The prevalence (36%) of overweight in this multiethnic inner-city pediatric clinic population exceeded the reported national data from NHANES III. Among the ethnic populations, and between male and female children, the prevalence of overweight was similar. This study shows that 29% (17 of 58) of the overweight children (2 to 18 years of age) had their diagnoses and intervention (15 of 17) documented in the medical record. In these 17 subjects, nutrition, exercise, and/or behavioral counseling were used, alone, or in combination, as an intervention with nutrition counseling being the most frequent therapy used by the providers. Further analysis revealed that blood pressure and cholesterol determinations were measured more frequently in the not documented overweight children than in those with normal weight. The rea son for this finding is not clear, and only leaves to speculation that the providers perhaps recognized an increased body weight, but failed to document the finding in the medical record. Medical documentation of overweight increased with increasing level of residency training. Higher blood pressure values were recorded in the overweight children than in normal weight children irrespective of the presence or absence of documentation. The average cholesterol level was also increased in overweight children between two and 18 years of age as compared to normal weight children, but the difference did not reach significance.
Denen et al. reported a retrospective review of medical records for outpatient evaluation of obesity in adults and children. The detection rate for obesity was 53% in adults and 18% (2 of 11) in children. In the adults, the documentation increased with increasing obesity, and when overweight patients were documented or recognized, they did receive the appropriate therapy. In our population, we had a higher percentage (29%) of the 58 overweight children between two and 18 years of age with documentation in the medical record. These results, however, still reflected deficiencies in charting, and appeared to be most dramatic in first year level residents. Similar to Denen et al documented overweight subjects had an average percentile significantly higher than the non-documented overweight subjects. This finding suggested that the providers could have been relying on visual inspection for overweight or obesity, and not the calculation of the indices of overweight such as BMI, weight to height ratio, or other indices, despite weight and height values being readily available at the time of the clinic visit. canadian pharmacy viagra
Of 49 children less than two years of age, the 10 with a BMI or weight to height ratio of > 90th percentile had no evidence in the medical record supporting the recognition or awareness of the potential risk for excessive body weight at a later age. Although controversy exists in the classification of overweight or obesity in children less that two years of age, recent studies have identified a relationship of high birth weights or rapid weight gain during the first four months of life to overweight at a later age which now raises new questions regarding the early identification, cause, treatment, and prevention of obesity in children over two years of age.
There is consensus among major health care organizations, which include American Medical Association, American Hospital Association, and the Health Insurance Association of America that the fundamental reason for maintaining an adequate medical record is its contribution to quality of medical care for patients. We conducted this study within the framework of an attending- resident supervision model, which revealed deficiencies in the level of faculty supervision and chart auditing procedures of the clinic operations. The patient’s medical record did not reflect the attending physician’s participation beyond a countersignature. Interestingly, we also found, similar to Denen et a, that children, whose excessive body weight was documented in the medical record, were most likely to receive therapeutic intervention.
The deficiencies surrounding adequacy of medical record documentation in outpatient settings are complex, and have not been effectively resolved using only peer-review or auditing procedures. Howell et al survey of emergency medicine residents including pediatrics revealed that most residents failed to record their faculty’s participation in the care of patients. Such practice leads to uncertainty in faculty’s compliance with the requirements for proper medical record documentation. Lopreiato et al. reported deficiencies in medical record documentation in areas of pediatric health maintenance. Their redesign of the resident curriculum using adult learning theory, with a focus on knowledge, skill and timely feedback, caused significant improvement in performance including medical record documentation. Such an approach is worthy of consideration for inclusion in a quality improvement program at the site of this study.
Our study reveals that overweight or obesity is under diagnosed in an inner-city clinic population of children who are expected to be at high-risk. Further, we found a significant association of higher mean level of blood pressure in those children with BMI > 90th percentile. The reasons for the low provider documentation and intervention in our population is not well-understood; however, increased provider education, curriculum redesign, appropriate support services, and available effective intervention programs are major changes that may improve the performance of providers resulting in more effective management of children with excessive or rapid increases in weight. Specifically, changes in nutrition, increased caloric expenditure by exercise, and behavioral modification are the three major categories of intervention used for the control and management of pediatric obesity. Surgical treatment and pharmaceutical therapies are being discussed for use in morbidly obese pediatric subjects, but is not considered for the first line of treatment. tadalis sx
In this study, the most frequent intervention was nutrition counseling consisting primarily of calorie reduction without alluding to other aspects such as diet content, eating pattern, or other types of intervention. Several investigators have warned that reduced caloric intake only is not optimal for long-term weight loss. In populations with children at risk for overweight or obesity, additional research is essential to assure the highest level of recognition through documentation, and development of comprehensive culturally sensitive treatment programs that include at least these three components of intervention (nutrition, exercise, and behavior modification). The prevention of gaining excessive body weight, instead of treating the problem after it has developed, is most likely to have the best personal and public health benefit.
There are several limitations to this study, which include being a retrospective review of medical records and the limited sample size. A larger sample size over a longer study period would have permitted an analysis by provider characteristics in addition to the level of residency training. Individual performances may vary from encounter to encounter, and also may be affected by the particular time period of the year. The objective of this study was to assess group practice pattern and not individual performances. The study of additional clinics with similar multiethnic populations and supervision model would offer the opportunity to produce results with a potentially wider application to a diverse inner-city community. tadacip