title: Clinical practice and variation in care for childhood obesity at seven clinics in California.
abstract: BACKGROUND
  The Healthy Eating Active Living TeleHealth Community of Practice is a virtual quality-improvement learning network of seven rural clinics in California. The goal of this network is to improve childhood obesity prevention and management practices at participating  clinics.
  
  
  OBJECTIVE
  Our objective is to describe clinical practices regarding weight assessment and nutrition and physical activity counselling at participating clinics before implementation of the quality improvement intervention.
  
  
  METHODS
  Participants were 2-11 year old  children seen for well-child care in 2010. Telephone surveys of English and Spanish-speaking parents were conducted within three days of their child's well-child visit to determine the content of counselling during the visit regarding nutrition and physical activity. Medical record reviews  were conducted to determine clinicians' assessment of weight status.
  
  
  RESULTS
  Twenty-seven clinicians conducted 144 well-child visits included in the study. Body mass index (BMI) was documented in 71% of medical records. Fewer than 10% of medical records had documentation of weight  category. Sixty-nine percent of parents received counselling on physical activity and 62% reported receiving counselling on fruit and vegetable intake. Parents were counselled less frequently on breakfast intake, sweetened beverages, television and family meals. Parents of overweight/obese  children did not receive more counselling than parents of children with a healthy BMI. Clinician-level effects accounted for moderately large amount of variation in counselling, but accounted for smaller variation in documentation of BMI and weight category. There was high between-clinic variation  in documentation practices, with 54% of the total variance for documentation attributable to clinic-level effects.
  
  
  CONCLUSIONS
  Rural clinicians, like those elsewhere, do not uniformly assess BMI percentile or counsel families on behavioural risk factors for paediatric obesity. There  exists considerable clinician-level variation in counselling practices and clinic-site level correlation in documentation practices related to BMI percentile and weight category.
authors.affiliation: Department of Pediatrics, University of California Davis School of Medicine, 2516 Stockton Blvd, Sacramento, CA 95817, USA. ushaikh@ucdavis.edu
authors.forename: Ulfat
authors.initials: U
authors.lastname: Shaikh
authors.forename: Jasmine
authors.initials: J
authors.lastname: Nettiksimmons
authors.forename: Jill G
authors.initials: JG
authors.lastname: Joseph
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Tancredi
authors.forename: Patrick S
authors.initials: PS
authors.lastname: Romano
mesh_terms: D015992:Body Mass Index; D002140:California; D002648:Child; D002675:Child, Preschool; D003376:Counseling / Q000379:methods* / Q000706:statistics & numerical data; D003430:Cross-Sectional Studies; D004032:Diet; D005260:Female; D019538:Health Care Surveys; D006293:Health Promotion / Q000379:methods* / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D009043:Motor Activity; D015999:Multivariate Analysis; D009765:Obesity / Q000517:prevention & control* / Q000628:therapy; D010818:Practice Patterns, Physicians' / Q000592:standards* / Q000706:statistics & numerical data; D011368:Professional-Family Relations; D019035:Rural Health Services; D000078329:Workforce