title: Comparative effectiveness of childhood obesity interventions in pediatric primary care: a cluster-randomized clinical trial.
abstract: OBJECTIVE
  Evidence of effective treatment of childhood obesity in primary care settings is limited.
  
  
  OBJECTIVE
  To examine the extent to which computerized clinical decision support (CDS) delivered to pediatric clinicians at the point of care of obese children, with or without individualized family coaching, improved body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) and quality of care.
  
  
  METHODS
  We conducted a cluster-randomized, 3-arm clinical trial. We enrolled 549 children aged 6 to 12 years with a BMI at the 95% percentile or higher from 14 primary care practices in Massachusetts from October 1, 2011, through June 30, 2012. Patients were followed up for 1 year (last follow-up, August 30, 2013). In intent-to-treat analyses, we used linear mixed-effects models to account for clustering by practice and within each person.
  
  
  METHODS
  In 5 practices randomized to CDS, pediatric clinicians received decision support on obesity management, and patients and their families received an intervention for self-guided behavior change. In 5 practices randomized to CDS + coaching, decision support was augmented by individualized family coaching. The remaining 4 practices were randomized to usual care.
  
  
  METHODS
  Smaller age-associated change in BMI and the Healthcare Effectiveness Data and Information Set (HEDIS) performance measures for obesity during the 1-year follow-up.
  
  
  RESULTS
  At baseline, mean (SD) patient age and BMI were 9.8 (1.9) years and 25.8 (4.3), respectively. At 1 year, we obtained BMI from 518 children (94.4%) and HEDIS measures from 491 visits (89.4%). The 3 randomization arms had different effects on BMI over time (P = .04). Compared with the usual care arm, BMI increased less in children in the CDS arm during 1 year (-0.51 [95% CI, -0.91 to -0.11]). The CDS + coaching arm had a smaller magnitude of effect (-0.34 [95% CI, -0.75 to 0.07]). We found substantially greater achievement of childhood obesity HEDIS measures in the CDS arm (adjusted odds ratio, 2.28 [95% CI, 1.15-4.53]) and CDS + coaching arm (adjusted odds ratio, 2.60 [95% CI, 1.25-5.41]) and higher use of HEDIS codes for nutrition or physical activity counseling (CDS arm, 45%; CDS + coaching arm, 25%; P < .001 compared with usual care arm).
  
  
  CONCLUSIONS
  An intervention that included computerized CDS for pediatric clinicians and support for self-guided behavior change for families resulted in improved childhood BMI. Both interventions improved the quality of care for childhood obesity.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT01537510.
authors.affiliation: Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital for Children, Boston2Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts.
authors.forename: Elsie M
authors.initials: EM
authors.lastname: Taveras
authors.affiliation: Department of Pediatrics, Harvard Vanguard Medical Associates, Boston, Massachusetts.
authors.forename: Richard
authors.initials: R
authors.lastname: Marshall
authors.affiliation: Obesity Prevention Program, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.
authors.forename: Ken P
authors.initials: KP
authors.lastname: Kleinman
authors.affiliation: Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts4Obesity Prevention Program, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.
authors.forename: Matthew W
authors.initials: MW
authors.lastname: Gillman
authors.affiliation: Allegheny County Health Department, Pittsburgh, Pennsylvania.
authors.forename: Karen
authors.initials: K
authors.lastname: Hacker
authors.affiliation: Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital for Children, Boston.
authors.forename: Christine M
authors.initials: CM
authors.lastname: Horan
authors.affiliation: Obesity Prevention Program, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.
authors.forename: Renata L
authors.initials: RL
authors.lastname: Smith
authors.affiliation: Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital for Children, Boston.
authors.forename: Sarah
authors.initials: S
authors.lastname: Price
authors.affiliation: Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital for Children, Boston.
authors.forename: Mona
authors.initials: M
authors.lastname: Sharifi
authors.affiliation: Obesity Prevention Program, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts.
authors.forename: Sheryl L
authors.initials: SL
authors.lastname: Rifas-Shiman
authors.affiliation: Section of General Internal Medicine, Veterans Affairs Boston Healthcare System, Boston, Massachusetts.
authors.forename: Steven R
authors.initials: SR
authors.lastname: Simon
mesh_terms: D001521:Behavior Therapy; D002648:Child; D016000:Cluster Analysis; D003131:Combined Modality Therapy; D003661:Decision Support Techniques; D004505:Education, Nonprofessional; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D063766:Pediatric Obesity / Q000628:therapy*; D010372:Pediatrics; D011320:Primary Health Care; D012648:Self Care; D012944:Social Support; D013813:Therapy, Computer-Assisted