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Using Telemedicine for Obesity Management in Rural California

November 26, 2013
by Rajiv Leventhal
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A virtual learning and quality improvement network has helped clinicians and patients better fight obesity

According to statistics, obesity has more than doubled in children and tripled in adolescents in the past 30 years. More evidence points to community-level contextual factors that may also be related to child obesity rates, with a particular focus on rural areas, including access to parks and recreation, access to full-service grocery stores, availability of fresh fruits and vegetables within schools, and availability of youth programming and recreation activities.

However, partaking in an online learning network has helped rural physicians—and by extension, their patients—improve their adherence to childhood obesity-prevention guidelines, according to a recent study published online in the American Journal of Medical Quality.

For the study, researchers from the Sacramento-based University of California, Davis (UC Davis) examined seven primary care clinics in rural California that participated in the Healthy Eating Active Living TeleHealth Community of Practice (HEALTH COP), a virtual learning and quality improvement network. The clinics participated in the HEALTH COP program for nine months to learn best practices regarding childhood-obesity prevention and share such practices with their colleagues.

A total of 144 children participated in the study by visiting one of the seven healthcare clinics two separate times: once between April and June of 2010 (before the HEALTH COP initiative began), and once between January and May of 2011 (after the HEALTH COP initiative began). The clinicians who participated in the program learned general pediatric obesity facts through videoconferencing and a set of online resources, says Ulfat Shaikh, M.D., lead researcher, pediatrician and director of healthcare quality at the UC Davis School of Medicine.

Shaikh says the collaborative began as a face-to-face pediatric obesity clinic where rural clinicians would meet one-on-one with patients for obesity prevention and management. “The issue with that was that due to the high prevalence of pediatric obesity—30 percent of kids in California are obese—we were getting a large number of consultations, and that led to quite a significant wait time at our telemedicine clinic.” As a result, the collaborative switched gears, deciding to use the existing telemedicine equipment that these clinics had to run the program virtually.

Unquestionably, because children in small communities are at an increased risk of obesity, they are at greater risk for diabetes, hypertension, depression, and other conditions. “Obesity prevention and management can be particularly challenging in rural areas,” Shaikh admits. “Families don’t have as much access to walking paths, play facilities and places to buy healthy food. There may be only one grocery store in town. Also, most of these clinics don’t have dieticians and social workers, leaving the bulk of the work with physicians.”

But through videoconferencing and other methods, rural clinicians in the program learned how to better assess patients’ weight; provide counseling on nutrition and physical activity; reorganize clinics to provide better care; screen for risk factors; and implement strategies to effectively discuss body weight.

The combination of clinical materials, education and peer support undoubtedly had a major impact on care. The Davis team looked at clinical practices, both before and after the program was implemented, and scored clinicians on their abilities to document their patient’s body mass index (BMI) and other weight measures, counsel patients and families, and provide family-centered care. Over the course of the study, the mean score increased from 3.5 to 4.6 on a zero-to-five scale.

Additionally, on average, clinicians who partook in the program discussed more topics regarding pediatric obesity with families after the intervention than before. The researchers noted a "significant" increase in counseling on sugary drinks and video games, and non-statistically significant increases in counseling on fruits and vegetables, breakfast, and family meals. Children who received care by clinicians who participated in HEALTH COP also reported positive gains in both nutrition and physical activity, the study found.

One specific challenge, Shaikh says, was that while some families broach the issue, others are in denial. “We provided instruction on motivational interviewing to help change lifestyle behavior. Teams were taught to assess where the family is and help them with their decision making.”

Just three months later, the team followed up to gather post-data, this time looking at whether the improved counseling had any behavioral impact. It had. “When we called kids and families [to follow up], they were eating better, exercising more, and watching less [television],” Shaikh says.  

And perhaps the most useful innovation was the connectivity between clinics. Peer support amongst rural clinicians allowed them to share experiences and knowledge, customize materials, such as parent education handouts, and find creative ways to improve access for their patients.

“As an urban pediatrician, if I can’t figure out a problem, all I have to do is find a colleague in the building and get their impressions,” Shaikh says. “By setting up this network, we made it easier for rural clinicians to do the same. Regardless of where they were in California, they all face similar problems. Now they can share solutions.”