Documentation Of Body Mass Index Research Articles

Development and testing of the rheumatoid arthritis quality of care survey

ObjectivesThe Rheumatoid Arthritis (RA) Quality of Care Survey (RAQCS) was developed to measure care quality according to a previously developed national RA quality improvement framework. MethodsThe development of the RAQCS occurred over 3 phases. First, the survey was developed by a team of healthcare providers, researchers, and two patient partners based on the existing national quality framework's 21 performance measures (PMs) and strategic objectives. Second, cognitive debriefing interviews were conducted with individuals living with RA to identify survey clarity, appropriateness of survey questions, and response options. Third, the survey was revised and distributed to participants recruited from Rheum4U (rheumatology longitudinal cohort). Results were tabulated and compared with a chart audit of participant medical records. ResultsFifty-three participants completed the RAQCS. High performance (i.e., ≥70% meeting PM) was observed for 13 of 20 PMs. Lower performance was seen for the remaining PMs, which included documentation of body mass index (BMI) and smoking status, discussion of physical activity goals, comorbidity management including risk assessments for cardiovascular health and fragility fractures and disease activity assessment. There was high agreement (≥70%) between the RAQCS and chart review for 9 of 20 PMs. ConclusionsHigh agreement was observed between the RAQCS and chart review for selected PMs. The RAQCS may also be a valuable tool for quality improvement for measures where data are not usually available through other sources. Further testing of the RAQCS is needed to ascertain its reliability and validity as a patient self-reported tool to measure RA care quality.

An Innovative, Multimodal Approach to Help Obstetric Nurses Realize That Caring for Bariatric Patients Is a Challenge

Obesity rates have increased dramatically worldwide over the past 20 years, and it is known that obesity negatively impacts obstetric and neonatal outcomes. Accurate determination and documentation of body mass index (BMI) at hospital admission are crucial for guiding appropriate patient care and nursing preparation. Work-related injuries are major safety concerns in the nursing profession, and risk for injury increases when caring for patients who are obese. Knowledge and use of safe patient handling techniques and safe patient mobilization devices have been shown to decrease risk for nurse injury and have the potential to prolong nursing career viability. Interpersonal, situational, organizational, and environmental influences impact nurses’ willingness to engage in safe patient handling and mobility. The purpose of this evidence-based practice project was to use innovative educational strategies to increase knowledge related to caring for obstetric patients who are obese. Results of a preintervention survey guided development of unit- and population-specific training to improve patient care and safety, increase use of safe patient mobilization techniques, reduce rate of nurse injury, and improve nursing documentation in the electronic medical record to accurately indicate the patient’s BMI. After a preintervention survey was administered, focused video and hands-on training was provided to nurses regarding how to safely care for obstetric patients who are obese. Content included correct BMI determination and documentation on admission, use of bed features and ergonomics to prevent nurse injury, and techniques to prevent postdelivery infection. The information also addressed the organizational and cultural influences that impact nurses’ willingness to engage in safe patient handling techniques. Significant improvements in knowledge and performance were noted at 1-, 3-, and 6-months postintervention, and nurse injury rates related to sprains and strains decreased. Pre- and postintervention evaluations included nurses’ level of knowledge, practice, and confidence related to caring for obstetric patients who are obese; rate of nurse injury on the involved nursing units; and compliance rates of documentation of BMI in the electronic medical record. Knowledge of appropriate safe patient handling and mobilization techniques is not enough to ensure consistent use during intrapartum patient care. The reduction of interpersonal and organizational barriers can improve patient care and decrease nurse injury.

Analysis of the practice and the reasons for under documentation of body mass index and unintentional weight loss in adult hospitalized patients in Indian set up

Background: The present study analyzed the practice of documentation of BMI and history of unintentional weight loss in adult hospitalized patients on admission by the health care staff and the causes for their under documentation. Methods: A cross-sectional study was conducted among 600 healthcare workers, 150 duty medical officers and 450 nurses attending to adult hospitalized patients in both public and private hospitals of Lucknow, U.P., India and nearby districts. Information was collected on the basis of a self-administered questionnaire, on the practice of recording of weight, height, BMI and history of unintentional weight loss in past three months in patient records and also for the reasons for the under-documentation. Results: Only 54.16% of the staff admitted documenting BMI of the patients regularly in their case notes. Similarly, only 60% of the staff documented history of unintentional weight loss in past three months in patient case notes. Documentation was omitted more by nurses as compared to medical officers. The main reasons for under-documentation were work overload and time constraints, lack of training, confusion regarding responsibility and mistaken opinion for malnutrition screening. Conclusions: BMI and weight loss are often not recorded by health staff, more so by nurses. They need to be provided sufficient time to perform nutritional assessment of patient; moreover we should make them competent and delineate roles to them as well as develop a nutrition culture in our health facilities.

Gaps in Addressing Cardiovascular Risk in Rheumatoid Arthritis: Assessing Performance Using Cardiovascular Quality Indicators.

Cardiovascular disease (CVD) is a major comorbidity for patients with rheumatoid arthritis (RA). This study sought to determine the performance of 11 recently developed CVD quality indicators (QI) for RA in clinical practice. Medical charts for patients with RA (early disease or biologic-treated) followed at 1 center were retrospectively reviewed. A systematic assessment of adherence to 11 QI over a 2-year period was completed. Performance on the QI was reported as a percentage pass rate. There were 170 charts reviewed (107 early disease and 63 biologic-treated). The most frequent CVD risk factors present at diagnosis (early disease) and biologic start (biologic-treated) included hypertension (26%), obesity (25%), smoking (21%), and dyslipidemia (15%). Performance on the CVD QI was highly variable. Areas of low performance (< 10% pass rates) included documentation of a formal CVD risk assessment, communication to the primary care physician (PCP) that patients with RA were at increased risk of CVD, body mass index documentation and counseling if overweight, communication to a PCP about an elevated blood pressure, and discussion of risks and benefits of antiinflammatories in patients at CVD risk. Rates of diabetes screening and lipid screening were 67% and 69%, respectively. The area of highest performance was observed for documentation of intent to taper corticosteroids (98%-100% for yrs 1 and 2, respectively). Gaps in CVD risk management were found and highlight the need for quality improvements. Key targets for improvement include coordination of CVD care between rheumatology and primary care, and communication of increased CVD risk in RA.

The use of routine thoracoabdominal CT scans in the polytrauma patient to estimate obesity

To utilize data from routine CT scans to quantify obesity in polytrauma patients without the need to obtain a height and weight. We utilized a comprehensive database including multidetector CT thoracoabdominal images of all polytrauma patients admitted to a Level 1 trauma center. One thousand one hundred seventy-four patients were reviewed from 2006 to 2008 and of these, 162 had previous documentation of Body Mass Index (BMI) or height and weight measurements as an outpatient within 6 months of trauma activation and with a truncal girth smaller than the scanning area of the CT machine. Truncal Adiposity Volume (TAV) was calculated from three dimensional reconstructions (3DRs) of the CT scans of the thorax and abdomen obtained in the emergency department. Statistical analysis yielded a fairly good correlation between TAV and BMI (correlation coefficient = 0.77; p-value < 0.0001). The intra-observer and inter-observer correlations in measuring TAV were high; 0.99 and 0.98 respectively. A linear regression equation of BMI on TAV was estimated and it had a form: 3DR BMI = 20.81+0.00064×TAV. In conclusion, TAV provides a reproducible means of evaluating obesity in trauma patients from routinely obtained CT scans. The TAV eliminates the often problematic task of obtaining a height and weight in a trauma patient and it correlates fairly well with the most commonly used clinical method of quantifying patient adiposity, BMI. This method may provide a more direct measurement of adiposity than does BMI, and holds promise for improving trauma care and research in the obese patient.

Method of electronic health record documentation and quality of primary care

Physicians who more intensively interact with electronic health records (EHRs) through their documentation style may pay greater attention to coded fields and clinical decision support and thus may deliver higher quality care. We measured the quality of care of physicians who used three predominating EHR documentation styles: dictation, structured documentation, and free text. We conducted a retrospective analysis of visits by patients with coronary artery disease and diabetes to the Partners Primary Care Practice Based Research Network. The main outcome measures were 15 EHR-based coronary artery disease and diabetes measures assessed 30 days after primary care visits. During the 9-month study period, 7000 coronary artery disease and diabetes patients made 18 569 visits to 234 primary care physicians of whom 20 (9%) predominantly dictated their notes, 68 (29%) predominantly used structured documentation, and 146 (62%) predominantly typed free text notes. In multivariable modeling adjusted for clustering by patient and physician, quality of care appeared significantly worse for dictators than for physicians using the other two documentation styles on three of 15 measures (antiplatelet medication, tobacco use documentation, and diabetic eye exam); better for structured documenters for three measures (blood pressure documentation, body mass index documentation, and diabetic foot exam); and better for free text documenters on one measure (influenza vaccination). There was no measure for which dictators had higher quality of care than physicians using the other two documentation styles. EHR-assessed quality is necessarily documentation-dependent, but physicians who dictated their notes appeared to have worse quality of care than physicians who used structured EHR documentation. ClinicalTrials.gov Identifier: NCT00235040.

Assessment of provider adherence to obesity treatment guidelines

AbstractPurposeDespite the presence of obesity treatment guidelines, healthcare providers often provide suboptimal weight management. The purpose of the quality improvement project was to systematically assess adherence with adult overweight/obesity guidelines in primary care to reduce patient risk.Data sourcesRetrospective analysis of 420 encounter notes from overweight and obese adult patients in three primary care clinics. Data were collected before and after a continuing education session for providers on guidelines for optimal management of obesity. Measures of completeness of quality indicators were abstracted from records.ConclusionsSignificant improvement in the completeness score and documentation of body mass index, height, diagnosis of overweight/obesity, and counseling for diet and physical activity were achieved.Implications for practiceThe proposed measures for systematically assessing the integration of obesity guidelines in primary care are feasible quality indicators and useful for evidence‐based decision making.

Childhood obesity: Can electronic medical records customized with clinical practice guidelines improve screening and diagnosis?

The purpose of this project was to determine if customization of the electronic medical record (EMR) using evidence-based practice guidelines developed by the National Association of Pediatric Nurse Practitioners and the Expert Panel recommendations for the prevention, screening, and treatment of childhood and adolescent overweight and obesity would improve the rate of screening and diagnosis of obesity in children, 7 to 18 years of age. A retrospective review of encounters before and after implementation of customized EMR was conducted in a community health center. Data collected were compared for documentation of body mass index (BMI), completion of growth charts, scoring of risk questionnaire, and diagnosis of overweight or obesity. There was a clear increase in the frequency of recording BMI, completing BMI growth charts, and scoring questionnaires between written and electronic medical records. The number of children diagnosed with overweight or obesity increased with customized EMR but still remains well below the rates of obesity for this community. Customizing EMR with clinical practice guidelines improved adherence to recommendations for screening and identification of childhood overweight and obesity. Increased recognition and diagnosis will lead to improved interventions and improve outcomes for childhood obesity.

Abstract 103: Obesity Paradox in Heart failure- Are African Americans Affected?

Background - Obesity is a major risk factor for heart failure. However, many studies have shown that obesity is paradoxically associated with better outcomes in those with chronic heart failure (HF). Initially thought to occur only in those with left ventricular systolic dysfunction (LVSD), recent studies such as CHARM and I-PRESERVE have described the same phenomenon in those with HF with preserved ejection fraction (HFpEF). It is also known that minorities have the highest rates of obesity in the United States, yet no major studies have included a large enough sample (&gt;10% minority representation) to study this relationship. Thus we propose to examine the relationship of different weight categories to HF outcomes in patients with LVSD (45%) utilizing a minority cohort. Methods - Outcomes (HF admissions &amp; cardiac admissions, non-cardiac admissions, and emergency room visits) were assessed for162 HF patients with documentation of body mass index (BMI) and ejection fraction from the Meharry Heart Failure Registry (a registry composed of 80% African Americans and Hispanics). The cohort was evenly divided by EF into HFpEF versus LVSD. Utilizing the Center for Disease Control definitions, 5 categories for BMI were defined: 40.0. ANOVA was applied to test for possible differences among BMI groups and outcomes. Results - There was a trend towards a paradoxical relationship noted between BMI and outcome in males with HFpEF when looking at all-cause readmissions (p&lt;0.0606). This same relationship was noted between BMI and outcome in women with HFpEF when looking at the all-cause emergency room visits (p&lt;0.0677). However, we failed to find a significant difference across BMI categories and outcome for those with LVSD. Conclusion - Our study suggests that irrespective of race, there is a paradoxical relationship noted between BMI and outcome for both men and women with HFpEF. However, contrary to current literature, we failed to find the same relationship in minority patients with LVSD. This may be due to the small sample size hence a larger prospective study of this group is warranted.

Documentation of body mass index and control of associated risk factors in a large primary care network.

BackgroundBody mass index (BMI) will be a reportable health measure in the United States (US) through implementation of Healthcare Effectiveness Data and Information Set (HEDIS) guidelines. We evaluated current documentation of BMI, and documentation and control of associated risk factors by BMI category, based on electronic health records from a 12-clinic primary care network.MethodsWe conducted a cross-sectional analysis of 79,947 active network patients greater than 18 years of age seen between 7/05 - 12/06. We defined BMI category as normal weight (NW, 18-24.9 kg/m2), overweight (OW, 25-29.9), and obese (OB, ≥ 30). We measured documentation (yes/no) and control (above/below) of the following three risk factors: blood pressure (BP) ≤130/≤85 mmHg, low-density lipoprotein (LDL) ≤130 mg/dL (3.367 mmol/L), and fasting glucose <100 mg/dL (5.55 mmol/L) or casual glucose <200 mg/dL (11.1 mmol/L).ResultsBMI was documented in 48,376 patients (61%, range 34-94%), distributed as 30% OB, 34% OW, and 36% NW. Documentation of all three risk factors was higher in obesity (OB = 58%, OW = 54%, NW = 41%, p for trend <0.0001), but control of all three was lower (OB = 44%, OW = 49%, NW = 62%, p = 0.0001). The presence of cardiovascular disease (CVD) or diabetes modified some associations with obesity, and OB patients with CVD or diabetes had low rates of control of all three risk factors (CVD: OB = 49%, OW = 50%, NW = 56%; diabetes: OB = 42%, OW = 47%, NW = 48%, p < 0.0001 for adiposity-CVD or diabetes interaction).ConclusionsIn a large primary care network BMI documentation has been incomplete and for patients with BMI measured, risk factor control has been poorer in obese patients compared with NW, even in those with obesity and CVD or diabetes. Better knowledge of BMI could provide an opportunity for improved quality in obesity care.

Obesity Evaluation and Intervention During Family Medicine Well Visits

The purpose of this study was to determine the extent that primary care providers assess overweight and obesity and offer treatment strategies during well visits in a family medicine setting. This was a cross-sectional study of 553 consecutive patients who presented for family medicine well visits. Patient charts were reviewed for documentation of body mass index (BMI) and patient education regarding weight, exercise, and diet. BMI was calculated for 63.5% of adults at the well visit. For patients who were overweight or obese (BMI greater than 25), 48.9% received education on weight, 50.2% on diet, and 41% on exercise. Adults who had BMI calculated were also more likely to receive weight-related education (P < .001). Although height and weight were measured for most of the children and adolescents, their BMI-for-age was not calculated and they were unlikely to receive weight-related education. Training staff to measure and record BMI is a useful prompt for the physician to discuss overweight. To address weight during critical periods of development, children and adolescents need to have growth monitored with standardized tools.

Digestive Diseases in the American Indian Population of the U˙S˙ Central Plains

Purpose: Little is known about the prevalence of digestive diseases among the American Indian population of the United States central plains. The Fred Leroy Clinic of Omaha, NE, provides medical care for over 4000 American Indians from 70 tribes throughout the Dakotas, Nebraska, and Kansas. Methods: A retrospective study of random Fred Leroy charts. Each chart was reviewed for documentation of Body Mass Index in kg/m2, colorectal cancer (CRC), cholelithiasis, viral hepatitis, and 6 other digestive diseases. Data was collected on health care screening. The prevalence of each of these conditions was compared to the prevalence in the entire United States. The one-sample z-test for proportions was used in statistical analyses. Results: 449 adult patient charts were reviewed. 138 male; 311 female. 330 age 19–50 years old; 119 age 50–79. The BMI was calculated for 447 patients. The prevalence of overweight/obesity (BMI>25, 381 patients) in this population is 85.3% (U.S.-65%, p < 0.00001), the prevalence of obesity (BMI>30, 268 patients) is 60.0% (U.S.-30%, p < 0.00001). No significant difference in the prevalence of CRC existed between the study population and the U.S. population. Of 123 persons eligible for CRC screening, only 14 (11.4%) were offered screening, significantly less than the 42.5% (p < 0.00001) of eligible U.S. patients underwent CRC screening in 2000. 61 patients (13.6%) have a history of cholelithiasis. No significant difference exists between the prevalence in this population and the U.S. prevalence of 10–15% (p < 0.00001). 27 patients (6%) have a history of Hepatitis C infection (U.S.-1.7%, p < 0.00001). Conclusions: This is the first study looking at the prevalence of digestive diseases other than cholelithiasis in the American Indian population of the U.S. central plains. This population has a 20% higher prevalence of overweight/obesity compared to the U.S. and three times the prevalence of Hepatitis C. No statistically significant difference exists between these populations for prevalence of cholelithiasis, contrary to previous studies. This population lacks access to CRC screening, which is standard-of-care in the U.S. The prevalence of CRC in this population may be underestimated. The reasons behind these disparities are unclear.

Teleconferenced educational detailing: Diabetes education for primary care physicians

Formal didactic continuing medical education (CME) is relatively ineffective for changing physician behaviour. Diabetes mellitus is an increasingly prevalent disease, and interventions to improve adherence to clinical practice guidelines (CPGs) are needed. A stratified, cluster-randomized, controlled trial design was used to evaluate the effects of a teleconferenced educational detailing (TED) CME on glycemic control (hemoglobin [Hb] A1c) and family physician adherence to national diabetes guidelines. TED employed sequential, small-group, case-based education using CPGs delivered by a diabetes specialist. Medical record audit data from baseline through the end of a 12-month postintervention period were compared for the control and intervention groups. Satisfaction with the intervention was evaluated. Sixty-one physicians provided 660 medical records. The intervention did not affect mean Hb A1c levels but did significantly (p = .04) alter the distribution of patients by category of glycemic control, with fewer in the intervention group in inadequate control (15.8% versus 23.9%). More patients took insulin (alone or with oral agents) in the intervention group (21.2% versus 12.0%, p = .03), and more took oral agents only in the control group (89.0% versus 82.9%, p = .005). More patients in the intervention group had documentation of body mass index (7.8% versus 1.9%, p < .02), eye exam (12.1% versus 5.1%, p = .02), and treatment plan (43.5% versus 23.6%, p = .01) and used a flow sheet (14.6% versus 7.7%, p < .03). Although there was general satisfaction with the teleconferencing format, specialist educators found the format more challenging than the family physicians. CME delivered by teleconference was feasible, well attended, well received by participants, and improved some key diabetes management practices and outcomes.