Results Service Utilization Weight Outcomes Outcomes of Structured Weight Management in Pediatric Tertiary Care Sarah E Hampl 1,2, Kelsey M Dean 2, Kelsey.

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Results Service Utilization Weight Outcomes Outcomes of Structured Weight Management in Pediatric Tertiary Care Sarah E Hampl 1,2, Kelsey M Dean 2, Kelsey B Borner 2, Katrina M. Poppert 2, Amy Papa 2, T Ryan Smith 3 and Ann M Davis 2,3 1 Children's Mercy Hospital, Kansas City, MO, United States; 2 Center for Children's Healthy Lifestyles & Nutrition, Kansas City, MO, United States and 3 Pediatrics, University of Kansas Medical Center, Kansas City, KS, United States Background One in three children is overweight or obese (Ogden et al., 2014). The 2007 Expert Committee recommended monthly visits for children in Stage 2 (Structured Weight Management) for 6 months (Spear et al). Although the effectiveness of Stage 2 treatment has been reported (Cheng et al, 2014; Dolinsky et al, 2012), little is known about patient characteristics associated with return to clinic. This study reviews a large cohort of children and adolescents with obesity seen in Stage 2 clinics to present retention rates, demographic predictors, and weight outcomes based on service utilization. Conclusions Slightly less than half of patients followed up after the 1 st visit, highlighting the continued important role that attrition plays in pediatric weight management. Only 6 patients were seen 6 times in 6 months. Although baseline BMI z-score did not significantly differ between those with no and ≥1 follow up visits, BMI percentile was greater in those who kept more follow up visits, perhaps indicating that heavier patients felt more compelled to follow up. Hispanic patients, those whose parent spoke Spanish and those insured by Medicaid were more likely to return to clinic at least once. Those who returned to clinic at least once had a significant reduction in BMI z-score, with continued significant, though less dramatic, BMI z-score reductions through the 4 th visit. The absence of significant reductions after the 4 th visit may be due to limited sample size. As determined by BMI z-score change, approximately 2/3rds of patients’ weight status improved at the 2 nd, 3 rd and 4 th visits within 6 months, and the weight status of 1/3rd of patients did not. Eighty-three percent of the small number of patients seen for a 5 th visit improved their weight status. Acknowledgements The authors thank the Health Care Foundation of Greater Kansas City for their support. Contact Information For more information, please contact Sarah Hampl, MD at Methods Procedures: Participants were drawn from structured weight management clinics, Promoting Health in Teens and Kids (PHIT Kids) and Healthy Hawks at 2 Midwestern hospitals from Participant demographic and anthropometric data were drawn from the patient’s electronic medical record. Prior to collecting data from the EMR, the study was approved by the hospital IRBs. Measures: Patient anthropometric data (i.e., height, weight) was measured at each clinic visit. Child height and weight were used to calculate BMI, BMI percentile, and BMI z- score using the Centers for Disease Control BMI calculator for the Statistical Analysis Software™ program. Participants: 2087 patients between the ages of 2 and 18 years old (M=10.86 years; SD=3.35) Baseline BMI Percentile=98.83, SD=1.24; Baseline BMI z-score=2.45, SD=0.49 Gender: 56.8% female Language: 83.9% English-speaking; 16.1% Spanish-speaking; and 0.4% Other Race/Ethnicity: 41.7% White; 26.1% African American; 20.6% Hispanic; 7.9% Other; 3.8% Not Recorded. Insurance status: Commercial: 34.1%; Government: 54.7%; No Insurance: 4.3%; Unknown: 0.5% References Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2014). Prevalence of childhood and adult obesity in the United States, JAMA, 311(8), Spear BA, Barlow SE, Ervin C, Ludwig DS, Saelens BE, Schetzina KE, Taveras EM. Recommendations for treatment of child and adolescent overweight and obesity. Pediatr 2007;120:S254-S288. Cheng JK, Wen X, Coletti KD, Cox JE, Taveras EM. Two-year BMI changes of children referred for multidisciplinary weight management. Intl J Pediatr 2014; 2014: doi: /2014/ Epub 2014 Jan 30. Dolinsky DH, Armstrong SC, Walter EB, Kemper AR. The effectiveness of a primary care-based pediatric obesity program. Clin Ped 2012;51: Monthly Change in zBMI by Service Use Category Service Use Category NMonthly Change in zBMISD 1 (Visit #2) a,b (Visit #3) a (Visit #4) b (Visit #5) (Visit #6) Demographic Predictors of Return to Clinic Did Not Return After Initial Appt. Return to Clinic At Least Once RACE WhiteObserved Expected BlackObserved Expected HispanicObserved Expected OtherObserved8381 Expected Chi-square = 17.14, p<.01 LANGUAGE EnglishObserved Expected SpanishObserved Expected Chi-square= 22.06, p<.001 GENDER MaleObserved Expected FemaleObserved Expected Chi-square= 0.49, p>.05 INSURANCE STATUS CommercialObserved Expected GovernmentObserved Expected No InsuranceObserved3851 Expected Chi-square = 10.28, p<.05 Baseline Weight Status by Service Use Category Service Use Category (within 6 months) Initial zBMI Initial BMI percentile 0 (No follow up) a,b,c 1 (One follow up) a 2 (Two follow up) b 3 (Three follow up) d 4 (Four follow ups) c,d Table 2. Baseline Weight Status by Service Use Category. Values of significance are as follows: a = significant difference between categories 0 and 1; b = significant difference between categories 0 and 2; c = significant difference between categories 0 and 4; and d = significant difference between categories 3 and 4. Category 5 omitted from analyses due to small sample size (N=6). Figure 1. Number of patients seeking Stage 2 treatment and retention rates during the first 6 months following initial visit. Percentages are as follows: Initial = 100%; Visit 2 = 46.33%; Visit 3 = 20.89%; Visit 4 = 7.71%; Visit 5 = 2.16%; Visit 6 = 0.29%. Table 4. Average monthly change in zBMI within service use categories. A one-way ANOVA was conducted between groups, and results indicated that a significant difference in monthly zBMI change existed between groups (F(4,1092)=5.277, p<.001). Therefore, independent samples T-tests were conducted to determine specific between group differences. Values of significance for independent samples t-tests are as follows: a = significant difference between categories 1 and 2; b = significant difference between categories 1 and 3. Table 3. Demographic predictors of Return to Clinic. Crosstab and Chi-square analyses were conducted within each racial, language, gender, and insurance group. Significant chi-square values indicate a significant difference in demographic variable by return to clinic. Service Use Categories N 0 (No follow up; One total visit) (One follow up; Two total visits)531 2 (Two follow ups; Three total visits)274 3 (Three follow ups; Four total visits)117 4 (Four follow ups; Five total visits)39 5 ( Five follow ups; Six total visits)6 Table 1. Service Use Categories. Participants are categorized by number of visits within 6 months (of initial visit). Participants in category 0 did not follow up. To account for variance in time between service use categories, monthly change in zBMI was calculated, which represents average monthly change in zBMI between visit 1 and last visit. To best approximate the recommendations of the Expert Committee, a service range was set for 6 months. Total number of visits within 6 months of initial visit are presented in Figure 1. Participants were grouped according to service use category. Number of participants within each service use category are presented in Table 1. Significant differences in initial BMI percentiles emerged between categories. See Table 2 for full results. Demographic predictors of return to clinic (for at least one visit after initial visit) are presented in Table 3. Crosstabs and chi-square analyses were conducted to predict expected status of return to clinic within each demographics category (Did Not Return, N=1120 vs. Return At Least Once, N=967). Significant differences in expected rates of return to clinic emerged within racial, language, and insurance categories. See Table 3 for observed and expected counts within each category and chi-square statistics. Monthly change (  ) analyses were completed between service use categories 1 through 4, and results are presented in Table 4. Individuals in service use category 1 evidenced a larger monthly reduction in zBMI than individuals in service use categories 2 or 3. Category 5 values are presented, but were not included in analyses due to small sample size. Figure 2. Percentages of weight loss/maintenance and weight gain (as determined by BMIz-score change) at last clinic visit, by service use category. Service category Five omitted from analyses due to small sample size (N=6). Monthly BMI z-score change values were then categorized into “Weight loss/Maintenance” (Monthly  ≤ 0) or “Weight Gain” (Monthly  > 0). Percentages of patients in weight change categories, by service use category, are presented in Figure 2.