A Plan for Action: Addressing Obesity in the Primary Care Setting

From the 2023 HVPA National Conference

Theresa Benskin MD (Cleveland Clinic Foundation), Paige Gurizzian MD, Davis Leaphart MD, Sofia Molina Garcia MD, Bennett Osantowski MD, Kaitlin Payne MD, Purnadeo Persaud DO, Jonathan Ravid MD, Michael Sheu MD, Jessica Donato MD

Background:
Obesity in the United States adult population has been steadily rising with a reported prevalence of 41.9% from 2017-2020 and known associated comorbidities including cardiovascular disease, osteoarthritis, sleep apnea, diabetes, and others. For patients with obesity, primary care physicians (PCPs) are often their established contact within the healthcare system, providing a vital and recurring opportunity for PCPs to address obesity directly during routine office visits. Multiple patient comorbidities, appointment time constraints, and social stigma are some of many reasons providers may not address this issue (Figure 1).

Objective: We sought to increase the percent of patients in primary care panels of internal medicine residents with obesity assessed and documented during routine outpatient visits by 20% over a 3-month time period.

Methods:
Baseline data was collected via sampling method for 36 patients with obesity (BMI >30) in primary care panels of nine internal medicine residents seen for annual physicals or routine follow-up visits in the prior three months. Data collection was completed via office visit chart review to determine if obesity was addressed and documented in the assessment and plan. To address the root cause of minimal prompts in clinic workflow that would otherwise lead providers to discuss and prioritize obesity management, the standard clinic template was adjusted to automatically incorporate patient’s BMI into the health maintenance section of the note with an EMR “hard stop” entry field so providers must address BMI before completing the note.

Results:  
At baseline, 22% (8/36) of patients sampled had documentation of obesity with an assessment and plan in the most recent clinic visit as established via chart review. Mean BMI of sample patients was 38.7. A significant number of patients had hypertension (72%), diabetes (36%), and vascular disease (13%). Post-Interventional Cycle 1 data showed 50% (11/22) of patients sampled had documentation of obesity with an assessment and plan in the most recent clinic visit. Interventional Cycle 2 data showed 58% % (17/29), and Interventional Cycle 3 data showed 50% (20/40) of patients sampled had similarly appropriate assessment and plan documentation (Figure 2).

Conclusion:
To help clinicians and patients, we implemented a change in clinic workflow by creating a BMI “hard stop” within the EMR clinic note template. Documentation of obesity in assessment and plan improved from baseline 22% to 50% (a 227% total increase) after Interventional Cycle 1, which is significantly greater than 20% improvement as stated in objective. Additional Cycles 2 and 3 had similar improvement from baseline of patients with obesity documented in the assessment and plan at 58% and 50% respectively. The implemented “hard stop” BMI entry field likely played a role in improving assessment and plan documentation, but comprehensive assessment of effectiveness of this sole intervention was limited by confounding factors such as weekly discussions of stated goal during QI meetings and limited patient data in the sampling timeframe. 

Clinical Implications:
The quality of patient care was improved with this initiative by increasing the likelihood of obesity being discussed during routine office visits, thus prompting providers and patients to have an assessment and plan for this problem. Given the associated comorbidities of obesity, and with upcoming improvements in medication management, we believe this EMR prompt for addressing obesity will be of utmost importance to providing comprehensive, quality patient care.

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