Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital for Children, Boston2Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts.
Department of Pediatrics, Harvard Vanguard Medical Associates, Boston, Massachusetts.
JAMA Pediatr. 2015 Jun;169(6):535-42. doi: 10.1001/jamapediatrics.2015.0182.
Evidence of effective treatment of childhood obesity in primary care settings is limited.
To examine the extent to which computerized clinical decision support (CDS) delivered to pediatric clinicians at the point of care of obese children, with or without individualized family coaching, improved body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) and quality of care.
DESIGN, SETTING, AND PARTICIPANTS: We conducted a cluster-randomized, 3-arm clinical trial. We enrolled 549 children aged 6 to 12 years with a BMI at the 95% percentile or higher from 14 primary care practices in Massachusetts from October 1, 2011, through June 30, 2012. Patients were followed up for 1 year (last follow-up, August 30, 2013). In intent-to-treat analyses, we used linear mixed-effects models to account for clustering by practice and within each person.
In 5 practices randomized to CDS, pediatric clinicians received decision support on obesity management, and patients and their families received an intervention for self-guided behavior change. In 5 practices randomized to CDS + coaching, decision support was augmented by individualized family coaching. The remaining 4 practices were randomized to usual care.
Smaller age-associated change in BMI and the Healthcare Effectiveness Data and Information Set (HEDIS) performance measures for obesity during the 1-year follow-up.
At baseline, mean (SD) patient age and BMI were 9.8 (1.9) years and 25.8 (4.3), respectively. At 1 year, we obtained BMI from 518 children (94.4%) and HEDIS measures from 491 visits (89.4%). The 3 randomization arms had different effects on BMI over time (P = .04). Compared with the usual care arm, BMI increased less in children in the CDS arm during 1 year (-0.51 [95% CI, -0.91 to -0.11]). The CDS + coaching arm had a smaller magnitude of effect (-0.34 [95% CI, -0.75 to 0.07]). We found substantially greater achievement of childhood obesity HEDIS measures in the CDS arm (adjusted odds ratio, 2.28 [95% CI, 1.15-4.53]) and CDS + coaching arm (adjusted odds ratio, 2.60 [95% CI, 1.25-5.41]) and higher use of HEDIS codes for nutrition or physical activity counseling (CDS arm, 45%; CDS + coaching arm, 25%; P < .001 compared with usual care arm).
An intervention that included computerized CDS for pediatric clinicians and support for self-guided behavior change for families resulted in improved childhood BMI. Both interventions improved the quality of care for childhood obesity.
clinicaltrials.gov Identifier: NCT01537510.
在初级保健环境中治疗儿童肥胖的有效证据有限。
研究在肥胖儿童接受护理时向儿科临床医生提供计算机化临床决策支持（CDS），无论是否结合个体化家庭指导，在多大程度上能改善体重指数（BMI；体重以千克为单位，身高以米为单位计算）和护理质量。
设计、地点和参与者：我们进行了一项集群随机、3 臂临床试验。我们招募了 549 名年龄在 6 至 12 岁之间的儿童，他们来自马萨诸塞州的 14 个初级保健机构，BMI 处于第 95 百分位或更高水平。招募时间为 2011 年 10 月 1 日至 2012 年 6 月 30 日。随访时间为 1 年（最后一次随访为 2013 年 8 月 30 日）。在意向治疗分析中，我们使用线性混合效应模型来解释实践和每个人内部的聚类。
在随机分配到 CDS 的 5 个实践中，儿科临床医生接受了肥胖管理决策支持，患者及其家属接受了自我指导行为改变的干预措施。在随机分配到 CDS +教练的 5 个实践中，决策支持通过个体化家庭指导得到加强。其余 4 个实践被随机分配到常规护理。
在 1 年的随访中，与 BMI 相关的较小年龄变化以及医疗保健效果数据和信息集（HEDIS）肥胖的表现衡量标准。
在基线时，患者的平均（SD）年龄和 BMI 分别为 9.8（1.9）岁和 25.8（4.3）。在 1 年时，我们从 518 名儿童（94.4%）获得了 BMI，从 491 次就诊（89.4%）获得了 HEDIS 测量值。3 个随机分组在 BMI 随时间的变化上有不同的效果（P =.04）。与常规护理组相比，CDS 组在 1 年内 BMI 增加较少（-0.51 [95%CI，-0.91 至-0.11]）。CDS +教练组的效果较小（-0.34 [95%CI，-0.75 至 0.07]）。我们发现 CDS 组（调整后的优势比，2.28 [95%CI，1.15-4.53]）和 CDS +教练组（调整后的优势比，2.60 [95%CI，1.25-5.41]）在儿童肥胖 HEDIS 衡量标准的实现方面取得了更大的成效，并且营养或身体活动咨询的 HEDIS 代码的使用更高（CDS 组，45%；CDS +教练组，25%；与常规护理组相比，均 P <.001）。
包括为儿科临床医生提供计算机化 CDS 以及为家庭提供自我指导行为改变支持的干预措施，可改善儿童 BMI。这两种干预措施都提高了儿童肥胖护理的质量。
clinicaltrials.gov 标识符：NCT01537510。
