Mothersele, Susan M., MS

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Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksUSF-LVHN SELECTCreation of a Pediatric Obesity ComorbidityScreening Sheet to be Implemented into EPICSusan M. Mothersele MSUSF MCOM- LVHN Campus, susan.mothersele@lvhn.orgFollow this and additional works at: http://scholarlyworks.lvhn.org/select-programPart of the Medical Education CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtMothersele, S. (2016, March 9). Creation of a Pediatric Obesity Comorbidity Screening Sheet to be Implemented into EPIC. Posterpresented at: The SELECT Capstone Project in the Kasych Conference Room, Lehigh Valley Health Network, Allentown, PA.   Intro/BackgroundThis project was done for internal quality improvement, thus was exempt from IRB. All LVHN primary care patients between the ages of 2 and 18 years old with a BMI greater than or equal to the 85th percentile are eligible, with no exclusions placed on gender or ethnicity. The LVHN Pediatric Obesity Prevention and Management Pathway was used as a guideline for inclusion of comorbidities to be incorporated in the screening template. The comorbidity screening template consists of 25 common comorbidities seen in pediatric patients with obesity.3 Information was gathered by conducting literature searches of specific comorbidities within the systems of cardiovascular, gastrointestinal, nutrition, endocrine, respiratory, neurologic, orthopaedic, genetic, and mental health (Appendix, Table 1). Comorbidities were included in the template based on recommendations from LVHN’s Pediatric department, as well as prominence in the literature. Patients are deemed to have a comorbid condition if the condition was diagnosed either contemporaneously with or following the initial documentation of the patient being overweight or obese. The prevalence of obesity in the United States has been steadily increasing and pediatric obesity has become a common problem seen in the primary care setting. A study that looked at obesity trends in US children and adolescents from 1999-2010 found that nationally in 2009-2010 16.9% of children were obese and 31.8% were either overweight or obese, with 12.3% of children falling above the 97th percentile of BMI for age.1 Clinical care pathways can improve the quality of clinical decision making by offering specific and detailed guidelines for clinicians, provide authoritative recommendations that reassure practitioners about the appropriateness of their treatment plans, and improve the consistency and effectiveness of medical care thereby optimizing patient outcomes.2 © 2016 Lehigh Valley Health NetworkMethodsThe CDC estimates that presently one-third of children and adolescents are overweight or obese in the United States. Chart reviews conducted in 2014 of two LVHN pediatric practices of over 100 patient charts from each revealed the prevalence of pediatric obesity in LVHN practices ranged from 30-36% of patients. A comorbidity screening sheet was constructed and designed to be used by physicians and other healthcare professionals to help manage pediatric patients whose BMIs classify them as overweight or obese. 25 comorbidities were selected for inclusion in the screening template (Appendix, Figure 1). This tool aims to standardize and streamline screening for and treatment of comorbidities that can be associated with obesity.Results Standardizing patient care and the use of clinical care pathways has been shown to improve patient outcomes and may improve efficiency and optimize value for the healthcare system by reducing unnecessary testing, procedures, and prescriptions.2 The comorbidity screening sheet was developed to be implemented into the EPIC electronic medical record and applied to the care of overweight and obese pediatric patients at LVHN. The goal of this standardized process is to properly diagnose and treat the multiple complications that are associated with the growing epidemic of pediatric obesity. The template will do this by providing specific recommendations about frequency of screenings, how to address abnormal laboratory results, and when and whom to make referrals to. Further study includes assessing patient outcomes and the cost effectiveness of this process. The process of developing this screening template may be applied to other areas of both pediatric and adult care to optimize the use of electronic medical record at LVHN.Conclusions and Future ImplicationsReferences:1.  Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of Obesity and Trends in Body Mass Index Among US Children and Adolescents, 1999-2010. JAMA.2012;307(5):483-490. doi:10.1001/jama.2012.40. 2.  Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Potential benefits, limitations, and harms of clinical guidelines. BMJ : British Medical Journal. 1999;318(7182):527-530.3.  Schwimmer JB, Burwinkle TM, Varni JW. Health-Related Quality of Life of Severely Obese Children and Adolescents. JAMA.2003;289(14):1813-1819. doi:10.1001/jama.289.14.1813. We sought to standardize the way Lehigh Valley Health Network’s primary care physicians manage and assess the comorbidities associated with pediatric obesity.Problem StatementFigure 1: LVHN Comorbidity Screening TemplateLehigh Valley Health Network, Allentown, PACreation of a Pediatric Obesity Comorbidity Screening Sheet to be Implemented into EPICSusan Marie MotherseleTable 1:  Comorbidities by System  Cardiovascular Hypertension;HyperlipidemiaGastrointestinalNon-alcoholic fatty liver disease/Non-alcoholic Steatohepatitis; Gallbladder disease;GERDNutrition Iron deficiency;Vitamin D deficiencyEndocrineDiabetes;PCOS;Hypothyroidism;Cushing’s DiseaseRespiratory Asthma;Obstructive Sleep ApneaNeurologic Pseudotumor Cerebri Syndrome;Disc diseaseOrthopaedicSCFE, Blount’s disease;Spondylolysis;SpondylolisthesisGeneticPrader-Willi, Bardet-Biedl;Down Syndrome;Fragile XMental HealthMood disorder;Anxiety;Eating disorder behavior;Bullying/Abuse/ViolenceLVHN Comorbidity Screening Template Cardiovascular • Hypertension – Patient’s blood pressure within normal limits for age group? • Yes – Repeat yearly • No, consider – Cardiology referral – Dietitian referral – Labs/Studies » Urinalysis » Fasting lipid panel » Fasting glucose » TSH, free T4 » Renal ultrasound with doppler of renal vascular » EKG • Hyperlipidemia – Risk factors • Has anyone had a heart attack or bypass surgery under the age of 65? – If so, at what age? (Note, early cardiac disease if < 55 yrs in men and <65 yrs in women) • Has anyone in the family died suddenly? • Parental history of high cholesterol? – If yes to any of the above, consider earlier screening between ages 2-8 with two average fasting lipid profiles – Labs done within the past 2 years? • Yes – Normal – Abnormal * (* indicates clinician must respond by placing an order or denoting why an order was not placed) » Repeat fasting lipid profile » Dietitian » Cardiology • No – Order » Fasting lipid profile » Non-fasting lipid profile – Deferred* Gastrointestinal • Non-Alcoholic Fatty Liver Disease (NAFLD)/Non-Alcoholic Steatohepatitis(NASH) – AST and ALT • Ordered in the last 2 years? • Yes – Normal – Abnormal* » Repeat AST/ALT » RUQ ultrasound » Referral to GI • No – Order » AST/ALT » Deferred* – Gallbladder disease • Potential associated symptoms – Recurrent abdominal pain – Vomiting • If positive, consider – RUQ ultrasound – GERD • Potential associated symptoms – Vomiting – Acid Reflux – Epigastric Pain – Chronic cough • If positive, consider – Diet changes – Antacid – PPI Therapy – UGI Nutrition – Iron Deficiency • Risk factors/symptoms of anemia? – Fatigue – Pallor – Diet history of excessive cow milk consumption/low iron diet • If yes, consider – CBC – Iron studies • Vitamin D Deficiency – Review diet history – 25 OH Vitamin D level » Normal » Abnormal* » Repeat Vitamin D » Order Vitamin D • Cholecalciferol • 400u/ml liquid • 1,000u chew • 2,000u capsule • 5,000u capsule • Ergocalciferol 50,000u capsule  Endocrine – Diabetes • Risk factors/Symptoms – Family history – Polyuria – Polydipsia – Nocturia/new onset enuresis – Acanthosis Nigricans • If any of the above are positive, consider – HbA1c – Fasting insulin/glucose • Labs within the past 2 years? – Yes » Normal » Abnormal* • HbA1c • Fasting insulin/glucose • Oral glucose tolerance test • Endocrine referral – No » Other • HbA1c • Fasting insulin/glucose • Oral glucose tolerance test » Deferred*  – PCOS • Verbal screen – History of irregular menses > 2 years post menarche? (irregular for 6 months or no menses for 3 months) – Signs of hyperandrogenism? (e.g. hirsutism, male pattern hair, balding or severe acne) – Signs of insulin resistance? (e.g. presence of acanthosis) – Need 3 positive answers to have a positive screen – If positive screen, consider referral to » Adolescent Medicine » Endocrine – Hypothyroid • Risk factors/symptoms – Family history – Slow linear growth – Excessive fatigue – Goiter • If any of the above are positive – TSH – Free T4 • TSH >5? – If yes, consider » TSH » Free T4 » Anti-thyroid peroxidase Ab » Anti-thyroglobulin Ab » Endocrine referral – Cushing’s disease • Risk factors/symptoms – Family history – Violaceous striae – Muscle weakness – Buffalo hump – Moon facies – Slow linear growth • If any of the above are positive, consider – Endocrine referral Respiratory – Asthma • Symptoms – Cough/Shortness of breath with exercise or during sleep – Wheezing • If yes, consider – Spirometry – CXR – Trial of bronchodilator – Asthma clinic/pulmonary referral – Sleep Apnea • Enlarged tonsils • Verbal screen – Snoring 3 or more nights a week? – Difficulty breathing during sleep (i.e. work hard to breathe, gasp for air, have retractions)? – School problems, ADHD or daytime sleepiness (fall asleep at school)? – If 2 out of  3 positive, screen is positive » Sleep study » Sleep center referral Neurologic – Pseudotumor Cerebri Syndrome • Verbal screen – Unexplained near-daily headaches (which may be worse in the supine position or upon awakening)? – Blurry or double vision? – Pulsatile tinnitus (heartbeat or whooshing sounds in the ears)? – If any one positive, screen is positive » Urgent Ophthalmology referral Orthopedic Conditions – SCFE, Blount’s Disease • Screening questions for SCFE – Pain in hip, knee or leg – Limp – Decreased hip range of motion – Unequal leg lengths • If patient has associated symptoms, consider imaging – SCFE with stable hips – Bilateral AP & Frog Leg Hip Xrays – SCFE with unstable hips – Bilateral PA & Lateral Hip Xrays • Screening question for Blount’s Disease – Leg bowing • If patient has associated symptoms, consider imaging – Bilateral Standing AP & Lateral LE Xray from hip to floor – Spondylolysis, Spondylolisthesis, Disc Disease • Screening questions – Pain in back, buttocks or leg – Sciatica – LE weakness – LE numbness – Decreased ROM of back • If positive, consider – Positive neurological exam – MRI of the spine – Negative neurological exam – Lumbar Spine Xrays AP, Lateral and Oblique Genetic Disorders – Prader-Willi, Bardet-Biedl, Down Syndrome, Fragile X • Potential physical exam findings – Short stature – Delayed development – Syndromal apperance – Undescended testes – Micropenis – Small hands and feet – Polydactyly • If positive, consider – Chromosomal testing – Genetics referral Mental Health – Pediatric Symptom Checklist • Depression • Anxiety • Eating disorder – Binging/purging, stealing/hoarding food • If positive, – Behavioral Health referral – Bullying/Abuse/Violence Screening Questionnaire for Children • If positive, consider referral to – Child Advocacy Center 

Creation of a Pediatric Obesity Comorbidity Screening Sheet to be Implemented into EPIC

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Creation of a Pediatric Obesity Comorbidity Screening Sheet to be Implemented into EPIC

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Lehigh Valley Health Network: LVHN Scholarly Works