1. Child Obesity Treatment Services: Where are Children’s Hospitals and where can we go? Stephen Cook, MD, MPH Associate Professor, Pediatrics UR Medicine’s Golisano Children’s Hospital April 2015

2. Disclosures Grant funding: NYS Dept of Health, Greater Rochester Health Foundation NIH CBPR project CDC Prevention Research Center Boards: ABOM, AAP IHCW..…and I used to work at a TJ’s Big Boy

3. Parents estimation of child’s weight status vs. measured weight, 2-9yo 3 Estimation of weight 193 parent/child dyads from Strong Pediatrics Tschamler, et al, Clin Peds, 2010;49:470

4. Adolescents’ Perceptions of Peers Being Teased or Bullied: Observed Frequency 4

5. Percentage of teen girls who report frequent weight teasing 5 Neumark-Sztainer. J Adolesc Health. 2009;44:206-213.

6. Treatment of Obesity in Children and Adolescents StageDeliveryBehaviors Stage 1 – Prevention Plus Office-based support, with scheduled follow-up 5 fruits and vegetables < 2 hrs of screen time > 1 hr of physical activity Stage 2 – Structured Weight Management Specially-trained staff in office with support from referrals Reduced-calorie eating plan < 1 hr of screen time Monitoring Stage 3 – Comprehensive Multidisciplinary Intervention Dedicated weight management program or registered dietician referral; weekly follow-up for 8-12 weeks More frequent contact, more structured monitoring, goal-setting Stage 4 – Tertiary Care Pediatric weight management center with multidisciplinary team; clinical or research protocol Medication, surgery, meal replacement, ongoing behavior change Adapted from Katzmarzyk 2014

7. Public: Illinois Medicaid Chicago: Healthcare and Family Services Wt Mgmt Visits: > 85 th percentile, > 2yrs Appropriate CPT or UB-04 code Appr. 5-digit ICD-9 code: 278-00-278-02 AND one V-code: V85.53 or V85.54 Cover 3 visits over 6mo w/ PCP (Overweight or Obesity as the ONLY diagnosis) If co-morbidity, then that is separate.

8. Step 2 Structured Weight Management: Primary Care Office With Support 1. Develop plan for balanced macronutrient intake with emphasis on portion size of high energy dense foods 2. Increase frequency of structured family meals, planning with an RD 3. Reemphasize importance of monitoring logs( age appropriate) 4. Supervised active play 60 minutes /d, community support 5. Weight goal: maintenance or loss of 1#/month (age 2-11) up to 1-2 #/week for obese teens) to achieve 85th percentile BMI 6. Revisit at least monthly with MD, RD, office staff. Reassess in 3-6 months proceed to stage 3 prn

9. Structured Weight Management Alliance for a Healthier Generation benefit: 4 visits w/ PCP for OW or OB, over 12 mo 4 visits w/ RD for OW or OB, over 12 mo 99213-214-215 use time-based billing Aetna & CD-PHP in New York RD codes: 97802 Initial, 97803 Follow-up and 97804 (group)

10. Treatment Outcomes of Overweight Children and Parents in the Medical Home 10

11. 11 Severe Obesity (>99 th %tile) among US Children & Teens, or 3.8% or 2.7 million

12. 12 Severe Obesity (>99 th %tile) among US Children & Teens, or 3.8% or 2.7 million

13. The Affordable Care Act Improves Prevention and Obesity Coverage ACA includes several provisions that promote preventive care including obesity- related services and coverage. These provisions include an enhanced federal match for states that cover all U.S. Preventive Services Task Force (USPSTF) grade A and B recommended preventive services with no cost-sharing. Obesity screening and counseling for children, adolescents and adults is a USPSTF recommended service.U.S. Preventive Services Task Force (USPSTF) grade A and B recommended preventive services The law calls for states to design public awareness campaigns to educate Medicaid enrollees on the availability and coverage of preventive services, including obesity- related services. To help states, CMS will host calls and webinars regarding coverage and promotion of preventive services, develop fact sheets that address Medicaid coverage of preventive services, and share examples of state Medicaid program efforts to increase awareness of preventive services. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of- Care/Reducing-Obesity.html

14. Treating Overweight & Obesity Stage 1 – a prevention program managed by a primary care physician Stage 2 – a structured weight management program managed by a primary care physician together with a pediatric health care provider, such as a dietitian Stage 3 – a comprehensive intervention involving a multidisciplinary obesity care team that can provide structured monitoring, counseling and assessment at specified intervals and interventions as needed, often at a children’s hospital. ** Stage 4 – tertiary care interventions that can include medication, very low calorie diets or bariatric surgery

15. Stage 3:Clinics & Programs Clinic: multidisciplinary treatment offered without a defined treatment period or a specified frequency. Program: multidisciplinary treatment following a curriculum and delivered over a specified duration of time with a specified number of visits.

16. Stage 3 / POWER As Stage 3 multidisciplinary care providers, children’s hospitals are primarily managing care for children who are obese (>95 percentile for BMI) or severely obese (>99 percentile for BMI). Data from a 2010 Children’s Hospital Association retrospective review of the 13 participating children’s hospital weight management programs in the Pediatric Obesity Weight Evaluation Registry (POWER) shows: 61.4 percent of patients were severely obese and 35 percent were obese at presentation More than 90 percent of patients two to five years old were severely obese at presentation Nearly 75 percent of patients presented with a comorbidity

17. “In God we trust; all others must bring data.” W. Edwards Deming 17

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21. Growth of Stage 3 Services

22. Stage 3:Clinics & Programs

23. Stage 3: Wait Time

24. Stage 3: Home Base 69% felt they had a champion for obesity treatment from hospital’s executive or medical leadership

25. Stage 3: Multi-specialty Services Offered

26. Staffing for Stage 3 Services Comprehensive weight management services typically include four key roles 97 percent of teams have a dietitian 86 percent of teams have one or more physician 75 percent of teams have a mental health professional 67 percent of teams have a physical activity specialist

27. Frequency of Funding Source for Staff

28. Stage 3: Data Collected on Parent

29. Stage 3: Data Collected on Outcomes

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31. Plans Beyond The Just The Clinic 61 percent of respondents report obesity has been identified as an area of concern on their hospital’s most recent community health needs assessment. Only 4 percent of respondents indicate it was not identified as an issue, the remaining 35 percent did not know either way. (N = 122) 54 percent of respondents cite obesity as a topic addressed in their institution’s strategic plan. 12 percent said specifically that it is not in their strategic plan, while 33 percent did not know. (N = 82) 31

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34. 34 3yr old WCC w/ pt Not Mykid

35. 35 Pt NW, first seen at 3yrs and noted to be obese PNP informed pt in ‘Red zone’ as unhealthy. Can we discuss?

36. 36 Pt MN

37. One city’s communities of solution 37 Reproduced and adapted with permission from: Folsom M. Health is a Community Affair: Report of the National Commission on Community Health Service. Cambridge, MA: Harvard University Press; 1967:3, Fig 1.Fig 1 Annals Family Medicine, May/June 2012 Vol. 10 no. 3 p 250-260 Note: Political boundaries, shown in solid lines, often bear little relation to a community’s problem-sheds or its medical trade area.

38. 38 Informed, Activated Patient Productive Interactions & Relationships Prepared Proactive Practice Team Delivery System Design/Reorient health services Decision Support Information Systems Self- Management Support/Develop personal skills Health System Create supportive environments Community The Expanded Care Model Population Health Outcomes / Functional & Clinical Outcomes Build healthy public policies Strengthen community action Activated Community Prepared Proactive Community Partners

39. Who are we really treating? Those with Overweight and above?? 25-30% Those with Obesity only?? 12-22% OW or OB and a parent w/ OW or OB?  2/3 of youth w/ OW or OB Or Those with Severe Obesity (>99 th percentile or > 120% of Obesity) 3-4 % of youth in your region. 39

40. Treatment of Obesity in Children and Adolescents StageDeliveryBehaviors Stage 1 – Prevention Plus Office-based support, with scheduled follow-up 5 fruits and vegetables < 2 hrs of screen time > 1 hr of physical activity Stage 2 – Structured Weight Management Specially-trained staff in office with support from referrals Reduced-calorie eating plan < 1 hr of screen time Monitoring Stage 3 – Comprehensive Multidisciplinary Intervention Dedicated weight management program or registered dietician referral; weekly follow-up for 8-12 weeks More frequent contact, more f 1/3rdstructured monitoring, goal-setting Stage 4 – Tertiary Care Pediatric weight management center with multidisciplinary team; clinical or research protocol Medication, surgery, meal replacement, ongoing behavior change Adapted from Katzmarzyk 2014 About 30-35% of 2-18 yr olds If 1/3 rd come / follow up= 10% If 1/3 rd continue, then ~3% If 1/3 rd continue, then ~1%

41. Questions?? @DrSteveCook

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