child obesity treatment services: where are children’s hospitals and where can we go? stephen...

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

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

Parents estimation of child’s weight status vs. measured weight, 2-9yo

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Estimation of weight 193 parent/child dyads from Strong Pediatrics

Tschamler, et al, Clin Peds, 2010;49:470

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

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Percentage of teen girls who report frequent weight teasing

5 Neumark-Sztainer. J Adolesc Health. 2009;44:206-213.

Treatment of Obesity in Children and Adolescents

Stage Delivery Behaviors

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

Public: Illinois Medicaid

Chicago: Healthcare and Family Services

Wt Mgmt Visits: > 85th 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.

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

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)

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

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

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 preve

ntive services

with no cost-sharing. Obesity screening and counseling for children, adolescents and

adults is a USPSTF recommended service.

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

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

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.

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

“In God we trust; all others must

bring data.”

W. Edwards Deming

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Growth of Stage 3 Services

Stage 3: Clinics & Programs

Stage 3: Wait Time

Stage 3: Home Base

69% felt they had a champion for obesity treatment from hospital’s

executive or medical leadership

Stage 3: Multi-specialty Services Offered

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

Frequency of Funding Source for Staff

Stage 3: Data Collected on Parent

Stage 3: Data Collected on Outcomes

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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)

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3yr old WCC w/ pt Not Mykid

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Pt NW, first seen at 3yrs and noted to be obese

PNP informed pt in ‘Red zone’ as unhealthy. Can we discuss?

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Pt MN

One city’s communities of solution

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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.

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.

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Informed,Activated

Patient

ProductiveInteractions & Relationships

PreparedProactivePractice

Team

• Delivery SystemDesign/Reorient health services

• DecisionSupport

• InformationSystems

• 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

ActivatedCommunity

PreparedProactive

Community Partners

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 (>99th percentile or > 120% of Obesity)

• 3-4 % of youth in your region.

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Treatment of Obesity in Children and Adolescents

Stage Delivery Behaviors

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 1/3rd come / follow up= 10%

If 1/3rd continue, then ~3%

If 1/3rd continue, then ~1%

Questions??

@DrSteveCook

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