Setting: Clinical

Stories from the Field: Denver Takes Action to Promote Healthy Child Weight

Posted on November 30, 2020

The information in this Story from the Field is intended only to provide educational information.

In this story from the field, partners at Denver Health worked with the CHOICES Team to see what might happen if they made changes to their electronic medical record systems to prompt pediatric medical providers to recognize children with too much weight for their health during well-child visits, and provide follow-up supportive care, education, and educational messages to families.

Identifying Priorities in Denver

Two departments of Denver Health – Denver Public Health and Community Health Services – identified healthy weight as a goal of their local Community Health Improvement Plan to address local population health priorities. Many partners had several ongoing initiatives to ensure that Denver’s children did not have too much weight for their health. As the health care provider for one-third of Denver’s children, Denver Health recognized its potential to reach more families by undertaking additional actions within its health system. Evidence suggests that racial, ethnic, and low-income groups in U.S. communities tend to have greater exposure to negative environmental influences and less access to protective factors, making maintaining a healthy weight more challenging.

Gathering Information for Action

In 2017, partners in Denver teamed up with the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Project at the Harvard T.H. Chan School of Public Health’s Learning Collaborative Partnership. The CHOICES Project works with health agencies to create new evidence to inform decision-making. Using local data, health agencies learn how to apply evaluations of effectiveness, reach, and cost to understand the relative cost-effectiveness of strategies to prevent and treat childhood obesity.

Strategy Selection

The Denver Learning Collaborative Partnership Team attended a CHOICES training and reviewed strategies to find best-value-for-money options for preventing children from having too much weight for health. One approach seemed particularly relevant: The Study of Technology to Accelerate Research (STAR), a clinical strategy that had been shown effective in a randomized trial.1

The Intervention

STAR uses decision support tools in the Epic electronic medical record system to help the health care team recognize and engage supports for children at annual well-child visits. Families receive education and can opt to receive text messages on healthy habits, like increasing physical activity and adopting healthier nutrition practices.

The Change Needed

While Denver Health had many pieces for STAR already in place, they would need several adjustments. Denver Health needed to modify its health record protocol to include diagnosis, screening, and decision support prompts for children with a BMI at or above 85%. Denver Health could build on its existing text messaging system and develop materials to provide relevant education and resources to parents and families, and then ensure training opportunities for pediatricians.

Steps Taken for Implementation

  • Interviewed clinicians to build engagement and incorporate feedback in Epic modifications to include decision support tools and prompts to help identify and manage children with too much weight for health

  • Surveyed families to inform educational content and text message program

  • Modified Epic to include decision support tools

  • Trained the health care team on the changes in Epic and the available resources for families

Helping Change Happen

Through the CHOICES Learning Collaborative Partnership, the CHOICES Team works with local stakeholders to make projections about what may happen if they implement a program or policy. Here they calculated that STAR could reach 19,400 children in Denver over ten years and prevent 300 children from having too much weight for their health. For every dollar spent implementing STAR, $0.78 would be saved in health care costs because more children would have a healthier weight.2 This strategy is projected to both improve overall population health, as well as reduce disparities in too much weight for health among children. What’s more, this information gave Denver Health data to support a grant application for strategy implementation. With leadership support and funding, Denver Health was well positioned to begin implementing components from STAR in 2019.

Impact & Lessons Learned

Since 2019:
An info graphic that states: "11 Denver health clinics implementing the strategy," and "8 Denver health training materials created."

With the STAR clinical strategy, it was so feasible compared to other strategies, and when looking at our entire budget, it is a drop in the overall bucket of funding.” – Jennifer Moreland, Chronic Disease Manager, Denver Public Health

References

  1. Taveras E., Marshall R., Kleinman KP, Gillman MW, Hacker K…Simon SR. (2015). Comparative Effectiveness of Childhood Obesity Interventions in Pediatric Primary Care: A Cluster-Randomized Clinical Trial, JAMA Pediatrics, 169(6):535-542

  2. Moreland J, Rosen J, Kraus E, Reiner J, Gortmaker S, Giles C, Ward Z. Denver: Study of Technology to Advance Research (STAR) [Issue Brief]. Denver Public Health and Denver Health, Denver, CO, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; July 2018.

Suggested Citation:

CHOICES Stories from the Field: Denver Takes Action to Promote Healthy Child Weight. Denver Public Health, a Department of Denver Health, Denver, CO, and the CHOICES Project Team at the Harvard T.H. Chan School of Public Health, Boston, MA; October 2020.

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Brief: Study of Technology to Accelerate Research (STAR) in Denver

Posted on December 6, 2018

Toddler girl laughing while doctor examines

The information in this brief is intended only to provide educational information.

This brief summarizes findings from a CHOICES Learning Collaborative Partnership model of implementation of the “Study of Technology to Accelerate Research” (STAR) intervention in Denver Health pediatric primary care settings. Denver STAR leverages electronic health record (EHR) decision support tools to facilitate the diagnosis and management of childhood obesity during well-child care visits.

The Issue

Over the past four decades, childhood obesity has tripled.1 Health care costs for treating obesity-related health conditions are high, costing $147 billion in 2008.2 Interventions in clinical settings that aim to manage childhood obesity have the potential to help children lead healthier lives, reduce obesity prevalence in adulthood, and reduce health care costs.3

In Denver, 13.9% of 2-12 years old seen at Denver Health clinics have obesity. Although time-intensive counseling to improve dietary intake and physical activity is recommended, these interventions are often time consuming, resource intensive, and difficult to implement and sustain.3,4 Leveraging existing EHRs to facilitate childhood obesity diagnosis and management, and engaging families through direct-to-parent communications, is a promising clinical strategy to reduce the prevalence of childhood obesity at a relatively low cost.

About STAR

The Denver STAR intervention leverages EHR decision support tools, operated by EPIC software, to promote recognition of pediatric obesity and facilitate recommended screening and management during pediatric well-child care visits. In addition, the Denver STAR intervention includes direct-to-parent communications in which parents receive text messages to support behavior change for their children. Families would also have access to a webpage that shares local health and wellness resources. Primary Care Physicians (PCPS) who see pediatric patients at Denver Health clinics would be trained in the EHR changes and motivational interviewing techniques to facilitate weight management discussions with the patients and families. Evidence obtained in a cluster randomized controlled trial showed that STAR helped to prevent excess weight gain compared to usual care.4

Comparing Costs and Outcomes

CHOICES cost-effectiveness analysis compared the costs and outcomes of the implementation of STAR within pediatric primary care practices in Denver Health with the costs and outcomes associated with not implementing STAR over a 10 year time period (2017-2027). The approach assumes that all Denver Health pediatric primary care clinics would implement STAR. We assume that all children ages 2- 12 with obesity (BMI > 95th percentile) who visit Denver Health clinics for well-child visits would benefit from the intervention.

Implementing STAR in Denver Health pediatric primary care settings is an investment in the future. By the end of 2027:
Infographic: 19,400 children reached and 303 cases of childhood obesity prevented by 2027 at $32.80 per child

Conclusions and Implications

Every child deserves a healthy start in life. This includes developing innovative clinical strategies that can be feasibly implemented to improve the quality of care for childhood obesity in pediatric primary care settings. By leveraging EHR tools managed by EPIC, Denver STAR is a scalable intervention that can be feasibly implemented in all Denver Health primary care clinics. The intervention is expected to reach 19,400 children over 10 years and would prevent 303 cases of childhood obesity in the final year of the model.

Denver STAR is a good buy as it is likely to have a high magnitude of effect on improving children’s health at a relatively low cost per child. For every $1 spent on implementing Denver STAR, a projected $0.78 would be saved in obesity-related health care costs. Denver STAR also supports institutional policies by collecting reportable data for Healthcare Effectiveness Data and Information Set (HEDIS) performance measures.

Denver STAR intervention is projected to both improve overall population health, as well as reduce disparities in childhood obesity. The modeled implementation of STAR in Denver Health, a health system that predominantly serves a higher proportion of racial/ethnic minority groups, is projected to result in significant health benefits among Hispanic and Black populations in Denver.

Evidence is growing about how to help children achieve a healthy weight. Interventions such as Denver STAR, which is evidence-based, feasible to implement, and relatively low cost, can improve the quality of care of childhood obesity in pediatric primary care.

References

  1. Fryar CD, Carroll MD, Ogden CL, Prevalence of overweight and obesity among children and adolescents: United States, 1963-1965 through 2011-2012. Atlanta, GA: National Center for Health Statistics, 2014.
  2. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates. Health Affairs. 2009;28(5).
  3. Sharifi, M., Franz, C., Horan, C. M., Giles, C. M., Long, M. W., Ward, Z. J., … & Taveras, E. M. Cost-Effectiveness of a Clinical Childhood Obesity Intervention. Pediatrics. 2017, e20162998.
  4. Taveras E., Marshall R., Kleinman KP, Gillman MW, Hacker K….Simon SR. (2015). Comparative Effectiveness of Childhood Obesity Interventions in Pediatric Primary Care: A Cluster-Randomized Clinical Trial, JAMA Pediatrics, 169(6):535-542
Suggested Citation:

Moreland J, Rosen J, Kraus E, Reiner J, Gortmaker S, Giles C, Ward Z. Denver: Study of Technology to Accelerate Research (STAR) {Issue Brief}. Denver Public Health and Denver Health, Denver, CO, and the CHOICES Learning Collaborative Partnership at the Harvard T.H. Chan School of Public Health, Boston, MA; July 2018. For more information, please visit www.choicesproject.org

The design for this brief and its graphics were developed by Molly Garrone, MA and partners at Burness.

This issue brief was developed at the Harvard T.H. Chan School of Public Health in collaboration with Denver Public Health and Denver Health through participation in the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) Learning Collaborative Partnership. This brief is intended for educational use only. This work is supported by The JPB Foundation. The findings and conclusions are those of the author(s) and do not necessarily represent the official position of the funder.

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Cost-Effectiveness of a Clinical Childhood Obesity Intervention

Posted on November 1, 2017

A CHOICES study estimates that the national implementation of an intervention focused on electronic health record (EHR)-based decision support for primary care providers and self-guided behavior change support for parents is likely a more cost-effective approach to treating children with obesity than previous clinical interventions reporting cost information.

Sharifi M, Franz C, Horan CM, Giles C, Long M, Ward Z, Resch S, Marshall R, Gortmaker S, Taveras E. Cost-Effectiveness of a Clinical Childhood Obesity Intervention. Pediatrics. 2017; 140(5):e20162998.

Over 12 million children and adolescents in the United States have obesity (17% of the population). The results of this study demonstrate that taking advantage of electronic health record (EHR) systems may be among the “best value for money” strategies currently tested for pediatric obesity treatment.

A child and doctor smiling“It is clear that the most cost-effective strategies for preventing new cases of obesity are population-level approaches like taxes and school-based policies,” said Mona Sharifi, lead author and Assistant Professor of Pediatrics at the Yale School of Medicine. “However, we need additional and different strategies to support the approximately 12 million children who already have obesity and are at highest risk for health complications and obesity in adulthood. Our study suggests that using the electronic health record to help primary care pediatricians deliver higher quality care for children with obesity may be relatively low hanging fruit among clinical interventions in terms of cost-effectiveness.”

The Study of Technology to Accelerate Research (STAR)1 involved modifications to existing EHR systems to facilitate childhood obesity management in pediatric primary care by prompting diagnosis as well as providing decision support and electronic resources for evaluation, management, and follow-up care. Evidence obtained in a cluster randomized controlled trial showed that STAR helped to prevent excess weight gain compared to usual care.

The CHOICES study of STAR offers an opportunity to both inform clinicians and policymakers about what investment would be required to adopt STAR in pediatric practices across the country and evaluate the cost-effectiveness and population impact of the intervention, if implemented nationally over 10 years from 2015-2025. Some of the key outcomes include:

  • Cases of obesity averted in 2025: 43,000
  • Life-years with obesity averted (2015-2025): 226,000
  • Cost per BMI unit reduced: $237
  • Mean BMI unit reduction: -0.5
  • 10-year reach: 2 million
  • Total health care costs saved (over 10 years): $64 million
  • 10-year net cost (the cost of implementation minus the health care cost saved): $175 million
  • Cost per child: $119

As more pediatric practices adopt fully functional EHRs (fueled by federal goals and incentives), the results indicate even greater reach and population health benefits, even if implementation is limited to large practices.

Overall, there is evidence that STAR can reduce the prevalence of childhood obesity by focusing on high-risk children, providing electronic decision support for pediatricians, and supplying self-guided behavior change strategies for parents to utilize outside of the clinical setting. Limited cost effectiveness information on other similar clinical interventions indicates that STAR is likely to have a higher magnitude of effect on improving children’s health at a lower cost per child.

STAR is one of 13 interventions that have been evaluated using CHOICES methods. While many strategies focused on preventing childhood obesity are more cost-effective than STAR, the projected impact of the STAR intervention on the prevalence of obesity is high and intervention costs are low when compared with other clinical interventions focused on treatment of obesity, such as bariatric surgery.

References:

  • Taveras EM, Marshall R, Kleinman KP, et al. Comparative effectiveness of childhood obesity interventions in pediatric primary care: A cluster-randomized clinical trial. (link: https://www.ncbi.nlm.nih.gov/pubmed/25895016) JAMA Pediatr. 2015;169(6):535-542.

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The Cost of a Primary Case-Based Childhood Obesity Prevention Intervention

Posted on January 30, 2014

Wright DR, Taveras EM, Gillman MW, Horan CM, Hohman KH, Gortmaker SL, Prosser LA. The cost of a primary care-based childhood obesity prevention intervention. BMC Health Serv Res. 2014 Jan 29;14:44. doi: 10.1186/1472-6963-14-44.

Abstract

Background

United States pediatric guidelines recommend that childhood obesity counseling be conducted in the primary care setting. Primary care-based interventions can be effective in improving health behaviors, but also costly. The purpose of this study was to evaluate the cost of a primary care-based obesity prevention intervention targeting children between the ages of two and six years who are at elevated risk for obesity, measured against usual care.

Methods

High Five for Kids was a cluster-randomized controlled clinical trial that aimed to modify children’s nutrition and TV viewing habits through a motivational interviewing intervention. We assessed visit-related costs from a societal perspective, including provider-incurred direct medical costs, provider-incurred equipment costs, parent time costs and parent out-of-pocket costs, in 2011 dollars for the intervention (n = 253) and usual care (n =192) groups. We conducted a net cost analysis using both societal and health plan costing perspectives and conducted one-way sensitivity and uncertainty analyses on results.

Results

The total costs for the intervention group and usual care groups in the first year of the intervention were $65,643 (95% CI [$64,522, $66,842]) and $12,192 (95% CI [$11,393, $13,174]). The mean costs for the intervention and usual care groups were $259 (95% CI [$255, $264]) and $63 (95% CI [$59, $69]) per child, respectively, for a incremental difference of $196 (95% CI [$191, $202]) per child. Children in the intervention group attended a mean of 2.4 of a possible 4 in-person visits and received 0.45 of a possible 2 counseling phone calls. Provider-incurred costs were the primary driver of cost estimates in sensitivity analyses.

Conclusions

High Five for Kids was a resource-intensive intervention. Further studies are needed to assess the cost-effectiveness of the intervention relative to other pediatric obesity interventions.

Trial registration: ClinicalTrials.gov NCT00377767.

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