Introduction: To support weight control and acquisition of healthy behavior in the families with overweight children, the essential first step is to create and sustain behavior change among the primary care providers (PCP) who are doing the counseling toward a standard of care. Despite regular access to families with young children, PCPs lack a comprehensive model for approaching office visits on pediatric excess weight. In 2007, an Expert Committee comprised of 15 national organizations established guidelines for a standard of care for managing pediatric excess weight centered on the PCP. Reluctance of PCPs to assume responsibility for weight management has been the result of numerous professional, practice, and patient related barriers. We hypothesized that improved PCP self-efficacy to counsel, documentation within the medical record around weight management, and knowledge of counseling recommendations, would improve the clinical effectiveness of PCPs and establish a standard of care around obesity management.
Methods: We developed “A Pound of Cure” (POC), a series of modularized office visits for use by PCPs, founded on the 2007 Expert Committee Recommendations. This program was piloted and efficacy established at an urban clinic with a diverse, low-income population by clinicians experienced in the tertiary care of obese children. The POC intervention tools provided PCPs with a counseling model, office systems, and educational tools to direct behavior modification in families with overweight children. Using a novel approach to behavior change first piloted in business, we adapted quality improvement methodology to host a 6-month Learning Collaborative comprised of Ohio PCPs. Here, we introduced the POC intervention tools and evaluated effectiveness of POC in modifying PCP behavior. The quality improvement methods focused on integration of the POC model and ECRs incrementally into the primary care practices. Physician outcomes were monitored through monthly chart reviews and surveys regarding their knowledge of the ECRs and sense of self-efficacy to counsel the overweight patient. Practice narratives, site visits, and closing interviews highlighted practice specific implementation of POC. Secondarily, patient outcomes were monitored through patient registries.
Results: “A Pound of Cure” physicians achieved a standard of care around obesity management. The Learning Collaborative fostered flexible, practice specific adaptations of the POC model, supported by changes in office systems to support weight management counseling. Provider self-efficacy increased by 10.85 points (p=0.000) during the collaborative while knowledge remained constant. Monthly chart reviews reflected improved PCP documentation around all weight management counseling encounter measures; 100% documentation was achieved for all measures except for documentation of laboratory assessment. Patient and family engagement remained a constant obstacle to counseling. Still, those children who persisted and whose care was captured in the patient registry experienced a modest decrease in BMI percentile, 0.313% (p=0.067).
Conclusion: In summary, the POC Learning Collaborative was a novel mechanism to incrementally improve PCP self-efficacy and documentation around weight management visits and created a supportive primary care environment. By offering serial POC Learning Collaboratives, Ohio PCPs will establish a standard of care on pediatric weight management within the practice setting, the optimal site for early identification and intervention in childhood obesity.