A quality improvement initiative helped pediatric practice sustain improvement in adherence to obesity management recommendations from the American Academy of Pediatrics.


Obesity affects about 13.7 million children and adolescents in the United States, and children with obesity are more likely to be obese as adults and suffer from obesity-related comorbidities. “In light of these data, efforts to prevent, screen, and treat obesity-related comorbidities are extremely critical and should start at a young age,” says Komal F. Satti, MD, MPH.

According to the American Academy of Pediatrics (AAP), the standard of care for all pediatric patients includes measuring BMI and screening for obesity-related comorbidities. In addition, AAP recommends providing positive reinforcement for healthy behaviors in a staged approach, with intensity of these efforts increasing as needed. “Despite this position, screening for obesity and recommended management at well-child checks by primary care providers is not done consistently,” Dr. Satti says. “Engagement with positive behavioral changes is challenging for patients and families, and assessments of readiness and motivation by clinicians are often time intensive.”


A Quality Improvement Initiative

At Children’s Hospital at Dartmouth-Hitchcock, Dr. Satti and colleagues initiated a quality improvement (QI) project to improve provider adherence to AAP recommendations. “We wanted to make systematic and iterative changes in our practice for pediatric patients with obesity who were seen for a preventive visit,” says Dr. Satti. The project goals were to improve rates of laboratory screening, obesity documentation on the problem list, and referrals to weight management programs. Other goals included increasing rates of providing lifestyle counseling and weight-specific follow-up visits.

“Our QI project was conducted in five improvement cycles,” explains Dr. Satti. “Briefly, these included: 1) educational sessions, 2) provision of practice support tools, 3) motivational interview training, 4) engagement of providers and staff for creating a culture of change, and 5) creating a best practice advisory in the EMR.” Findings from the QI project were published in Pediatric Quality & Safety.


Improved Adherence With AAP Recommendations

According to the results, the QI initiative led to improvements in all five process measures assessed, and continued improvements were seen in four of five measures. A comparison of baseline and intervention period rates revealed statistically significant improvements in three out of five measures (Table). “Results from our initiative indicate that system-wide changes to encourage adoption of standardized practice approaches to obesity management in primary care can improve adherence to expert recommendations,” Dr. Satti says.

Of note, adherence rates were low in patients aged 2-to-6 despite the QI initiative efforts. Providers ordered laboratory tests in only 13% of encounters for children in this age range, compared with a 45% rate that was seen for older children. However, significant improvements were still seen with obesity documentation on the problem list and referrals made to a weight management program.

“Importantly, throughout the QI initiative process, all of our interventions were somewhat effective, but we needed to create a culture of change to improve care in a meaningful, sustainable way,” says Dr. Satti. “We involved the entire clinic staff by creating ‘obesity champions’ within the practice. These champions included nurses, medical assistants, and physicians with a special interest in obesity. With improved screening and establishing obesity champions, we can expect more timely interventions for obesity-related metabolic processes, which in turn can have a long-lasting impact on children’s health and our healthcare system.”


A Critical Opportunity for Future Improvement

An important next step is to investigate reasons for age-related care disparities seen in younger children. “Previous studies have shown that preschool-aged children have a drastic change in their diets, switching to more nutrient-poor and energy-rich foods,” Dr. Satti says. “Evidence also shows that most excess weight before puberty is gained before aged 5 and is predictive of weight at age 9. Our study furthers this work by identifying a potential age bias in which obesity and its related comorbidities are left underrecognized and undertreated in the youngest and most vulnerable patients. This is a critical opportunity for future improvement. It’s important to gain a better understanding of these differences so we can offer prevention strategies at an early age so that it may result in lifelong impact.”