Innovative Information Technology-Powered Population Health Care Management Improves Outcomes and Reduces Hospital Readmissions and Emergency Department Visits.

BACKGROUND: Patients with chronic conditions are often the most frequent users of health care. Moreover, adapting to developments in one's illness, understanding how to self-manage a chronic illness, and sharing information between primary care and specialty providers, can be a full-time job for someone with a chronic illness. In response to these challenges, Christiana Care Health System (Wilmington, Delaware) developed Care Link, an information technology (IT)-enhanced care management support to enable populations of patients to achieve better clinical outcomes at lower cost. METHODS: In 2012 Christiana Care received a grant to design a generalizable, scalable, and replicable IT-driven care model that would integrate disparate clinical and registry data generated from routine care to support longitudinal care management for patients with ischemic heart disease. The single-disease care management program was expanded beginning in mid-2015 to serve risk-based models for many diseases and chronic conditions. RESULTS: More than 8,600 patients in several surgical and medical populations, including joint replacement, cervical spine surgery, and congestive heart failure, have been supported by Care Link. For example, preoperative assessment of patients with elective joint replacement to predict post-acute care needs led to an increase in the volume of patients discharged to home with self-care or with home health care by 30%-from 61% to 80%. CONCLUSION: Care Link IT functions can be replicated to address the unique longitudinal care needs of any population. Care Link's next steps are to continue to increase the number of patients served throughout the region and to expand the scope of care management programming.

Improving Infusion Pump Safety Through Usability Testing.

With the recognition that the introduction of new technology causes changes in workflow and may introduce new errors to the system, usability testing was performed to provide data on nursing practice and interaction with infusion pump technology. Usability testing provides the opportunity to detect and analyze potentially dangerous problems with the design of infusion pumps that could cause or allow avoidable errors. This work will reduce preventable harm through the optimization of health care delivery.

Childhood obesity in secondary care: national prospective audit of Australian pediatric practice.

OBJECTIVE: In many countries, pediatricians offer skilled secondary care for children with conditions more challenging than can readily be managed in the primary care sector, but the extent to which this sector engages with the detection and management of obesity remains largely unexplored. This study aimed to audit the prevalence, diagnosis, patient, and consultation characteristics of obesity in Australian pediatric practices. METHODS: This was a national prospective patient audit in Australia. During the course of 2 weeks, members of the Australian Paediatric Research Network prospectively recorded consecutive outpatient consultations by using a brief standardized data collection form. Measures included height, weight, demographics, child and parent health ratings, diagnoses, referrals, investigations, and consultation characteristics. We compared the prevalence of pediatrician-diagnosed and measured obesity (body mass index ≥95th percentile) and top-ranked diagnoses, patient, and consultation characteristics in (a) obese and nonobese children, and (b) obese children with and without a diagnosis. RESULTS: A total of 198 pediatricians recorded 5466 consultations with 2-17 year olds, with body mass index z-scores calculated for 3436 (62.9%). Of the 12.6% obese children, only one-third received an "overweight/obese" diagnosis. Obese children diagnosed as overweight/obese were heavier, older, and in poorer health than those not diagnosed and incurred more Medicare (government-funded health system) cost and referrals. CONCLUSIONS: Obesity is infrequently clinically diagnosed by Australian pediatricians and measurement practices vary widely. Further research could focus on supporting and normalizing clinical obesity activities from which pediatricians and parents could see clear benefits.

Physical activity and 3-year BMI change in overweight and obese children.

OBJECTIVES: Targeting physical activity (PA) is a mainstay in obesity treatment, but its BMI benefits are poorly quantified. We studied long-term predictive PA-BMI relationships in overweight/obese children presenting to primary care. METHODS: Three-year follow-up of 182 overweight/obese 5- to 10-year-olds recruited from 45 Melbourne general practices. PREDICTOR: 7-day accelerometry (counts per minute, cpm). OUTCOMES: change in BMI z score, BMI category, and clinically significant BMI improvement (z score change ≥0.5). ANALYSIS: Linear and logistic regression. RESULTS: Mean (SD) baseline and 3-year BMI z scores were 1.8 (0.6) and 1.8 (0.7), and mean (SD) activity scores 334 (111) and 284 (104) cpm, respectively. Baseline activity did not predict BMI change. However, for every 100 cpm increase in change in activity over 3 years, BMI z score fell by 0.11 (95% confidence interval [CI] 0.03-0.20; P = .006). There were also trends toward greater odds of staying in the same, versus moving to a higher, BMI category (odds ratio 1.85, 95% CI 0.99-3.46) and clinically significant BMI improvement (odds ratio 1.96, 95% CI 0.90-4.27; P = .09). Change in percentage time spent in moderate-vigorous (P = .01), but not sedentary (P = .39) or light (P = .59), activity predicted reduced BMI z score. CONCLUSIONS: Sustained increase in moderate-vigorous PA predicts reducing BMI z score over 3 years in overweight/obese children presenting to primary care. However, the small BMI change associated with even the largest activity changes may explain disappointing BMI outcomes of brief primary care interventions targeting PA.

How training affects Australian paediatricians' management of obesity.

OBJECTIVE: Secondary care could be the optimal sector for managing child and adolescent obesity, given low primary care uptake and limited tertiary services. We aimed to determine Australian paediatricians' self-reported competence and training in managing obesity and, in a linked patient-level audit, whether these predict rates of measurement and obesity diagnosis. DESIGN, SETTING AND PATIENTS: Australian Paediatric Research Network members completed an online survey, plus a prospective patient-level audit of up to 100 consecutive consultations over 2 weeks. SURVEY: self-reported competencies, training in and use of clinical skills in obesity and its comorbidities. Audit: paediatricians reported each child's height, weight, age, sex and diagnoses including overweight/obesity. RESULTS: Of 166 (44.7% response) paediatricians, most felt very/quite competent in assessing (89%) and managing (68%) obesity, but few in making a difference to obesity (20%) or managing hypertension (45%), insulin resistance (32%), fatty liver disease (22%) or dyslipidaemia (21%). The audit of 200 (66.2% response) paediatricians included 8345 patients. On average paediatricians recorded height and weight for 66.5% of patients (SD 30.0%, range 0-100%). Of the 296 (12.3%) patients obese by CDC cutpoints, 118 (39.9%) were diagnosed as obese; perceived competence increased the odds of recording this diagnosis but not measurement. Training levels were low, showed little association with measurement or obesity diagnosis, and skills learnt were not routinely used. CONCLUSIONS: There is a clear need for better paediatrician training in obesity management. However, care and outcomes for obese children are unlikely to improve unless effective management models can be operationalised systematically.

Improving access to hard-to-reach services: a soft entry approach to drug and alcohol services for rural Australian Aboriginal communities.

Australian Aboriginal communities are concerned about drug- and alcohol-related harms in their communities. There are a significantly higher proportion of substance problems experienced by Aboriginal Australians than non-Indigenous Australians. Ways to address these problems are limited by racial barriers to mainstream services, especially in the rural context. Soft entry was an approach designed to increase Aboriginal Australians' access to Drug & Alcohol (D&A) services. The approach was designed to put control over when and how D&A interventions were delivered in the hands of the community and individuals within it by giving them ready access to a human services worker with specialist knowledge. Quantitative and qualitative evaluation methods found that soft entry substantially increased the number of Aboriginal and non-Aboriginal women accessing drug and alcohol services. It fundamentally shifted the power relationship between counselors and community, providing opportunities to develop a non-stigmatizing trustful rapport to facilitate discussion of harmful substance use. The challenges for drug and alcohol counselors were the slow unpredictability of the approach and the need for highly skilled and responsive communication techniques. However, the factor most likely to improve access to services, once trust is developed, is regular and frequent attendance at the service delivery site.

Is the adiposity rebound a rebound in adiposity?

OBJECTIVE: Early adiposity rebound ([AR], when body mass index [BMI] rises after reaching a nadir) strongly predicts later obesity. We investigated whether the upswing in BMI at AR is accompanied by an increase in body fat. DESIGN: Community-based cohort study. SUBJECTS: A total of 299 first-born children (49% male). Measurements. Six-monthly anthropometry and bioelectrical impedance, 4-6.5 years; lean and fat mass index (kg/m(2)) for direct comparison with BMI. Supplementary (0-2 years) weight and length measures (needed for growth curve modelling) were drawn from subjects' child health records. METHODS: AR was estimated from individually modelled BMI curves from birth to 6.5 years. Two main analyses were performed: 1) cross-sectional comparisons of BMI, fat mass index (FMI), lean mass index (LMI) and percent body fat in children with early (<5 years) and later (>5 years) rebound; and 2) investigation of linear trends in BMI, FMI, LMI and percent body fat before and after AR. Results. The 81 children (27%) experiencing early AR had higher BMI, FMI, LMI and percent fat at 6.5 years. Overall, FMI decreased steeply pre-AR, at -0.56 (0.02) kg/m(2) per year (mean [Standard Error]), then flattened post-AR to 0.07 (0.05) kg/m(2) per year. In contrast, LMI increased pre-AR (0.34 [0.01]) and steepened post-AR (0.47 [0.03] kg/m(2) per year). CONCLUSION: The 'adiposity rebound' is characterised by increasing lean mass index, coupled with cessation of the decline in fat mass index. Understanding what controls the dynamics of childhood body composition and mechanisms that delay AR could help prevent obesity.

New directions in childhood obesity research: how a comprehensive biorepository will allow better prediction of outcomes.

BACKGROUND: Childhood obesity is associated with the early development of diseases such as type 2 diabetes and cardiovascular disease. Unfortunately, to date, traditional methods of research have failed to identify effective prevention and treatment strategies, and large numbers of children and adolescents continue to be at high risk of developing weight-related disease. AIM: To establish a unique 'biorepository' of data and biological samples from overweight and obese children, in order to investigate the complex 'gene × environment' interactions that govern disease risk. METHODS: The 'Childhood Overweight BioRepository of Australia' collects baseline environmental, clinical and anthropometric data, alongside storage of blood samples for genetic, metabolic and hormonal profiles. Opportunities for longitudinal data collection have also been incorporated into the study design. National and international harmonization of data and sample collection will achieve required statistical power. RESULTS: Ethical approval in the parent site has been obtained and early data indicate a high response rate among eligible participants (71%) with a high level of compliance for comprehensive data collection (range 56% to 97% for individual study components). Multi-site ethical approval is now underway. CONCLUSIONS: In time, it is anticipated that this comprehensive approach to data collection will allow early identification of individuals most susceptible to disease, as well as facilitating refinement of prevention and treatment programs.

The Light Time-Use Diary and preschool activity patterns: exploratory study.

AIM: To conduct an exploratory study of time-use patterns in Australian 5-year-old children, and to pilot the novel Children's Light Time-Use Diary as a potential tool for investigating relationships between children's time-use and weight status. METHODS: Subjects for the present cross-sectional study were drawn from an established longitudinal cohort and included eighty-four 5-year-old Australian children (36 males) originally recruited as infants in three local government areas of Melbourne. Children were weighed and measured, and body mass index (BMI; kg/m(2)) calculated. Over three to four complete 24-hour periods, parents completed the Children's Light Time-Use Diary to record their child's activities in 15-minute blocks and details about the context in which the activities took place, selecting from a list of predetermined options. RESULTS: The children studied were largely sedentary, with television viewing the most time-consuming activity outside sleep. Only 49% of children spent any time walking for transport or pleasure. Children spent a median of 71% of their time in activities that were likely to be physically active when outdoors, compared with 3% when indoors, but averaged only 110 minutes/day outdoors (excluding passive transport). The 11 overweight/obese children watched significantly more television than non-overweight children. CONCLUSION: The Children's Light Time-Use Diary appears to be a practical and informative tool, which may complement accelerometry as a tool relevant to future studies of the determinants of child overweight/obesity. Further validation studies and larger research trials seem warranted.

Comparing estimates of body fat in children using published bioelectrical impedance analysis equations.

BACKGROUND: The level of body fat mass (BFM) in childhood that is associated with weight related morbidity is unclear. Bioelectrical impedance analysis (BIA) offers an inexpensive, acceptable and portable method for measuring body composition in children. However, different equations have been derived to estimate BFM, and relationships between equations have not been explored. OBJECTIVE: To compare body mass index (BMI) and BIA as tools for estimating adiposity-related health risks in children. METHODS: Height, weight and BIA were measured in a population based cross-sectional survey of 341 healthy 5-year-old Australian children. Percent BFM was estimated using four published BIA-based predictive equations for pre-school children. Ranking of children according to total BFM was compared for all equations. RESULTS: Each equation produced different estimates of percent BFM. In general, increasing BMI was associated with increasing BFM, but wide ranges of BFM estimates were produced for children of similar BMI. For all of the equations, females had a higher percent BFM compared with males of the same BMI (p<0.001). Percent BFM estimates rose rapidly in children classified as overweight/obese (1990 UK growth standard). The equations were highly correlated in their ranking of children from lowest to highest percent BFM. CONCLUSION: Results support concerns about the validity of BMI as an accurate measure of absolute BFM. Percent BFM estimates produced by the four BIA equations were highly correlated, indicating they rank children according to BFM in the same order. This suggests any single equation could provide a measure of relative BFM in children for population and longitudinal studies.

Maternal concern and perceptions of overweight in Australian preschool-aged children.

OBJECTIVE: To assess maternal concern about overweight in Australian preschool-aged children and factors predicting maternal concern about children's current and future weight status. DESIGN: Cross-sectional survey of child's body mass index and parent questionnaire. SETTING: Metropolitan Melbourne, Victoria, 2002. PARTICIPANTS: A community-based cohort of 324 4-year-old children and their parents. MAIN OUTCOME MEASURES: Mothers' reports of concern about the child's current and future weight status, and perceptions of the child's weight, diet and activity relative to their peers were compared with the child's measured weight status, and parent and child characteristics. RESULTS: The prevalence of overweight or obesity was 19%, but only 5% of mothers indicated concern about their child being currently overweight, while 16% worried their child would become overweight. Over 70% of mothers of overweight children saw them as being of similar weight to their peers. Most mothers saw their children as being equally or more active than other children and having a diet at least as healthy as their peers. Overweight daughters were more likely to elicit maternal concern about current weight than overweight sons (relative risk, 4.6; 95% CI, 1.1-19.8). Mothers were more likely to worry about their child's potential for future overweight if they or the child's father were overweight. CONCLUSIONS: Despite mounting public concern about childhood obesity in Australia, most mothers surveyed were not concerned about their child's weight, and many mothers did not perceive their overweight children as different from their peers. This may have implications for interventions that rely on acknowledgement of child overweight as a first step to change.