Documentation of body mass index and control of associated risk factors in a large primary care network

  • Stephanie A Rose1Email author,

    Affiliated with

    • Alexander Turchin2,

      Affiliated with

      • Richard W Grant3 and

        Affiliated with

        • James B Meigs4

          Affiliated with

          BMC Health Services Research20099:236

          DOI: 10.1186/1472-6963-9-236

          Received: 17 May 2009

          Accepted: 16 December 2009

          Published: 16 December 2009

          Abstract

          Background

          Body mass index (BMI) will be a reportable health measure in the United States (US) through implementation of Healthcare Effectiveness Data and Information Set (HEDIS) guidelines. We evaluated current documentation of BMI, and documentation and control of associated risk factors by BMI category, based on electronic health records from a 12-clinic primary care network.

          Methods

          We conducted a cross-sectional analysis of 79,947 active network patients greater than 18 years of age seen between 7/05 - 12/06. We defined BMI category as normal weight (NW, 18-24.9 kg/m2), overweight (OW, 25-29.9), and obese (OB, ≥ 30). We measured documentation (yes/no) and control (above/below) of the following three risk factors: blood pressure (BP) ≤130/≤85 mmHg, low-density lipoprotein (LDL) ≤130 mg/dL (3.367 mmol/L), and fasting glucose <100 mg/dL (5.55 mmol/L) or casual glucose <200 mg/dL (11.1 mmol/L).

          Results

          BMI was documented in 48,376 patients (61%, range 34-94%), distributed as 30% OB, 34% OW, and 36% NW. Documentation of all three risk factors was higher in obesity (OB = 58%, OW = 54%, NW = 41%, p for trend <0.0001), but control of all three was lower (OB = 44%, OW = 49%, NW = 62%, p = 0.0001). The presence of cardiovascular disease (CVD) or diabetes modified some associations with obesity, and OB patients with CVD or diabetes had low rates of control of all three risk factors (CVD: OB = 49%, OW = 50%, NW = 56%; diabetes: OB = 42%, OW = 47%, NW = 48%, p < 0.0001 for adiposity-CVD or diabetes interaction).

          Conclusions

          In a large primary care network BMI documentation has been incomplete and for patients with BMI measured, risk factor control has been poorer in obese patients compared with NW, even in those with obesity and CVD or diabetes. Better knowledge of BMI could provide an opportunity for improved quality in obesity care.

          Background

          Obesity is a common problem in the United States that independently confers risk for chronic disease and early mortality [1]. Several studies address the importance of recognition and treatment of obesity in chronic disease management, but few evaluate body mass index (BMI) assessment and risk factor documentation and control in patients who are obese both with and without cardiovascular disease (CVD), diabetes or risk factors [26].

          Assessments of BMI and CVD or diabetes risk factors are simple, inexpensive tools that can be used by primary care physicians (PCPs) to address obesity and its complications. Little consensus exists in current guidelines concerning the need to screen for BMI and associated risk factors [715]. In 1998 the National Heart, Lung, and Blood Institute (NHLBI) established guidelines for BMI and risk factor measurement in all patients under 80 years of age with the goal of implementation of strategies for weight loss and risk factor control in patients with a BMI of ≥ 30 kg/m2 or 25-29.9 kg/m2 and ≥ two risk factors [10]. In 2007 the National Committee for Quality Assurance (NCQA) organized field tests of a prospective Healthcare Effectiveness Data and Information Set (HEDIS) measure to assess the percentage of members 18-74 years of age with an outpatient visit, and who had BMI documented and risk factors documented if found to have a BMI of ≥30 kg/m2 [16]. Their work led to the proposed HEDIS 2009 measure BMI Assessment [17], which is proposed for reporting by commercial, Medicaid, and Medicare plans.

          Given the magnitude and clinical impact of the current obesity epidemic and its risk factors, and the potential implementation of the HEDIS BMI Assessment measure, we aimed to examine current care in BMI and risk factor assessment for patients in a large network of primary care practices that use a common electronic health record (EHR). We investigated the prevalence of BMI measurement and documentation and control of the CVD and diabetes risk factors blood pressure (BP), low density lipoprotein (LDL), and fasting and casual glucose. We examined these risk factors according to the BMI categories normal weight, overweight, and obese. We hypothesized that documentation of BMI would vary widely in clinical practice, and that patients who were obese would be more likely to have better documentation, but poorer control, of risk factors than patients of normal weight.

          Methods

          Setting and Patients

          We identified 138,933 patients in our primary care research network of twelve practices that make up the Massachusetts General Hospital Primary Care Practice Based Research Network (PBRN). Practices include urban academic faculty practices, private offices, and community health centers in and around Boston, Massachusetts. These twelve practices use a common EHR that contains all clinical and utilization data for each patient. The data from the EHR data are searchable in the Research Patient Data Repository (RPDR) [18]. From these, we included 79,947 patients who were at least 18 years of age and had at least two clinic visits billed to their PCP between 7/1/05 and 12/31/06, and did not have a height greater than or equal to seven feet (2.13 meters), weight <70 or >1000 pounds (<31.8 or >453.6 kilograms), systolic BP <50 or >260 mmHg, or diastolic BP <30 or >150 mmHg. The study was approved by the Partners Health Care System Institutional Review Board.

          BMI Measurement

          The intent of the HEDIS initiative is to measure and increase documentation of BMI. We obtained BMI from height and weight data recorded in the EHR, where they are used to automatically calculate and display BMI. For this analysis we calculated BMI from the most recent weight in the 18-month period and the most recent height prior to 12/31/06 from structured coded entries in the EHR. For completeness, we also searched the text of narrative notes in the EHR using a validated Natural Language Processing abstraction tool that computationally abstracts weight, height, and BP values from the free text of clinician notes [19, 20]. The sensitivity and specificity of the approach to abstraction (compared with a trained chart abstractor) are 87.9% and 99% for detection of height, 91.8% and 92.1% for detection of weight, and 91% and 96% for detection of BP [19, 20]. Because of high rates of missing heights, we confirmed with clinic site medical directors that we had searched in all the appropriate places in the clincial record for height and weight information.

          We categorized BMI using Centers for Disease Control (CDC) definitions, with underweight equal to BMI <18.5 kg/m2, normal weight equal to a BMI of 18.5-<25 kg/m2, overweight BMI equal to 25-<30 kg/m2, and obese BMI ≤30 kg/m2 [21]. We included underweight patients when measuring documentation of BMI, but excluded them otherwise. Among those with a documented BMI, we examined documentation and control of three risk factors: blood pressure (BP), LDL cholesterol, and fasting or casual glucose levels, or both. We examined risk factor documentation and control in the clinic population overall, and stratified by three BMI categories.

          Risk Factor, CVD, and Diabetes Measurement

          Documentation of a risk factor was defined as being found in the EHR at least once within the study period. If a risk factor was documented more than once, we used the most recently documented value. A risk factor was defined as controlled if within normal range, defined as: BP ≤130/≤85 mmHg, LDL<130 mg/dL (3.367 mmol/L), and fasting glucose <100 mg/dL (5.55 mmol/L) or casual glucose <200 mg/dL (11.1 mmol/L) [2224]. We also measured documentation and control of all three risk factors combined as an aggregate measure of risk factor management.

          We defined clinical CVD as coronary artery disease, cerebrovascular accident, or peripheral vascular disease listed on the EHR Problem List, or as having two outpatient or one inpatient International Classification of Diseases, Ninth Revision (ICD-9) codes for CVD. We defined clinical diabetes as diabetes on the EHR problem list and a diabetes medication on the medication list, or as having two outpatient or one inpatient codes related to diabetes. The definitions of diabetes, hypertension, hyperlipidemia and CVD have previously been validated [25, 26]. For instance, the sensitivity of our approach for diabetes or CVD are >98% and specificity of >97% compared to the gold standard of trained research nurse chart abstraction. We used the same approach as for diabetes to define hypertension and hyperlipidemia. Other measurements included age, race, gender, number of PCP visits during the study period, insurance type, and clinic site.

          Statistical Analysis

          We conducted a cross-sectional analysis. We measured rates of BMI documentation in each clinic site and overall. Among those with a BMI, we measured risk factor documentation and control overall, and stratified by the three BMI categories. We further stratified the analysis by the presence or absence of CVD or diabetes. We used generalized linear models or chi-square tests to test levels or rates of characteristics by BMI category. We used the Breslow Day test for homogeneity of odds ratios to test for effect modification of CVD or diabetes on the association of BMI with risk factor documentation and control. We used SAS version 9.1 (Cary, NC) for all analyses, and considered a p value of <0.05 to indicate statistical significance.

          Results

          BMI Documentation and Characteristics of Patients with Documented BMI

          Of 79,947 patients, 72,633 (90.9%) had an available weight, 50,345 (63.0%) had an available height, and 48,376 (60.5%) had both height and weight recorded to calculate BMI (Table 1). Of those with BMI present, 14,290 patients (30%) were classified as obese, 16,402 (34%) overweight, 16,936 (36%) normal weight, and 748 (2%) underweight. Compared to those missing BMI, patients with BMI documented were younger, had a higher mean number of PCP visits, were more likely to be women, and were more likely to have commercial insurance or Medicare than patients without a BMI (p < 0.0001 for all; Table 2). As expected, patients with obesity were older, less likely to be women, white, or to have private insurance or Medicare, had a higher mean number of PCP visits, and were more likely to have a history of CVD, diabetes, hypertension, and dyslipidemia than patients of normal weight (p < 0.0001 for all; Table 3).
          Table 1

          Body Mass Index Documentation in 79,947 Patients in 12 Primary Care Clinics

          Clinic

          N

          BMI

          Height Documented

          Weight Documented

            

          %

          %

          %

          1

          3,027

          93.5

          94.1

          99.1

          2

          4,559

          89.8

          95.7

          91.6

          3

          3,274

          86.9

          87.5

          99.1

          4

          3,989

          85.8

          94.5

          87.4

          5

          1,344

          75.1

          75.2

          99.5

          6

          7,747

          65.8

          66.0

          99.0

          7

          21,299

          64.0

          65.8

          96.1

          8

          3,962

          55.4

          55.8

          98.7

          9

          12,919

          50.2

          55.4

          71.1

          10

          4,781

          41.9

          44.4

          78.4

          11

          8,052

          38.2

          38.3

          99.0

          12

          4,994

          34.0

          35.7

          88.9

          Total

          48,376

          60.5

          63.0

          90.9

          Data are ranked by BMI documentation rate, include patients at least 18 years of age with at least two clinic visits billed to their PCP between 7/1/05 and 12/31/06, and include underweight patients (BMI <18.5 kg/m2) excluded from the main analysis. BMI = Body Mass Index (weight in kilograms/height in meters2)

          Table 2

          Patient Demographics and Clinical Characteristics in 79,947 Patients in 12 Primary Care Clinics by Documentation or Missingness of BMI

          Characteristic

            

          BMI Documented

          48,376

          BMI not Documented

          31,571

          P value

          Clinic

          n

          %

              

          <0.0001

             1

            

          2,830

          5.9

          197

          0.6

           

             2

            

          4,093

          8.5

          466

          1.5

           

             3

            

          2,844

          5.9

          430

          1.4

           

             4

            

          3,421

          7.1

          568

          1.8

           

             5

            

          1,009

          2.1

          335

          1.1

           

             6

            

          5,095

          10.5

          2,652

          8.4

           

             7

            

          13,630

          28.2

          7,669

          24.3

           

             8

            

          2,194

          4.5

          1,768

          5.6

           

             9

            

          6,489

          13.4

          6,431

          20.4

           

             10

            

          2,003

          4.1

          2,778

          8.8

           

             11

            

          3,073

          6.4

          4,979

          15.8

           

             12

            

          1,696

          3.5

          3,298

          10.5

           

          Age

          mean years

          51

           

          53

           

          <0.0001

          Women

          n

          %

          31,412

          64.9

          15,986

          50.6

          <0.0001

          Race

          n

          %

              

          <0.0001

             White

            

          37,625

          77.8

          25,264

          80.0

           

             Asian

            

          2,057

          4.3

          1,426

          4.5

           

             Black

            

          2,908

          6.0

          1,464

          4.6

           

             Hispanic

            

          4,123

          8.5

          2,397

          7.6

           

          Number of PCP visits

          mean

          range

          4.2

          (2-61)

          3.9

          (2-56)

          <0.0001

          Commercial Insurance or Medicare

          n

          %

          42,740

          88.4

          27,522

          87.2

          <0.0001

          History of CVD

          n

          %

          7,298

          15.1

          4,989

          15.8

          0.0060

          History of diabetes

          n

          %

          5,872

          12.1

          3,453

          10.9

          <0.0001

          History of hypertension

          n

          %

          22,121

          45.7

          14,698

          46.6

          0.02

          History of dyslipidemia

          n

          %

          25,698

          53.1

          17,133

          54.3

          0.002

          HbA1c

          %

           

          6.7

           

          6.8

           

          0.0001

          Blood pressure

          mean mmHg

          122/75

           

          123/74

           

          <0.0001

          Total cholesterol

          mean mg/dL (mmol/L)

          188.1 (4.87)

           

          188.5 (4.88)

           

          0.29

          LDL

          mean mg/dL (mmol/L)

          104.1 (2.70)

           

          105 (2.72)

           

          0.001

          HDL

          mean mg/dL (mmol/L)

          59.3 (1.54)

           

          57.8 (1.50)

           

          <0.0001

          Triglyceride level

          mean mg/dL (mmol/L)

          127.8 (1.44)

           

          132.6 (1.50)

           

          <0.0001

          Casual glucose

          mean mg/dL (mmol/L)

          101.8 (5.65)

           

          100.8 (5.59)

           

          0.0007

          Fasting glucose

          mean mg/dL (mmol/L)

          102.4 (5.68)

           

          100.9 (5.60)

           

          0.0007

          Risk factor documentation

          Total n

          %

               

          Blood Pressure

          64,204

          80.3

          37,489

          77.5

          26,715

          84.6

          <0.0001

          LDL

          55,210

          69.1

          33,788

          69.8

          21,422

          67.9

          <0.0001

          Casual glucose

          56,984

          71.3

          35,125

          72.6

          21,859

          69.2

          <0.0001

          Fasting glucose

          21,533

          26.9

          13,533

          28.0

          8,000

          25.3

          <0.0001

          HbA1c

          14,252

          17.8

          9,367

          19.4

          4,885

          15.5

          <0.0001

          Total cholesterol

          58,951

          73.7

          36,247

          74.9

          22,704

          71.9

          <0.0001

          HDL

          58,373

          73.0

          35,874

          74.2

          22,499

          71.3

          <0.0001

          Triglycerides

          55,948

          70.0

          34,247

          70.8

          21,701

          68.7

          <0.0001

          Risk factor control in those with documented risk factor

          Total n

          %

               

          Blood Pressure <130 and < 85 mmHg

          46,748

          72.8

          27,212

          72.6

          19,536

          73.1

          0.13

          LDL <130 mg/dL

          43,369

          78.6

          26,656

          78.9

          16,713

          78.0

          0.015

          Casual glucose < 200 mg/dL

          55,642

          97.6

          34,231

          97.5

          21,411

          98.0

          0.0001

          Fasting glucose < 100 mg/dL

          13,782

          64.0

          8,574

          63.4

          5,208

          65.1

          0.01

          HbA1c <7%

          9,638

          67.6

          6,463

          69.0

          3,175

          65.0

          <0.0001

          Total cholesterol <200 mg/dL

          37,279

          63.2

          22,952

          63.3

          14,327

          63.1

          0.59

          HDL >35 mg/dL (male) and >40 mg/dL (female)

          52,971

          90.8

          32,742

          91.3

          20,229

          89.9

          <0.0001

          Triglycerides <150 mg/dL

          48,188

          86.1

          29,675

          86.7

          18,513

          85.3

          <0.0001

          P-value compares BMI documented with BMI not documented. BMI = Body Mass Index (weight in kilograms/height in meters2), PCP = Primary Care Physician, CVD = Cardiovascular Disease, HbA1c = Hemoglobin A1C, LDL=low density lipoprotein cholesterol, HDL = high density lipoprotein cholesterol. LDL <130 mg/dL = <3.367 mmol/L; casual glucose <200 mg/dL = <5.55 mmol/L; fasting glucose <100 mg/dL = <11.1 mmol/L

          Table 3

          Characteristics of 47,628 Primary Care Patients by BMI Category

          Characteristic

           

          Obese

          n = 14,290

          Overweight

          n = 16,402

          Normal

          n = 16,936

          P value

          Age

          (mean years)

          53

          53

          48

          <0.0001

          Number of PCP visits

          (mean)

          4.7

          4.2

          3.9

          <0.0001

          Women

          n (%)

          8,565

          59.9

          8,899

          54.3

          13,272

          78.4

          <0.0001

          Race*

          n (%)

                

          <0.0001

             White

           

          10,712

          75.0

          12,674

          77.3

          13,655

          80.6

           

             Asian

           

          179

          1.3

          567

          3.5

          1,229

          7.3

           

             Black

           

          1,244

          8.7

          989

          6.0

          649

          3.8

           

             Hispanic

           

          1,722

          12.1

          1,561

          9.5

          811

          4.8

           

          Private Insurance or Medicare

          n (%)

          12,104

          84.7

          14,502

          88.4

          15,467

          91.3

          <0.0001

          History of CVD

          n (%)

          2,647

          18.5

          2,699

          16.5

          1,862

          11.0

          <0.0001

          History of diabetes

          n (%)

          3,238

          22.7

          1,789

          10.9

          824

          4.9

          <0.0001

          History of hypertension

          n (%)

          9,116

          63.8

          7,895

          48.1

          4,931

          29.1

          <0.0001

          History of dyslipidemia

          n (%)

          9,235

          64.6

          9,495

          57.9

          6,769

          40.0

          <0.0001

          P-value is for general association across BMI categories. BMI = Body Mass Index (weight in kilograms/height in meters2), PCP = Primary Care Physician, and CVD = Cardiovascular Disease. *Designation "Other" for race deleted from set.

          Documentation and Control of Risk Factors

          Overall, less than 78% had at least one risk factor documented and just half had all three documented (Table 4, Figure 1). Of these, about half of all patients had all three risk factors controlled (Figure 1). Documentation of all three risk factors was higher in obesity than in overweight or normal weight (p < 0.0001), but control of all three risk factors was lower, (p < 0.0001), with only 44% of patients with obesity having all risk factors under control.
          Table 4

          Documentation and Control of Risk Factors among 47,628 Primary Care Patients, by BMI Category

          Risk Factor Documentation

          Total

          n = 47,628

          Obese

          n = 14,290

          Overweight

          n = 16,402

          Normal

          n = 16,936

          P value

           

          n

          %

          n

          %

          n

          %

          n

          %

           

          BP

          36,934

          77.6

          10,900

          76.3

          12,890

          78.6

          13,144

          77.6

          <0.0001

          LDL

          33,427

          70.2

          11,239

          78.7

          12,013

          73.2

          10,175

          60.1

          <0.0001

          Casual Glucose

          34,589

          72.6

          11,216

          78.5

          11,901

          72.6

          11,472

          67.7

          <0.0001

          Fasting Glucose

          13,421

          28.2

          5,347

          37.4

          4,804

          29.3

          3,270

          19.3

          <0.0001

          Risk Factor Control

          Total

          Obese

          Overweight

          Normal

          P value

           

          n

          %

          n

          %

          n

          %

          n

          %

           

          BP <130 and < 85 mmHg

          26,736

          72.4

          6,801

          62.4

          9,202

          71.4

          10,733

          81.7

          <0.0001

          LDL <130 mg/dL

          26,328

          78.8

          8,777

          78.1

          9,273

          77.2

          8,278

          81.4

          <0.0001

          Casual glucose < 200 mg/dL

          33,698

          97.4

          10,707

          95.5

          11,635

          97.8

          11,356

          99.0

          <0.0001

          Fasting glucose < 100 mg/dL

          8,482

          63.2

          2,753

          51.5

          3,146

          65.5

          2,583

          79.0

          <0.0001

          P-value is for general association across BMI categories. BMI=Body Mass Index (weight in kilograms/height in meters²); LDL <130 mg/dL=<3.367 mmol/L; casual glucose <200 mg/dL=<5.55 mmol/L; fasting glucose <100 mg/dL=<11.1 mmol/L.

          http://static-content.springer.com/image/art%3A10.1186%2F1472-6963-9-236/MediaObjects/12913_2009_Article_1107_Fig1_HTML.jpg
          Figure 1

          Documentation and control of all three risk factors by BMI category. A. Documentation of all 3 risk factors by BMI category; B. Documentation of all 3 risk factors by BMI category, stratified by history of CVD; C. Documentation of all 3 risk factors by BMI category, stratified by history of diabetes. D. Control of all 3 risk factors by BMI category; E. Control of all 3 risk factors by BMI category, stratified by history of CVD; F. Control of all 3 risk factors by BMI category, stratified by history of diabetes.

          The presence of CVD or diabetes modified some associations of BMI category with risk factor documentation and control. In patients with CVD or diabetes, the rates of documentation were generally less different comparing patients with obesity with those of normal weight, while in patients without CVD or diabetes, rates of documentation were strikingly higher in patients with obesity than normal weight (Figure 1, Table 5, p = 0.26 to <0.0001 for CVD- or diabetes-by-BMI category interaction). Likewise, in patients with CVD or diabetes the rates of control were generally less different comparing patients with obesity with those with normal weight, but in patients without CVD or diabetes, rates of control were strikingly lower in patients with obesity than normal weight (Figure 1, Table 6). Overall 50% or fewer of the patients with obesity and CVD or diabetes had all three risk factors under control (Figure 1, Tables 5 and 6).
          Table 5

          Documentation of Risk Factors in 47,628 Patients in 12 Primary Care Clinics Stratified by BMI Category and History of CVD or Diabetes

          Risk Factors

          Total

          Obese

          n = 14,290

          Overweight

          n = 16,402

          Normal Weight

          n = 16,936

          P value

          History of CVD

          n

          %

          n

          %

          n

          %

          n

          %

           

             H/O CVD n = 7,208

            

          H/O CVD N = 2,647

          H/O CVD N = 2,699

          H/O CVD N = 1,862

           

             NO H/O CVD n = 40,420

            

          No H/O CVD N = 11,643

          NO H/O CVD N = 13,703

          NO H/O CVD N = 15,074

           

          BP

            

          n = 10,900

          n = 12,890

          n = 13,144

           

             H/O CVD

          5,297

          73.5

          1,931

          73.0

          1,991

          73.8

          1,375

          73.9

          0.26

             NO H/O CVD

          31,637

          78.3

          8,969

          77.0

          10,899

          79.5

          11,769

          78.1

           

          LDL

            

          n = 11,239

          n = 12,013

          n = 10,175

           

             H/O CVD

          6,199

          86.0

          2,393

          90.4

          2,358

          87.4

          1,448

          77.8

          0.15

             NO H/O CVD

          27,228

          67.4

          8,846

          76.0

          9,655

          70.5

          8,727

          57.9

           

          Casual glucose

            

          n = 11,216

          n = 11,901

          n = 11,472

           

             H/O CVD

          6,305

          87.5

          2,355

          89.0

          2,322

          86.0

          1,628

          87.4

          0.0001

             NO H/O CVD

          28,284

          70.0

          8,861

          76.1

          9,579

          69.9

          9,844

          65.3

           

          Fasting glucose

            

          n = 5,347

          n = 4,804

          n = 3,270

           

             H/O CVD

          2,741

          38.0

          1,158

          43.8

          1,023

          37.9

          560

          30.1

          <0.0001

             NO H/O CVD

          10,680

          26.4

          4,189

          36.0

          3,781

          27.6

          2,710

          18.0

           

          All 3 risk factors

            

          n = 8,247

          n = 8,797

          n = 6,986

           

             H/O CVD

          4,417

          61.3

          1,696

          64.1

          1,693

          62.7

          1,028

          55.2

          <0.0001

             NO H/O CVD

          19,613

          48.5

          6,551

          56.3

          7,104

          51.8

          5,958

          39.5

           

          History of DM

            

          n

          %

          n

          %

          n

          %

           

             H/O diabetes n = 5,851

            

          H/O diabetes N = 3,238

          H/O diabetes N = 1,789

          H/O diabetes N = 824

           

          NO H/O diabetes

          n = 41,777

            

          NO H/O diabetes N = 11,052

          NO H/O diabetes N = 14,613

          NO H/O diabetes N = 16,112

           

          BP

            

          n = 10,900

          n = 12,890

          n = 13,144

           

             H/O diabetes

          4,398

          75.2

          2,447

          75.6

          1,366

          76.4

          585

          71.0

          0.002

             NO H/O diabetes

          32,536

          77.9

          8,453

          76.5

          11,524

          78.9

          12,559

          78.0

           

          LDL

            

          n = 11,239

          n = 12,013

          n = 10,175

           

             H/O diabetes

          5,285

          90.3

          2,963

          91.5

          1,617

          90.4

          705

          86.2

          0.51

             NO H/O diabetes

          28,142

          67.4

          8,276

          74.9

          10,396

          71.1

          9,470

          58.8

           

          Casual glucose

            

          n = 11,216

          n = 11,901

          n = 11,472

           

             H/O diabetes

          5,225

          89.3

          2,884

          89.1

          1,596

          89.2

          745

          90.4

          <0.0001

             NO H/O diabetes

          29,634

          70.9

          8,332

          75.4

          10,305

          70.5

          10,727

          66.6

           

          Fasting glucose

            

          n = 5,347

          n = 4,804

          n = 3,270

           

             H/O diabetes

          2,736

          46.8

          1,619

          50.0

          812

          45.4

          305

          37.0

          0.003

             NO H/O diabetes

          10,685

          25.6

          3,728

          33.7

          3,992

          27.3

          2,965

          18.4

           

          All 3 risk factors

            

          n = 8,247

          n = 8,797

          n = 6,986

           

             H/O diabetes

          3,936

          67.3

          2,197

          67.9

          1,240

          69.3

          499

          60.6

          0.001

             NO H/O diabetes

          20,094

          48.1

          6,050

          54.7

          7,557

          51.7

          6,487

          40.3

           

          P-value compares homogeneity of odds ratios across groups. CVD = Cardiovascular Disease, BMI = Body Mass Index (weight in kilograms/height in meters2), BP = Blood Pressure, LDL = low density lipoprotein cholesterol, HDL = high density lipoprotein cholesterol. All 3 risk factors documented = documentation of BP + LDL + casual OR fasting glucose. Numbers and percentages in table reflect percentage of risk factor documented by BMI type in patients either with or without a history of CVD or DM (i.e., 1,931 = 73% of 2,647 patients who are obese with BP documented with a history of CVD).

          Table 6

          Control of Risk Factors in 47,628 Patients in 12 Primary Care Clinics Stratified by BMI Category and History of CVD or Diabetes

          Outcome

          Total Documented

           

          Total Controlled

           

          Obese

           

          Overweight

           

          Normal

           

          P value

          History of CVD

          n

          %

          n

          %

          n

          %

          n

          %

          n

          %

           

          H/O CVD n = 7,208

                     

          NO H/O CVD

          n = 40,420

                     

          BP < 130 and < 85 mmHg

              

          H/O CVD N = 1,931

          H/O CVD N = 1,991

          H/O CVD N = 1,375

           
               

          NO H/O CVD 8,969

          NO H/O CVD N = 10,899

          NO H/O CVD N = 11,769

           
               

          n = 6,801

          n = 9,202

          n = 10,733

           

             H/O CVD

          5,297

          73.5

          3,338

          63.0

          1,155

          59.8

          1,256

          63.1

          927

          67.4

          <0.0001

             NO H/O CVD

          31,637

          78.3

          23,399

          74.0

          5,647

          63.0

          7,946

          72.9

          9,806

          83.3

           

          LDL < 130 md/dL

              

          H/O CVD N = 2,393

          H/O CVD N = 2,358

          H/O CVD N = 1,448

           
               

          NO H/O CVD N = 8,846

          NO H/O CVD N = 9,655

          NO H/O CVD N = 6,989

           
               

          n = 8,777

          n = 9,273

          n = 8,278

           

             H/O CVD

          6,199

          86.0

          5,515

          89.0

          2,152

          89.9

          2,074

          88.0

          1,289

          89.0

          0.002

             NO H/O CVD

          27,228

          67.4

          20,813

          76.4

          6,625

          74.9

          7,199

          74.6

          6,989

          80.1

           

          Casual glucose < 200 mg/dL

              

          H/O CVD N = 2,355

          H/O CVD N = 2,322

          H/O CVD N = 1,628

           
               

          NO H/O CVD N = 8,861

          NO H/O CVD N = 9,579

          NO H/O CVD N = 9,844

           
               

          n = 10,707

          n = 11,635

          n = 11,356

           

             H/O CVD

          6,305

          87.5

          5,979

          94.8

          2,173

          92.3

          2,218

          95.5

          1,588

          97.5

          0.13

             NO H/O CVD

          28,284

          70.0

          27,719

          98.0

          8,534

          96.3

          9,417

          98.3

          9,768

          99.2

           

          Fasting glucose < 100 mg/dL

              

          H/O CVD N = 1,158

          H/O CVD N = 1,023

          H/O CVD N = 560

           
               

          NO H/O CVD N = 4,189

          NO H/O CVD N = 3,781

          NO H/O CVD N = 2,710

           
               

          n = 2,753

          n = 3,146

          n = 2,583

           

             H/O CVD

          2,741

          38.0

          1,325

          48.3

          415

          35.8

          561

          54.8

          349

          62.3

          0.0005

             NO H/O CVD

          10,680

          26.4

          7,157

          67.0

          2,338

          55.8

          2,585

          68.4

          2,234

          82.4

           

          All 3 risk factors

              

          H/O CVD N = 829

          H/O CVD N = 1,693

          H/O CVD N = 1,028

           
               

          NO H/O CVD N = 2,767

          NO H/O CVD N = 7,104

          NO H/O CVD N = 5,958

           
               

          n = 3,596

          n = 4,344

          n = 4,327

           

             H/O CVD

          4,417

          61.3

          2,252

          51.0

          829

          48.9

          850

          50.2

          573

          55.7

          <0.0001

             NO H/O CVD

          19,613

          48.5

          10,015

          51.1

          2,767

          42.2

          3,494

          49.2

          3,754

          63.0

           

          History of diabetes

                     

          H/O diabetes n = 5,851

                     

          NO H/O diabetes n = 41,777

                     

          BP < 130 and < 85 mmHg

              

          H/O diabetes N = 2,447

          H/O diabetes N = 1,366

          H/O diabetes N = 585

           
               

          NO H/O diabetes 8,453

          NO H/O diabetes N = 11,524

          NO H/O diabetes N = 12,559

           
               

          n = 6,801

          n = 9,202

          n = 10,733

           

             H/O diabetes

          4,398

          75.2

          2,775

          63.1

          1,476

          60.3

          919

          67.3

          380

          65.0

          <0.0001

             NO H/O diabetes

          32,536

          77.9

          23,961

          73.6

          5,325

          63.0

          8,283

          71.9

          10,353

          82

           

          LDL < 130 md/dL

              

          H/O diabetes N = 2,963

          H/O diabetes N = 1,617

          H/O diabetes N = 705

           
               

          NO H/O diabetes N = 8,276

          NO H/O diabetes N = 10,396

          NO H/O diabetes N = 9,470

           
               

          n = 8,777

          n = 9,273

          n = 8,278

           

             H/O diabetes

          5,285

          90.3

          4,746

          89.8

          2,635

          88.9

          1,462

          90.4

          649

          92.1

          0.57

             NO H/O diabetes

          28,142

          67.4

          21,583

          76.7

          6,143

          74.2

          7,811

          75.1

          7,629

          80.6

           

          Casual glucose < 200 mg/dL

              

          H/O diabetes N = 2,884

          H/O diabetes N = 1,596

          H/O diabetes N = 745

           
               

          NO H/O diabetes N = 8,332

          NO H/O diabetes N = 10,305

          NO H/O diabetes N = 10,727

           
               

          n = 10,707

          n = 11,635

          n = 11,356

           

             H/O diabetes

          5,225

          89.3

          4,383

          83.9

          2,400

          83.2

          1,342

          84.1

          641

          86.0

          0.015

             NO H/O diabetes

          29,634

          70.9

          29,315

          98.9

          8,307

          99.7

          10,293

          99.9

          10,715

          99.9

           

          Fasting glucose < 100 mg/dL

              

          H/O diabetes N = 1,619

           

          H/O diabetes N = 812

           

          H/O diabetes N = 305

           

          0.24

               

          NO H/O diabetes N = 3,728

           

          NO H/O diabetes N = 3,992

           

          NO H/O diabetes 2,965

            
               

          n = 2,753

          n = 3,146

          n = 2,583

           

             H/O diabetes

          2,736

          46.8

          554

          20.2

          285

          17.6

          170

          20.9

          99

          32.5

           

             NO H/O diabetes

          10,685

          25.6

          7,928

          74.2

          2,468

          66.2

          2,976

          74.6

          2,484

          83.8

           

          All 3 risk factors

              

          H/O diabetes N = 2,197

          H/O diabetes N = 1,240

          H/O diabetes N = 499

          <0.0001

               

          NO H/O diabetes N = 6,050

          NO H/O diabetes N = 7,557

          NO H/O diabetes N = 6,487

           
               

          n = 3,596

          n = 4,344

          n = 4,327

           

             H/O diabetes

          3,936

          67.3

          1,754

          44.6

          929

          42.3

          587

          47.3

          238

          47.7

           

             NO H/O diabetes

          20,094

          48.1

          10,513

          52.3

          2,667

          44.1

          3,757

          49.7

          4,089

          63.0

           

          P-value compares homogeneity of the odds ratios across groups. CVD = Cardiovascular Disease, BMI = Body Mass Index (weight in kilograms/height in meters2), BP = Blood Pressure, LDL = Low density lipoprotein cholesterol, HDL = High density lipoprotein cholesterol. Risk factor control rates are from patients with risk factors documented. Numbers and percentages in table reflect percentage of risk factor documented by BMI type in patients either with or without a history of CVD or DM (i.e., 1,931 = 73% of 2,647 patients who are obese with BP documented with a history of CVD). All 3 risk factors controlled = control of BP + LDL + casual OR fasting glucose. Documentation or control of all 3 risk factors defined as BP, LDL, and fasting or casual glucose below the thresholds indicated.

          Discussion

          We examined the current state of BMI documentation and documentation and control of associated risk factors by BMI category, based on EHR data from almost 80,000 adult patients seen in a 12-clinic primary care network during 18 months in 2005-2006. Our findings demonstrate variations in risk factor recognition and control for obese persons compared to those of normal weight, as well as for those with and without CVD or type 2 diabetes. We found that documentation of BMI varied widely by clinic site and was overall low. Among patients with a BMI recorded, documentation of most risk factors was higher in patients with obesity compared with normal weight patients; however, control of risk factors was poorer in obesity than normal weight. Patients without a documented history of CVD or diabetes had strikingly more dissimilar rates of documentation and control between weight categories than patients with CVD or diabetes. Overall, patients with obesity with or without CVD or diabetes had lower rates of risk factor documentation and control than may be ideal given their high absolute risk of adverse health outcomes.

          Our study builds upon findings from previous studies. Lemay et al audited medical records from 465 adult patients seen at a community health center during one week in February of 1999 to evaluate height and weight documentation and obesity diagnosis by the practitioner over a prior six-month period, and found that only 63% of their patient cohort had a height and weight documented [27]. Similar to our study, Lemay looked a group of patients in normal clinical practice; however, we were able to expand upon this study in terms of a far larger study sample as well as a longer sampling frame to assess provision of services (18 months versus 6 months), potentially providing a more accurate picture of risk factor evaluation. Six years after this study and seven years after the establishment of the NHLBI guidelines, we found the percentage of BMI documentation to be essentially the same (63% versus 60.5%). Rifas-Shiman et al studied 5,025 members of the same insurance plan and group practice who were a subset of participants from a cohort study and were continuously enrolled since 1999, had a visit in 2000, had a BMI measurement between January 1, 2000 and December 31, 2000, and who did not have medical conditions related to weight loss or CVD. They found that higher BMI was an independent predictor of increased fasting glucose, triglyceride, LDL cholesterol, and HDL cholesterol screening [28]. Rifas-Shiman identified lipid and glucose abnormalities over a two-year period, comparable in time to our study. Neither we nor Rifas-Shiman could evaluate attempts at management, so reasons for increased documentation such as guideline adherence could not be assessed. Our analysis extends prior studies by evaluating whether those with documentation of risk factors had those risk factors in control according to Adult Treatment Panel III (ATP III) metabolic syndrome guidelines for a patient with average cardiovascular risk.

          Molenaar et al studied rates of treatment and control of hypercholesterolemia, hypertension, and diabetes in normal weight, overweight, and obese subjects with a history of these conditions utilizing a CVD-free subset of the Framingham Heart Study. They found that subjects with hypercholesterolemia and hypertension who were obese were more likely to have these conditions treated than normal weight subjects. Rates of control of hypertension and hypercholesterolemia were uniformly poor and did not differ between weight groups. Rates of control of diabetes were poor among all three weight groups, but subjects who were obese were less likely to have control of fasting blood glucose than normal weight subjects. The goal of our study, however, was different from that of Molenaar. Molenaar studied rates of treatment and control of hypercholesterolemia, hypertension, and diabetes in normal weight, overweight, and obese subjects with a history of these conditions who were free of CVD, a subgroup of patients with a clear indication for BMI screening. Our goal was to evaluate in all patients, both with and without obesity-associated risk factors, the current state of BMI screening and subsequent screening for associated risk factors by BMI group, according to HEDIS and NHLBI guidelines. Molenaar et al examined a well-known, standardized study population, where only 196 subjects had missing BMI data. Our population was a non-standardized data source, and our subjects were a mixture of both those with and without CVD and its risk factors, with further subanalysis in patients with a history of CVD and diabetes. Despite these differences, findings from the structured Framingham population and from our analysis of usual clinical care are strikingly similar. This minimizes to a large degree the concern that high rates of missing BMI information could have distorted our findings, and may explain why our percentages of control were higher than those found by Molenaar, albeit still low overall [29].

          The rapidly growing prevalence of obesity has pushed BMI assessment to appropriate prominence as a newly proposed reportable HEDIS measure. BMI assessment will be made by several means, including survey of EHRs in health care networks. Our results suggest that the HEDIS BMI Assessment measure has potential to provide a timely quality and safety foundation to improve care for patients with obesity. At least in our large primary care network, there clearly is substantial room for improvement in documentation of BMI and documentation and control of BMI-associated risk factors. While height and weight and BMI documentation may reflect individual physician practice styles, by speaking with medical directors we found that lack of height and weight appeared to be a clinic-level and not an individual PCP issue, with height and weight recording often performed or not performed before the PCP sees the patient. It is expected that introduction of the HEDIS BMI Assessment measure will improve this state of affairs, although the effectiveness of BMI documentation alone to improve care remains to be demonstrated.

          According to our study, patients with already documented CVD or diabetes are more likely to have risk factor documentation and control regardless of BMI category. Those without a documented history of CVD or diabetes demonstrated more variation in risk factor documentation and control by BMI category. At least two recent studies corroborate these data. Melamed et al measured BMI in 289 patients in seven family practice clinics in Israel, and found that BMI was documented in only half of obese patients and 39% of overweight patients, and that patients with other chronic medical conditions were more likely to have BMI documented than those without documented comorbidities [30]. Waring et al looked at 2,330 overweight and obese patients included in the Cholesterol Education and Research Trial, and found increased odds of overweight or obesity management in relation to weight-related comorbidities for those with moderate or severe obesity [31].

          Risk factor control appears to be related to a previously diagnosed risk factor and not to obesity. These findings become even more relevant in light of recent studies that demonstrate increased CVD risk in patients who are overweight and obese compared to normal weight patients, independent of hypertension and hypercholesterolemia [32]. This implies an important need to recognize overweight and obesity, ideally using a simple technique such as BMI, in order to enhance CVD and diabetes complications prevention. Our findings suggest that PCPs are aware of CVD, diabetes, and obesity as strongly tied risk factors, but that they may not recognize obesity as a risk factor for morbidity and mortality independent of these other comorbidities.

          Limitations

          Our results must be interpreted with some limitations in mind. This is clinical, not research, data, which naturally suffers from information that is missing and inconsistent in its recording. We carefully addressed missingness with multiple methods of ascertaining exposures, and addressed inconsistencies in data recording by removal of clinically illogical extreme outliers. Evaluation of BMI documentation rates, with the inherent missing data, was a goal of our study. Furthermore, despite its limitations, evaluation of clinical data is a strength of this study, in that it provides a glimpse into current obesity care and insights into improving this practice. Although our data were derived from a single academic health care network, the sites included a representative mixture of urban, suburban, and hospital-based practices, making our findings generalizable and potentially replicable. Another important strength of our study is the use of a long-standing, widely used EHR encompassing all aspects of patient care from a large network of diverse clinics and patient populations. EHRs, while not a perfect tool due to the potential for improperly entered or overlooked data, have great potential for research, with studies showing that EHRs have potential for increasing documentation and treatment of obese patients [33]. Finally while there were differences seen in the percentages of documentation of risk factors, this may be due mainly to test indication, whereby certain tests such as cholesterol levels are more likely to be ordered on most patients than fasting glucose. However, our overall documentation numbers were large enough to yield consistent results across BMI categories.

          Conclusions

          It is well-accepted that intentional weight loss mitigates many of the risk factors associated with obesity. Despite rising rates of obesity, physicians appear not to routinely assess BMI during office visits [34]. According to the NCQA, multiple organizations recommend measuring BMI as part of the routine physical examination [16, 9, 10, 14, 15]. Treatment recommendations for obesity depend on ascertainment of BMI and complications of obesity. Therefore, screening for BMI and comorbidities could change patient management. In light of new studies implicating overweight and obesity as independent risk factors for CVD, recognition of BMI becomes even more important in the primary care setting. We examined a large, diverse primary care network to evaluate current care and found that EHRs will be a useful tool to evaluate BMI assessment. We demonstrate substantial opportunities for improvement in the assessment and control of adiposity and associated risk factors that are needed to address the US obesity epidemic.

          Abbreviations

          (ATP III): 

          Adult Treatment Panel III

          (BP): 

          Blood Pressure

          (BMI): 

          Body Mass Index

          (CVD): 

          Cardiovascular disease

          (CDC): 

          Centers for Disease Control

          (EHR): 

          Electronic Health Record

          (HEDIS): 

          Healthcare Effectiveness Data and Information Set

          (ICD-9): 

          International Classification of Diseases, Ninth Revision

          (LDL): 

          Low-density Lipoprotein

          (MGH): 

          Massachusetts General Hospital

          (NCQA): 

          National Committee for Quality Assurance

          (NHLBI): 

          National Heart, Lung, and Blood Institute

          (NIDDK): 

          National Institute of Diabetes and Digestive and Kidney Diseases

          (NW): 

          Normal weight

          (OB): 

          Obese

          (OW): 

          Overweight

          (PBRN): 

          Practice-Based Research Network

          (PCP): 

          Primary Care Physician

          (RPDR): 

          Research Patient Data Repository

          (US): 

          United States.

          Declarations

          Acknowledgements

          We thank Peter Shrader and Amy Cohen for their assistance with the analysis, and Daniel Singer, M.D., for review and comment on an earlier draft of the manuscript. Dr. Rose was supported by an Institutional National Research Service Award #5 T32 HP11001-19. Dr. Grant was supported by an NIDDK Career Development Award (K23 DK067452). Dr. Meigs was supported by NIDDK K24 DK080140. Dr. Meigs currently has research grants from GlaxoSmithKline and sanofi-aventis, and has consulting agreements with GlaxoSmithKline, sanofi-aventis, Interleukin Genetics, Kalypsis, and Outcomes Science. This work has been presented in poster form at the New England Regional Society of General Internal Medicine Conference in March of 2008, the Massachusetts Medical Society Poster Symposium in April of 2008, where it was the Second Prize Winner for Clinical Research, the Massachusetts General Hospital Clinical Research Day in May of 2008, and the Obesity Society Annual Meeting on October 6, 2008.

          Authors’ Affiliations

          (1)
          Division of General Internal Medicine, University of Kentucky
          (2)
          Clinical Informatics Research and Development,and Division of Endocrinology, Harvard University,Brigham and Women's Hospital
          (3)
          General Medicine Division, Massachusetts General Hospital
          (4)
          General Medicine Division, Massachusetts General Hospital

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          35. Pre-publication history

            1. The pre-publication history for this paper can be accessed here:http://​www.​biomedcentral.​com/​1472-6963/​9/​236/​prepub

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          © Rose et al. 2009

          This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.