Parents of overweight children and their pediatricians agree that doctors routinely provide weight-management counseling -- but they disagree on just what the doctor actually ordered, a study by researchers at UC Davis has found.
The rigorous study, which involved the use of parent questionnaires, audiotapes of well-child visits during which the weight-management counseling was delivered, and examination of electronic health records, found that parents tend to overreport and doctors under report the counseling delivered on weight, nutrition and physical activity.
The study on the "Accuracy of parental report and electronic health record documentation as measures of diet and physical activity counseling," is published online today in the journal Academic Pediatrics.
"It's important to find ways to accurately understand what occurs during medical care," said Ulfat Shaikh, director of Healthcare Quality Integration at the UC Davis Schools of Health and the study's lead author. "Reviews of medical records and patient surveys are commonly used as proxies for actually being inside an examination room and observing the visit. But before we use these methods to figure out what happens during a patient visit, we first need to make sure that what we measure reflects what actually happened."
Nearly one-third of the estimated 75 million children in the United States between the ages of 2 and 19 are overweight or obese -- 17 percent are obese and 15 percent are overweight. Overweight and obesity are risk factors for the development of multiple health conditions in children and adults, such as diabetes and heart disease.
Modifying children's food intake and increasing their levels of physical activity are cornerstones of weight management and obesity prevention, and a key source of advice on weight management and weight loss is physician counseling on nutrition and physical activity.
In fact, doctors are required to provide such counseling to address this serious health concern. Counseling for nutrition and physical activity for children and adolescents is a quality measure in the Healthcare Effectiveness Data and Information Set, a widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance (NCQA). The counseling also is a criterion for "meaningful use" of electronic health records under the American Recovery and Reinvestment Act of 2009.
To assess how frequently physicians provided weight-management counseling, Shaikh and her colleagues at UC Davis enrolled 198 diverse children between 2 and 12 years of age who were seen for well-child visits in the general pediatrics outpatient clinic at UC Davis Children's Hospital. The children averaged 5 ½ years of age, roughly divided evenly between boys and girls.
The children's parents were informed that the study would assess their perspectives about the well-child visit. The 38 treating physicians in the clinic were informed that parent education would be assessed for these patients, but the topics that would be evaluated were not specified.
With parents' and physicians' full knowledge, audiotape recorders were placed in the examination rooms in inconspicuous locations. The researchers audiotaped each complete visit for study participants. After the well-child visits a research assistant entered the examination room and provided parents with a questionnaire to complete before they departed the clinic.
The researchers then compared the parental reports of counseling on the questionnaires, the audiotaped records, and what information was included in the electronic health record by the physician after the conclusion of the well-child visit. The study found significant differences between what the parents reported, what was recorded on the audiotapes, and what appeared in the electronic health record.
Parents, in general, tended to remember and report discussing a wide variety of topics with greater frequency than was recorded in the audiotapes, indicating a high level of "false positive" reports.
For example, 90 percent of parents reported receiving counseling on weight management on the questionnaires; the audiotaped assessments indicated that the topics were discussed 87 percent of the time; the medical record documented these discussions at only 39 percent. Parents indicated that their pediatricians discussed consumption of fruits and vegetables 80 percent of the time; the audiotaped assessments recorded these discussions at 77 percent; but the medical record documentation indicated these discussions took place only 44 percent of the time.
Documentation of counseling in medical records is important because it serves as a memory aid to physicians when they talk to families at future visits, said Shaikh, who also is an associate professor of pediatrics. Knowing what lifestyle goals were set during the last visit helps physicians follow-up on these goals and provide support to patients and their families to help them make lifestyle changes and maintain a healthy weight. Detailed documentation in the health record also helps to improve communication between clinicians and patients, thereby improving clinical care.
Documentation in medical records of counseling on weight, nutrition and physical activity also is now used by insurers as a measurement of whether counseling has been provided and is tied to physician payment.
The study suggests that for health-care professionals, medical record documentation may inaccurately underestimate the counseling that patients receive. The study also suggests that what goes into electronic medical records may vary depending upon nuances in electronic health record tools and templates used by physicians.
"Parental report via the use of a questionnaire administered immediately following the patient visit is a more valid method of assessing physician counseling on weight, nutrition and physical activity in pediatric primary care, compared to medical record documentation," Shaikh said.
Additional study authors include Jasmine Nettiksimmons, Robert Bell, Daniel Tancredi and Patrick Romano, all of UC Davis.
The study was funded by a grant from the UC Davis Center for Healthcare Policy and Research and the Center for Clinical and Translational Research. Shaikh also is supported by a career development award from the Agency for Healthcare Research and Quality.