient knowing their BMI can change or impact their desire to lose weight.

36 Acknowledgments Co-investigators: Mary Jane Torres, RN; Maria Campbell, RN; and Judith E. Mitchell, MD To the entire CCU staff headed by Maria Carney who provided support.