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Promoting Gestational Weight Gain Counseling Using an Electronic

Medical Record “Best Practice Alert”

Cynthie K. Anderson, MD, MPH, FACOG

Director, Obstetrics & Gynecology Residency Clinic

Overview

� Background

� IOM Guidelines

� Counseling Gaps

� Quality Improvement Initiative

� “Meaningful Use” of the EMR

� Nutrition & Dietary Referrals

� Early Diabetes Screening

Introduction

� Cynthie K. Anderson, MD, MPH, FACOGDirector, OB/Gyn Residency Clinic

Assistant Professor, Department of Obstetrics & Gynecology

UW School of Medicine & Public Health, Madison, WI

Nothing to disclose

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Obesity Trends Among U.S. AdultsBRFSS, 1990, 2000, 2010

(*BMI ≥≥≥≥30, or about 30 lbs. overweight for 5’4” person)

1990 2000

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

2010

Women of Childbearing Age

Percent Overweight/Obese

29

30

31

32

33

34

35

36

37

38

2001-2002 2003-2004 2005-2006 2007-2008

Percent

Flegal KM, et al. Prevalence and trends in obesity among US adults, 1999-2008.

JAMA 2010;303:235-41.

Excess Gestational Weight Gain

Health Impacts on Pregnancy:

• Arrest of labor

• Failed induction

• Cesarean delivery

• Gestational diabetes

• Hypertensive disorders

• Fetal macrosomia

• Shoulder dystocia

Excess Gestational Weight Gain

Health Impacts on Women:

• Postpartum weight retention

• Long-term weight gain

• Excess body fat

• Incident obesity

• Sleep apnea

• Pre-diabetes/diabetes

• Coronary heart disease

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Excess Gestational Weight Gain

Health Impacts on Neonates & Children:• Low 5-minute Apgar scores

• Neonatal seizures

• Hypoglycemia

• Large for gestational age infants

• Meconium aspiration

• NICU admission

• 4-fold increased lifetime risk of overweight/obesity

• Lifelong elevated risk for diabetes, hypertension, cardiovascular disease, cancer, early death

2009 Institute of Medicine Guidelines

Source: Institute of Medicine, 2009

2009 Institute of Medicine (IOM) Guidelines

• Institute of Medicine guidelines are tailored to reflect different metabolic needs of women who start pregnancy at different weights.

Source: Institute of Medicine, 2009

* Singleton pregnancy

Healthy Gestational Weight Gain

Improves Outcomes

• Mamun AA, et al. Associations of excess weight gain during pregnancy with long-term maternal overweight and obesity: evidence from 21 y postpartum follow up. Am J Clin Nutr. 2010 May;91(5):1336-41.

• Cohort 2,055 women

• 21 Years Follow-Up

• Excess GWG Odds Ratio 3.72 for presence of Overweight/Obese at follow up

• Adjusting for Pre-Gravid BMI strengthened this relationship

Conclusion: Excess weight gain during pregnancy

independently predicts long-term obesity among women

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AJOG *Editor’s Choice*McDonald SD, et al. Despite 2009 guidelines, few women report being

counseled correctly about weight gain in pregnancy. Am J Obstet Gynecol

2011;205:333.e1-6.

• 93% response rate

• 47% reported any weight gain counseling

• 28% reported being given a specific goal

• 12% reported that they achieved the goal

Why Counsel? There’s nothing I can do to prevent women from eating…

• Women are 5 times more likely to internalize the goal –they trust their providers!

• Only 28-40% of women receive accurate counseling -despite professional association recommendations

• 51% gain excess gestational weight

• Excess gestational weight gain carries

serious long-term health risks

Institute of Medicine 2009

http://www.iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx

Ambulatory Care Innovation Grant

• Specific Aims:

1. Establish baseline proportion of prenatal patients in UW Health who received antenatal gestational weight gain counseling consistent with revised 2009 IOM guidelines

2. a. Increase by 10% prenatal patients in UW Health with pre-pregnancy BMI documented in the EMR

b. Increase by 10% prenatal patients in UW Health who receive gestational weight gain counseling consistent with revised 2009 IOM guidelines.

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Baseline Chart Review

UW-Health Clinics: June-September 2011

Clinic Site OB Patients

UWHC West OB n = 152

UWMF 20 S. Park OB n = 110

UWHC West CNM n = 68

Sun Prairie DFM n = 32

Odana Atrium DFM n = 23

Total = 385

Characteristic Pre-Intervention(n = 388)

Post-Intervention(n = 346)

Maternal age (years) 31.07 ± 4.81 29.95 ± 5.38

Maternal race

White 296 (76.3) 236 (68.2)

Asian 36 (9.3) 25 (7.2)

Non-Hispanic Black 22 (5.7) 15 (14.3)

Hispanic/Latina 22 (5.7) 6 (1.7)

American Indian/Pacific Islander 3 (0.8) 2 (0.6)

Other/Not Specified 9 (2.3) 62 (17.9)

Number of prior deliveries

0 171 (44.1) 166 (48.1)

1 146 (37.6) 112 (32.5)

2 49 (12.6) 43 (12.5)

3 or more 21 (5.4) 24 (6.9)

Pre-gravid BMI classification†

Underweight 13 (4.2) 9 (2.9)

Normal weight 168 (54.2) 168 (53.7)

Overweight 71 (22.9) 73 (23.3)

Obese 58 (18.7) 63 (20.1)

Provider type

Obstetrician 264 (68.0) 243 (72.8)

Family practice 56 (14.4) 59 (17.7)

Certified nurse midwife 68 (17.5) 32 (9.6)

Table 1. Characteristics of patients included in the chart reviews

Data are mean ± standard deviation or n (%) unless otherwise specified.† Pre-gravid BMI classifications are reported for patients with a valid pre-gravid BMI value recorded in the EMR.

Pre-gravid BMI was missing from the EMRs of 76 (19.7%) patients in the pre-intervention group and 32 (9.2%) patients in the post-intervention group.

Demographics

Baseline Findings

• Pregravid BMI:

– No pre-gravid BMI recorded in EMR = 20%

– Of those (80%) with pre-gravid BMI recorded:

• 4% underweight

• 59% normal weight

• 23% overweight

• 19% obese42% overweight/obese

Baseline Findings

• Total GWG:

– Mean weight gain:

~30 lbs or 13.5 kg

– Range:

-4 kg to +29 kg

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Total Gestational Weight Gain

by Pre-Gravid BMI

GWG Counseling at UW-Health Clinics

• What was the extent of counseling documented?

80% received some counseling

GWG Counseling at UW-Health Clinics

• What was the extent of counseling documented?

4% received numerical GWG goal

GWG Counseling at UW-Health Clinics

• What was the extent of counseling documented?

3% received a goal consistent with IOM guidelines

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GWG Counseling at UW-Health Clinics

• Quality improvement project aimed to expand

the blue areas of these graphs

• “Best Practice Alert” (BPA)

– Introduced into the Epic OB Navigator (workspace within the

Electronic Medical Record)

– Designed for use at new OB intake visit

Meaningful Use of the EMR

BPA Elements

� Scripted Counseling

� Optional Links� Feedback on functionality

� Medical content questions to provider

� View or print IOM Guidelines

� Link to “Smart Set”� Orders: Fasting glucose, nutrition consult, dietary referral

� Documentation: Provider note, Patient Instructions for

After-Visit Summary (electronic or print)

� Diagnosis Codes: Overweight/Obesity, Obesity in

Pregnancy

� Tracking mechanism with reporting tool

Provider DocumentationInsert 32831 - UNDERWEIGHT (PREGRAVID BMI<18.5)

Gestational Weight Gain Counseling: Based on the Institute of Medicine

guidelines and the patient’s pre-pregnancy BMI of @PRENATBMI@, the patient was counseled about her goals for weight gain in this pregnancy. We

{DID/DID NOT:10342} discuss the option of nutrition or dietary counseling to optimize healthy weight gain.

Healthy Range of Total Weight Gain: 28-40 pounds

Target Rate of Weight Gain in 2nd and 3rd Trimesters: 1-1.3 pounds per week

Current Weight: @WTTODAY@

Total Weight Gain to Date: @TWG@

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Provider DocumentationInsert 32834 - OBESE (PREGRAVID BMI > 30.0)

Gestational Weight Gain Counseling: Based on the Institute of Medicine

guidelines and the patient’s pre-pregnancy BMI of @PRENATBMI@ , the patient was counseled about her goals for weight gain in this pregnancy. We

{DID/DID NOT:10342} discuss the option of nutrition or dietary counseling to optimize healthy weight gain.

Healthy Range of Total Weight Gain: 11-20 pounds

Target Rate of Weight Gain in 2nd and 3rd Trimesters:

0.4-0.6 pounds per week

Current Weight: @WTTODAY@

Total Weight Gain to Date: @TWG@

Patient InstructionsElectronic or Print

Insert 32826 - Underweight (Pregravid BMI <18.5)

Healthy Weight Gain in Pregnancy

Gaining weight is normal during pregnancy. Gaining too much weight can cause problems for you and your baby, such as increased risk for diabetes,

increased risk for high blood pressure, having a baby that is too large or too small, increased risk for cesarean section, or being overweight or obese after

your pregnancy. Gaining weight in a healthy range is better for you and your baby.

Based your weight and height and using national guidelines from the Institute of Medicine, a healthy range of total weight gain for you in this pregnancy is

between 28-40 pounds. A healthy rate of weight gain in the 2nd and 3rd

trimester is about 1 pound per week. If you and your doctor think it would be helpful, you could meet with a nutritionist or dietician to discuss how to eat a

healthy diet and gain a healthy amount of weight in this pregnancy.

Patient InstructionsElectronic or Print

Insert 32829 - Obese (Pregravid BMI ≥30.0)

Healthy Weight Gain in Pregnancy

Gaining weight is normal during pregnancy. Gaining too much weight can cause problems for you and your baby, such as increased risk for diabetes,

increased risk for high blood pressure, having a baby that is too large or too small, increased risk for cesarean section, or being overweight or obese after

your pregnancy. Gaining weight in a healthy range is better for you and your baby.

Based your weight and height and using national guidelines from the Institute of Medicine, a healthy range of total weight gain for you in this pregnancy is

between 11-20 pounds. A healthy rate of weight gain in the 2nd and 3rd

trimester is about one half of a pound each week. If you and your doctor think it would be helpful, you could meet with a nutritionist or dietician to discuss

how to eat a healthy diet and gain a healthy amount of weight in this pregnancy.

Results350 patients initiated prenatal care May-August 2012

0

10

20

30

40

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60

70

80

90

100

Pre- Intervention Post- Intervention

Pre-gravid BMI

Documented

in EMR

0

10

20

30

40

50

60

70

80

90

100

Pre- Intervention Post- Intervention

Gestational Weight Gain Counseling

Any Counseling

Other Specific

Goal Provided

IOM-Consistent

Goal

Increase from 80% to 89% (p < 0.01) Increase from 3% to 51% (p < 0.01)

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UW 20 S Park - Obstetricians

0

10

20

30

40

50

60

70

80

90

100

Pre- Intervention Post- Intervention . Pre-Intervention Post-Intervention

Gestational Weight Gain Counseling

Any Counseling

Other Specific Goal Provided

IOM-Consistent Goal

Overall 20 S. Park OB

UW West Junction Road - Obstetricians

0

10

20

30

40

50

60

70

80

90

100

Pre- Intervention Post- Intervention . Pre-Intervention Post-Intervention

Gestational Weight Gain Counseling

Any Counseling

Other Specific Goal Provided

IOM-Consistent Goal

Overall West OB

UW Sun Prairie - Family Medicine

0

10

20

30

40

50

60

70

80

90

100

Pre- Intervention Post- Intervention . Pre-Intervention Post-Intervention

Gestational Weight Gain Counseling

Any Counseling

Other Specific Goal Provided

IOM-Consistent Goal

Overall Sun Prairie

UW Odana Atrium - Family Medicine

0

10

20

30

40

50

60

70

80

90

100

Pre- Intervention Post- Intervention . Pre-Intervention Post-Intervention

Gestational Weight Gain Counseling

Any Counseling

Other Specific Goal Provided

IOM-Consistent Goal

Overall Odana Atrium

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UW West Junction Road – Certified

Nurse Midwives

0

10

20

30

40

50

60

70

80

90

100

Pre- Intervention Post- Intervention . Pre-Intervention Post-Intervention

Gestational Weight Gain Counseling

Any Counseling

Other Specific Goal Provided

IOM-Consistent Goal

Overall West Midwives

Meaningful Use of the EMR

Introduction of a “Best Practice Alert”

� Entry of Pregravid BMI improved significantly

• 89% - up from 80% before intervention (p < 0.01)

� Accurate GWG counseling improved substantially

• 51% - up from 3% (p < 0.01)

• Improvement achieved across all clinic sites, all provider

types (CNM, FP, OB)

� Further Data Collection:

• Nutrition & dietary referrals

• Early diabetes screening

• Weight gained

• Birth outcomes

• Patient & Provider satisfaction

“Clinical Decision Support”

Ongoing Efforts

� Academic Partnership with YMCA of Dane County

� 2-year partnership grant

� Assess community readiness, coalition self-assessment through the Alliance for a Healthy South

Madison

� Create novel, community-based integrated programs

to help women achieve healthy weight gain

� Funding for this project is provided by the UW

School of Medicine and Public Health from the

Wisconsin Partnership Program

Closing Statements

� Excess weight gain in pregnancy poses serious short and long-term health risks for women and

children

� Counseling women about healthy weight gain in pregnancy should be consistent and based on the

most current national guidelines

� EMR systems may be an effective tool for improvinggestational weight gain counseling and may promote

best practices via clinical decision support

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Acknowledgements� Natalie Abts, Industrial Engineering Intern

� Greg Bills, MD, Division Director

� Heather Groene, Epic Support

� Catherine James, MD, DFM

� Sally Kraft, MD, Quality Improvement Guru

� David Queoff, MD, DFM

� Laurel Rice, MD, Chairperson

� Maureen Smith, MD, MPH, PhD, Health Innovation Program

� Jodi Wagner, CNM

� Lori Wollet, Office of Clinical Trials

This work was funded by the UW Health Ambulatory Care Innovation Grant Program,

supported by the University of Wisconsin Medical Foundation and Physicians Plus Insurance

Corporation.