Small Screen, Big Quality Improvement

bmi-chart

By Dianna Douglas

The benefits of measuring body mass index (BMI) are clear: a physician who knows a patient’s BMI is more likely to counsel her on lifestyle changes, and people are more likely to try diet and exercise on a doctor’s advice. But in the often-rushed environment of the clinic, even the quick calculations required to know a patient’s BMI can get lost in the shuffle.

Internal medicine residents at the Medical Center noticed that almost none of their patients had a BMI recorded on their charts, but many of their patients seemed overweight and obese.

“They initially wanted to improve obesity rates in patients,” said Vineet Arora, MD, who participates in teaching a quality improvement curriculum to residents and is senior author of a study. “But we needed something feasible. Recording and calculating most patients’ BMI was something they could change.”

Their quality improvement initiative and a study about it, published online in March in the American Journal of Medical Quality, grew out of the quality improvement education that all residents now receive at the University of Chicago.

Neda Laiteerapong, MD, was an internal medicine resident at the University of Chicago Medical Center when she decided that measuring BMI was vital to improving patient care. “We couldn’t even identify who was obese in our clinic. If you don’t identify it, you’re not going to treat it on a patient-by-patient basis,” she said.

Laiteerapong and nine of her fellow residents looked at the triage of patients in the clinic, and decided that they could easily make a few small changes to the vital signs that nurses record when a patient is checked in. “Most clinics weigh people, but they don’t measure height,” Laiteerapong said, noting that the combination of height and weight is usually only measured in children. She also said that asking a patient his height isn’t an accurate way to calculate BMI, since people often overestimate how tall they are.

The residents added rulers in the clinics, height and weight charts in the patient rooms, and a slot on the patient intake form for BMI. The nurses took the measurements, and the residents were responsible for calculating BMI. Within a month, the number of patients with a recorded BMI jumped from 4% to 80%.

Julie Oyler, MD, assistant professor of medicine and associate program director for the internal medicine residency, implemented the quality improvement curriculum for residents in 2006. “I would consider this a successful project,” she said. “Instead of complaining about poor practices in a clinic, the residents are getting experience changing and fixing the clinics.”

The improvements to patient care were immediate. Patients with a high BMI were diagnosed with obesity as a medical condition. Laiteerapong said calculating a patient’s BMI can take a lot of the stigma out of the term “obese,” and helps a physician feel more comfortable addressing it.

“People who got their BMI calculated were more likely to get lifestyle modification counseling,” Laiteerapong said. “A patient’s BMI is not emotionally charged. It’s scientific, and the reason we care about it is that people who have high BMIs have a high risk of other health problems. By telling someone their BMI, I’m not placing judgment on their past or blaming them—I’m just trying to treat their health.”

With America growing fatter, overweight and obese people are more likely to consider themselves to be normal weight than they were 20 years ago because they look like their neighbors and friends. Laiteerapong said many of her patients were surprised when she told them they had a weight problem. “It’s discouraging when patients tell me that they never knew they were obese. I know I’m not the first physician they’ve seen,” she said.

The patients aren’t the only ones who have grown accustomed to seeing larger body shapes. “Physicians aren’t good at evaluating if people are obese, because they look normal now,” said Olyer. “When trying to figure out obesity and how to properly care for patients, a BMI is an important number.”

The residents who started the quality improvement project came back to the clinic after they rotated out, to see if their improvements had become permanent. A year later, the BMI documentation rates had dropped to 43%. While it was still significantly higher than baseline, the residents were determined to fix it.

Some of the physicians reported that they would feel more comfortable bringing up obesity if they knew where to refer people for help. “We created another handout, informing people on local resources that physicians could use to encourage their patients to make better choices,” Laiteerapong said. They also replaced BMI charts that were missing from a few patient exam rooms.

One step in this chain will soon become easier: BMI will be calculated by the medical center’s new electronic medical record system, so the residents will no longer have to calculate BMI from height and weight. “Nurses are already asking height 97-98% of the time in patient visits, and getting weight measurements,” Oyler said.  BMI will be automatically calculated with those inputs in the new system.

The residents involved in the project were pleased that they had a lasting impact on patient care at the Medical Center. “Residents down in the trenches have an interesting view of the hospital,” Laiteerapong said. “Involving residents in fixing flaws in the system can help them feel like their viewpoint is important, and will help them combat burnout later in their career.”

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Laiteerapong, N., Keh, C., Naylor, K., Yang, V., Vinci, L., Oyler, J., & Arora, V. (2011). A Resident-Led Quality Improvement Initiative to Improve Obesity Screening American Journal of Medical Quality DOI: 10.1177/1062860610395930

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