Improving Effective Screening and Management of Obesity in an Urgent Care Clinic

The Obesity Society ¹³ indicates obesity is not only a contributing factor to multiple health conditions but a chronic disease in its own right. Multiple agencies, including the AACE, American Heart Association, World Health Organization, and the National Institute for Health share the same consensus in guidelines that recommend the use of body mass index (BMI), waist circumference (WC), and additional patient risk factors in screening for obesity on a yearly basis ^{8, 14}. Best practices included encouraging physical activity, decreasing calorie intake, assessing readiness to change as well as barriers to change, screening for co-morbidities, monitoring medication therapy, and using pharmacotherapy with comprehensive lifestyle changes ^{3, 4, 14}. Nonetheless, there are numerous gaps in obesity care from screening recommendations, to diagnosis, to a consensus on what constitutes best practices in and how to standardize care.

Effective healthcare defined by the Institute of Medicine (IOM) focuses on aiding those who need it based on a specific set of data while avoiding misuse and underutilization ¹. Effective care was implemented utilizing SBIRT (screening, a brief intervention, and referral to treatment), which provides a concise, universal, and comprehensive framework. The aim of this quality improvement study was to increase effective care (screening, patient engagement, and referral to treatment) in adult patients with a BMI greater than 30 kg/m² to 75% within 90 days.

The project started with four core interventions related to screening, patient engagement, referral to treatment, and team engagement. All patients presenting for weight loss were screened with BMI and waist circumference for improved identification and management initiation. Patients were educated on the correlation between BMI and waist circumference, stressing the health risks of obesity. Each patient was asked to complete a readiness to change questionnaire and a menu for action to incorporate personalized goals. To ensure best practices and needs were being met, a referral to the treatment log, which had 10 specific targets, was completed. A team engagement plan was prepared to educate and empower the staff while augmenting teamwork in the change process. Further interventions and modifications are found in Table 1.

Qualitative and quantitative data were obtained through chart audits, SDMTs, and referral checklists every 3 days, while staff survey data was collected every 14 days over the four PDSA cycles. The information was then used to evaluate each intervention and the influence it had on effective care ¹⁷.

Data points were recorded on run charts and evaluated for shifts, trends, and runs to determine if the interventions were effective or needed modification. Evaluations and changes were made on a bi-weekly basis during this iterative process.

A total of 10 measures were evaluated, which included the aim, a process, and an outcome for each of the four interventions and a balancing measure. The measurement worksheet (Table 2) provides operational definitions related to each of the 10 measures. Outcome measures included a screening and referral checklist to track qualifying patients, a validated readiness to change questionnaire, and a menu for action to promote patient engagement, explaining the stages of change and encouraging small meaningful goals. A team engagement plan was devised to motivate and foster enhanced collaboration and communication.

A staff satisfaction survey was incorporated to ascertain if the increased workload had a negative impact. All the weight loss charts were reviewed by the project team lead, and the result was shared with the team to ensure the completeness and accuracy of the data.

Quantitative data from checklists, surveys, and Likert-scales was plotted on run charts and evaluated for impact based on a calculated median and set goal. Qualitative data from SDMTs was collected, tracked in aggregate data worksheets, and used to identify patterns. This doctoral project was excused from review by the Institutional Review Board at Frontier Nursing University because it does not qualify as human subjects research and meets federal requirements for quality improvement. No outside funding for this project was received.

In PDSA 1, the screening checklist was implemented, and 38 patients were screened for height, weight, and BMI accounting for a 41.2% increase. The height, weight, and BMI were completed 100% of the time in the last three PDSA cycles. WC was obtained at 65.8% in PDSA1. After receiving feedback that providers were not remembering to measure it, PDSA 2 introduced a reminder card for obtaining the WC on the screening checklist. It proved to be successful as there was a 25.2% increase in WC recordings. PDSA 3 placed more emphasis on obtaining a WC by highlighting it on the screening checklist which increased it modestly by another 2.42%. PDSA 4 included one final reminder to obtain WC by placing a sticker on all the charts, which was the most successful intervention, resulting in 92.9% being screened.

Ready to Change Questionnaire (RTC) and the Menu for Action (MFA) were both implemented in PDSA 1. In PDSA 1, 71.1% of patients completed the tool, with an average RTC score of 23, improved from a baseline of 22.6. In PDSA 2, 76.5% of patients were ready to initiate a change scoring of 24. PDSA 3, had 93.3% of patients submitting the RTC tool with an average score of 24.3. The revised RTC tool in PDSA 4, showed 85.7% of patients were ready to take action with a slightly lower average score of 23.5. The MFA had 81.6% of patients choosing a goal in PDSA 1. During PDSA 2, 94.1% of patients decided on a goal. In PDSA 3, the pharmacy technicians provided the MFA to patients before seeing the provider, proving the most impactful intervention, with 97% of patients committing to a goal. The MFA was used with 100% of patients in PDSA 4. The most common goals for the MFA in each PDSA cycle were increasing physical activity and increasing daily water intake.

In PDSA 1, data showed the referral checklist was used with varying degrees dependent on the checklist item with an average mean percent total of 15.2% over the baseline. The average mean percent total increased in PDSA 2 by 8.2 percentage points after initiating a reminder card. When a logbook was introduced in PDSA 3, there was a decrease in the use of the referral checklist of 3.47%. The completion of the checklist increased 8.2 percentage points in PDSA 4. Significant omissions included lipid and HgbA1C levels, food trackers, and blood pressure not at goal (Table 3).

Lipid level compliance increased by 25.2 percentage points between PDSA 1and PDSA 4 HgbA1C compliance improved from PDSA 1 to PDSA 4 by 22.5 percentage points. Food trackers were returned 15.8% in PDSA 1 and increased 27.1 percentage points by PDSA 4. Blood pressure at goal showed a 27% increase from PDSA 1 to PDSA 4. Extrinsic motivation in the form of an incentive prize drawing was attempted to improve patient compliance for individual items, which was minimally successful.

Team engagement for PDSA 1 was 75.5% with the introduction of the team engagement plan and increased to 93.1% by PDSA 4. Survey data showed that Attitudes Towards Obese Persons (ATOP) at baseline was 65 of a possible 78 and had risen by 3.6% at the end of PDSA 4 indicating a positive attitude regarding obesity as a disease. The Beliefs About Obese Persons (BAOP) at baseline was 21 of a possible 48 and showed an 8.2% drop at the end of PDSA 4 indicating a personal bias that the individual is to blame for their obesity (Figure 1). A total of 23 questionnaires were collected over the four PDSA cycles, twice during PDSA 1 then only once in the remaining cycles. Staff satisfaction, a balancing measure, demonstrated a significant regression of 17.1% from a baseline of 4.7 of a possible five in PDSA 1, showing the negative consequences of the added workload. By PDSA 4 staff satisfaction had improved but remained below baseline by 1.2%.

Figure 1.Mean Team Values Regarding Obesity

Figure 1. ATOP and BAOP surveys showed that there were mostly positive attitudes towards our obese patients but some of the staff held biases believing it was the individual’s choice or lack of action as the cause of obesity.

This initiative impacted the knowledge and awareness of best practices related to obesity care within the urgent care setting. Standardization of the process augmented the effectiveness of care provided.Patients with a BMI greater than 30 kg/m² at increased risk were identified and educated about the correlation of BMI and waist circumference to co-morbidities. This helped the patients better understand the inherent risks associated with obesity through dialog that was initiated through the measurement of WC. It encouraged action and modification of behaviors to support improved health. The initiative was a success because both providers and patients became more informed and educated. Patients were apprehensive and not completely confident in their ability to make lifestyle changes for more than a few days to a week at a time, but as the project progressed and the patients saw the improvements, they became more willing to commit to the changes. Focusing on one small realistic goal enabled the patients to see that they could make a sustainable, impactful change. The patients contributed to successful effective care through their engagement in the tests of change. The project supported the literature that the patient engagement with provider relationship builds trust and motivation ¹².

Despite the success, there were barriers encountered during each PDSA cycle with the staff, which included time constraints, added workload, memory lapses regarding new processes, and small staffing numbers. This project demonstrated that support and communication are essential for any change and improvement to occur. The team was supportive, encouraging, and adaptable with each test of change, which confirmed the literature according to Fiscella, Maukshc, Bodenheimer, and Salas (2017) that it is crucial to go from “I provide care” to “We provide care.” The role of the staff as change agents and their positive attitude and flexibility was invaluable to every aspect of this undertaking.

Several limitations were noted during this project. The project was completed over a brief time in a small urgent care setting, and generalizability to primary care, other specialty care clinics, or a larger practice may not be possible. Patient engagement may have been because of obligation or extrinsic motivation versus genuine desire. Internal validity may have been limited by ambiguity in measurement techniques. Efforts were made to minimize limitations through reminders, one-on-one teaching, and assistance from the project lead.