QUALITY IMPROVEMENT REPORT

Assessment of provider adherence to obesity treatment

guidelines
Nicole Farran, MSN, RN, APRN, WHCNP, ANP-BC (Nurse Practitioner, Doctorate of Nursing Practice Student),
Peggy Ellis, PhD, RN, ANP, FNP (Capstone Committee Chair), & Mary Lee Barron, PhD, RN, APRN, FNP-BC
(Capstone Committee Member)
School of Nursing, Saint Louis University, St. Louis, Missouri

Keywords
Obesity; patient care outcomes; patient
outcomes; primary care; quality improvement;
quality.
Correspondence
Nicole Farran, MSN, RN, APRN, WHCNP,
ANP-BC, 1617 Sumter Court Franklin, TN 37067.
Tel: 615-495-8023;
Fax: 615-872-9967;
E-mail: nfarran@sjnmr.com, nfarran@slu.edu,
Nicole.neffgen@hotmail.com
Received: December 2011;
accepted: June 2012
doi: 10.1111/j.1745-7599.2012.00769.x
Disclosure: There were no grants, financial
assistance, equipment, or other sources of
support provided for the purpose of this study.
Abstract
Purpose: Despite the presence of obesity treatment guidelines, healthcare
providers often provide suboptimal weight management. The purpose of the
quality improvement project was to systematically assess adherence with adult
overweight/obesity guidelines in primary care to reduce patient risk.
Data sources: Retrospective analysis of 420 encounter notes from overweight
and obese adult patients in three primary care clinics. Data were collected be-
fore and after a continuing education session for providers on guidelines for
optimal management of obesity. Measures of completeness of quality indica-
tors were abstracted from records.
Conclusions: Significant improvement in the completeness score and docu-
mentation of body mass index, height, diagnosis of overweight/obesity, and
counseling for diet and physical activity were achieved.
Implications for practice: The proposed measures for systematically assess-
ing the integration of obesity guidelines in primary care are feasible quality
indicators and useful for evidence-based decision making.

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Introduction
Background knowledge
The prevalence of obesity in the United States is signif-
icant, as over two thirds of adults are considered over-
weight or obese (Flegal, Carroll, Ogden, & Curtin, 2010).
The prevalence of this condition has increased from 23%
to 34% since the 1980s, and is greatest among women
and minority groups, such as Hispanics or African Amer-
icans (Ogden & Carroll, 2010). Overweight, defined as
a body mass index (BMI) of 25–29.9, and obesity, de-
fined as a BMI of 30 or more, are major risk factors for
diabetes mellitus type two (National Heart, Lung, and
Blood Institute [NHLBI], 1998) and is associated with a
decreased quality of life (Ogden & Clementi, 2010). Ad-
ditionally, the economic impact of obesity is considerable.
The rising prevalence of obesity contributed to nearly
$40 billion in increased medical expenditure through
2006, and is expected to escalate. Per capita medical costs
are 42% higher for obese individuals as compared to
individuals with normal weight (Finkelstein, Trogdon,
Cohen, & Dietz, 2009).
Because of the need to reduce healthcare expenditure
and augment care quality, emphasis is being placed on

Journal of the American Academy of Nurse Practitioners 00 (2012) 1–9 

C 2012 The Author(s) 1
Journal compilation 
C 2012 American Academy of Nurse Practitioners
Assessment of provider adherence
healthcare quality indicators developed by organizations
including the National Committee for Quality Assurance
(NCQA), and the Agency for Healthcare Research and
Quality (AHRQ). Their goal is to implement quality im-
provement strategies to enhance accountability and ef-
fectiveness of health care (AHRQ, 2007). Via utilizing the
desired indicators, derived from evidence-based practice,
the consistent measurement of care quality is possible
(Institute of Medicine, Committee on Quality of Health-
care in America, 2000).
Quality indicators can improve care delivery in numer-
ous ways. First, these indicators can function as a screen-
ing tool, at the practitioner or practice level, to identify ar-
eas where modification is necessary. Second, data on care
delivery can compare treatments filtered by patient char-
acteristics, such as comorbidities. Third, state agencies can
aggregate information to inform public health initiatives.
Lastly, patients can access public information to compare
providers (AHRQ, 2007).
Process-based measures, which scrutinize the quality of
care provided, can facilitate the examination of provider
adherence. Conversely, outcome-based measures exam-
ine the health status of a patient as a result of care deliv-
ery. Development of process measures should be empha-
sized, as these actionable criteria are key factors in quality
improvement strategies (National Quality Forum, 2009).
Process measures do not require risk adjustment and
are able to be collected quickly and unobtrusively. Al-
ternatively, patient outcome events may occur with low
frequency or may require a long period of time to deter-
mine, such as mortality rates. Additionally, patient out-
comes are influenced by a variety of factors and may not
reflect the quality of care provided (Lauck, Johnson, &
Ratner, 2009).
Despite the growing emphasis on quality indicators,
there are little data on the quality of primary care pro-
vided to overweight and obese adults. While most of
the research on quality has been in the hospital setting,
the United Kingdom’s Quality and Outcomes Framework
(QOF) study supports the need for implementation in pri-
mary care. Reduced frequency of many chronic condi-
tions, such as obesity and hypertension, is correlated with
improved primary care provider performance (Ashworth,
Schofield, Seed, Durbaba, Kordowicz, & Jones, 2011). In
order to develop strategies to positively affect care provi-
sion, systematic measures for assessing the quality of care
provided to overweight and obese adults are needed.
Local problem and intended improvement
Despite the prevalence of obesity in the United States
and the existence of clinical guidelines by the NHLBI
(1998), current practice habits do not result in effec-
2
N. Farran et al.
tive obesity management. In a nationwide survey of
providers who treat overweight patients, 35% said they
are currently aiding only 10% of their obese patients with
weight loss (Advance for Nurse Practitioner, 2009). Sim-
ilarly, Noel et al. (2010) found that only 28% of obese
patients had a diagnosis of obesity and 34% of the obese
patients received counseling regarding nutrition and ex-
ercise. Likewise, in a retrospective audit of 2543 obese
patient records, approximately 80% did not have a diag-
nosis of obesity or a management plan documented (Bar-
dia, Holtan, Slezak, & Thompson, 2007). A documented
diagnosis of obesity is critical, as it is correlated with re-
ceipt of lifestyle counseling for weight loss (Noel et al.,
2010). This diagnosis assists the provider in recognizing
obesity as a separate disease and subsequently determin-
ing a treatment plan (Bardia et al., 2007). When counsel-
ing does occur, specific recommendations are rarely pro-
vided. In a nationwide review of practitioners, the most
commonly reported weight loss advice was “eat less, ex-
ercise more,” (Advance for Nurse Practitioners, 2009).
Thus, when overweight and obese adults are identified
and diagnosed, effective counseling is not occurring.
Several barriers hinder practitioner-provided weight
loss education. These include time constraints, lack of
skills needed to assist with weight loss efforts, failure
to recognize obesity as a medical priority, and clini-
cal inertia (Forman-Hoffman, Little, & Wahls, 2006).
Furthermore, providers report receiving insufficient
training and feeling unprepared to provide nutritional
recommendations (Wynn, Trudeau, & Taunton, 2010).
In a recent survey of primary care clinicians, almost 90%
of providers viewed obesity treatment as part of their
responsibility, yet nearly 72% did not have anyone in
their practice trained to provide weight loss counseling
(STOP Obesity Alliance, 2010). Additionally, providers
report discomfort in addressing the need for weight loss
with patients because of acceptance as a societal norm or
fear of negative reactions from the individuals (Spivack,
Swietlik, Alessandrini, & Faith, 2010). These barriers
may culminate in negative beliefs regarding the potential
for effective weight management.
An established provider–patient relationship, such as in
primary care, is ideal to support weight loss counseling,
as this has been associated with greater success (Thande,
Hurstak, Sciacca, & Giardina, 2008). Numerous clinical
guidelines exist to assist primary care providers with the
management of overweight/obese patients. Quality indi-
cators, derived from these guidelines, are necessary to
monitor care and stimulate performance improvements.
Organizations, such as the NCQA, have examined the
use of quality indicators that reflect treatment of obe-
sity, including BMI measurement, as well as counsel-
ing for nutrition and physical activity, in the pediatric
N. Farran et al.
setting (NCQA, 2010). However, in the adult population,
clear quality indicators, other than BMI, have not been
established for obesity management (NCQA, 2010). As
BMI measurements reflect overweight/obesity identifica-
tion rather than treatment, further development of qual-
ity indicators in this population is necessary.
Oversight of providers’ performance is needed to assess
adherence to quality indicators, derived from the clinical
guidelines, in order to monitor care provision to over-
weight/obese adults and design effective improvement
strategies. Consistent application of guideline recommen-
dations with systematic assessment of provider adherence
is necessary to enhance the quality of care provided to
this population.
Study questions
The following questions were considered: (a) can qual-
ity indicators regarding the adherence of primary care
providers and their clinical support staff to “Clinical
Guidelines on the Identification, Evaluation, and Treat-
ment of Overweight and Obesity in Adults,” (NHLBI,
1998) be systematically measured? (b) Can guideline
compliance among quality indicators be improved by
20% compared to baseline, 3 months after a continuing
education (CE) among primary care providers and clinical
support staff, where adherence refers to documentation
of: patient’s height, weight, BMI, waist circumference,
obesity diagnosis, and counseling regarding diet, physical
activity, and behavioral recommendations?
Methods
Ethical issues, setting, sample size and selection
Saint Louis University’s Institutional Review Board re-
viewed and approved this minimal risk study. Three ur-
ban private practices in the Nashville, Tennessee area
served as the study setting. These practices represent the
care provided by five nurse practitioners, two physicians,
and their respective clinical support staff. The patient
population of all study sites shares a similar mix of pay-
ers, demographics, and economic status. The principal in-
vestigator (PI) obtained data from the encounter notes in
the medical records of overweight and obese adults in the
study locations.
The sample size was generated via calculations that
were computed from the source population at the study
sites. The PI derived sample size estimations from a power
analysis based on the anticipated completeness score. The
investigator expected equal numbers from each of the
three study sites from the period of time before and
after the CE session. Alpha was assumed to be 0.05
Assessment of provider adherence
with 80% power. A similarly designed study reported an
approximate 20% improvement in compliance to obe-
sity guidelines (Gance-Cleveland, Gilbert, Kopanos, &
Gilbert, 2010). Therefore, an estimated impact of 20%
improved compliance was used for calculation of sample
size, resulting in a sample size of 210 encounter notes
before and 210 encounter notes (for a total of 420 en-
counter notes) after the CE session from the same pa-
tients’ medical records. To ensure equal sample sizes
among study sites, the PI selected 70 encounter notes
from each of the three sites to represent the quality of
care provided during the period of time between Jan-
uary and March, 2011 and between May and July, 2011
(E. Armbrecht, personal communication, April 15, 2011).
To protect the confidentiality and anonymity of the
subjects, the PI systematically selected the medical
records of every other patient seen by the providers,
during the specified period of time, for eligibility crite-
ria (Polit & Beck, 2011). Inclusion criteria for encounter
notes were: adults aged 18–65, overweight/obese diag-
nosis or BMI of 25 or more, who were patients at the se-
lected primary care practices, and who had eligible office
visits during both the pre- and post-CE session periods
(January through March, 2011 and again between May
and July, 2011). Eligible office visits for inclusion were
physicals or follow-up visits. If more than one encounter
note was eligible for inclusion, then the first eligible visit
was included in analysis. Exclusion criteria for encounter
notes were: did not meet inclusion criteria, and/or were
currently pregnant or breastfeeding. Also excluded were
clinic visits that were not physicals or follow-ups.
Planning the intervention
The Agree Instrument was used to undertake a criti-
cal appraisal of existing clinical guidelines utilized by pri-
mary care clinicians for management of overweight and
obese adults (The AGREE Collaboration, 2001) to assess
the following: scope and purpose, stakeholder involve-
ment, rigor of development, clarity and presentation, ap-
plicability, and editorial independence. The guidelines de-
veloped by the U.S. Department of Veterans Affairs and
Department of Defense (2006), the Scottish Inter-
collegiate Guidelines (2010), and the NHLBI (1998)
were evaluated. While all three guidelines detailed effec-
tive management strategies for obesity in primary care,
the NHLBI’s clinical guidelines were the most compre-
hensive and included simple, specific strategies that are
easily incorporated in clinical practice.
Quality indicators based on the NHLBI’s 1998
overweight and obesity guidelines were identified in
accordance with the Institute of Medicine’s criteria of
clinical importance, scientific soundness, feasibility for
3
Assessment of provider adherence
indicator selection, and criteria specific to the limitations
of the data source (Institute of Medicine, Committee on
Quality of Healthcare in America, 2001). The quality indi-
cators included the following: weight, height, BMI, waist
circumference, a diagnosis of overweight/obesity, and ed-
ucation related to diet, physical activity, and behavioral
modification. Three primary care practices were identi-
fied to evaluate the use of these quality indicators in prac-
tice. Provider and clinical staff at these study locations re-
ceived CE sessions to review the NHLBI’s guidelines in
April 2011. During the CE, a tool was provided to as-
sist clinicians and staff with implementing the guidelines
in practice (Supporting information). Additionally, the PI
provided recommendations to improve guideline integra-
tion in practice, such as modification of the electronic
medical record templates to include BMI and placement
of a tape measure for waist circumference measurement
near the scales (Supporting information).
Systematic sampling of medical records, a retrospective
study design, and the establishment of defined, objective
outcomes using standardized measurements all served to
reduce potential bias. It was assumed that documentation
in the healthcare record is a precise representation of care
provided (Aschengrau & Seage, 2008). Confounding was
reduced through restricting encounter notes by eligibil-
ity criteria and through analysis of only records from in-
dividuals who are overweight or obese. To analyze the
differences between the quality of care before and af-
ter the CE session, the encounter notes from the same
patients’ medical records were reviewed (Aschengrau &
Seage, 2008).
Planning the study of the intervention
The specific aim of the retrospective quality improve-
ment study was to systematically assess compliance with
the clinical guidelines for the identification and manage-
ment of overweight and obese adults. To assess guide-
line compliance with the identified quality indicators,
the PI conducted a medical record audit to review doc-
umented care in encounter notes from overweight and
obese adults seen in the primary care setting 3 months
before and 3 months after the educational session that
occurred in April 2011. The PI systematically selected
the medical records from office visits of overweight/obese
adults, ages 18–65, to assess documentation of quality
indicators. The same patients’ medical records were re-
viewed to obtain data from encounters that occurred
within the 3 months prior to and after the CE session.
The primary outcome was the proportion of
the providers’ and clinical support staff’s compliance
to the NHLBI’s (1998) obesity guideline before and
after the CE session. Compliance was defined as the
4
N. Farran et al.
presence or absence of documentation of the following
quality indicators: height, weight, BMI, waist circumfer-
ence, diagnosis of overweight/obesity, and counseling
regarding dietary, physical activity, and behavioral
recommendations. Noncompliance was defined as the
lack of documentation of the compliance measures. The
PI calculated an overall compliance score, termed the
completeness score, through tallying the total number
of points earned, with each measure equaling one point
if the measure was performed and zero points if the
measure was not performed. A total of eight points were
possible for quality indicators in each encounter note
reviewed.
Data collection and analysis
The PI solely performed all record selection and data
extraction. The nominal variables, recorded as “yes” or
“no,” to document the providers’ compliance prior to
and after the CE included: weight, height, BMI, obesity
diagnosis, waist circumference, and counseling regarding
dietary, physical activity, and behavioral recommenda-
tions. A completeness score was also calculated from
each encounter note through tallying the total number of
points earned for each indicator. Each measure equaled
one point if the measure was performed and zero points
if the measure was not performed. A total of eight
points was possible. Patient data, including age, gender,
BMI, and insurance distribution (Medicare, Medicaid,
commercial insurance, or self-pay) was recorded, as
these may influence care quality. The PI recorded data
using PASW Statistics Gradpack 17.0 software (PASW
Statistics Gradpack, 2009) to ensure equal sample sizes
among offices.
A quality improvement tally sheet, created using
PASW statistics Gradpack version 17.0 (2009) was uti-
lized to record and analyze data. Descriptive statistics and
chi-square analyses were calculated to examine patient
demographics and compare baseline characteristics of
the sample. The Wilcoxon test evaluated the differences
achieved in the completeness score before and after the
CE session. Lastly, analysis of variance determined the
proportion of variability in the change in the complete-
ness scores attributed to patient characteristics. Data
analysis for statistical significance utilized a one-tailed
test at a p < .05 level of significance (Cronk, 2008).
Results
Demographics
The retrospective medical record review consisted of
210 patients’ charts, consisting of 89 males and 121 fe-
males whose average age was 43. The BMI range of the
N. Farran et al. Assessment of provider adherence

Table 1 Patient body mass index description tion improved by 22.4%, 11.9%, and 10%, respectively.
Body mass
(Figure 1).
index category 199 pre-CE 206 post-CE pre-CE post-CE The Wilcoxon test examined the results of the pre- and
post-CE completeness scores. A significant difference was
25–29 49 57 24.6% 27.7%
found in the results (Z = −10.391, p < .0001). There
30–34 74 74 37.2% 35.9%∗∗∗
was statistically significant improvement in the post-CE
35–39 33 33 16.6% 16.0%
40 and above 43 42 21.6% 20.4% completeness scores as compared to pre-CE completeness
Mean pre Mean post scores (Table 3).
Mean body mass index 34.6 34.3 A “score change” was created by calculating the
Standard deviation 6.925 6.791 post-CE minus the pre-CE scores. The PI conducted an
Range 25–56 25–54 analysis of variance to assess patient characteristics with
Note. CE, continuing education; pre-CE, patient information obtained be-
completeness score change. There was no significant
tween January and March of 2011; post-CE, patient information obtained difference between the pre- and post-CE completeness
between May and July of 2011. Pre-CE BMI was unable to be determined scores by gender (F (1, 208) = 1.276, p > .05); age (F (44,
in 11 of the encounter notes. Post-CE BMI was unable to be determined 165) = 1.065, p > .05); insurance (F (3, 206) = 0.466,
in three of the encounter notes. Statistical significance with a p < .0001 is p > .05); and BMI (F (1, 208) = 0.480, p > .05). The
indicated by ∗∗∗ . score change did not differ significantly by patient char-
acteristics (Table 4).

subjects was 25–56, with 75.3% of participants evidenc-

ing a BMI over 30 in the pre-CE data and 21.6% evi-
dencing a BMI over 40. The mean pre-CE BMI score was
34.6. The PI was unable to calculate BMI in 5.2% and
2% of the pre-CE and post-CE data, respectively, because
of lack of data (Table 1). A chi-square analysis was con-
ducted comparing the baseline patient characteristics by
age, BMI, gender, and insurance status. Significant de-
viation from the hypothesized equal values was found
among age categories (χ 2 (3) = 19.562, p < .0001), BMI
categories (χ 2 (3) = 18.387, p < .0001), gender (χ 2 (1) =
4.88, p < .05), and insurance types (χ 2 (1) = 274.61, p <
.0001). Individuals 30–41 years old, with a BMI between
30 and 34, females, and commercial insurance were pre-
dominant in the sample.
Outcomes
A chi-square analysis was conducted comparing the
frequency of pre-CE and post-CE documentation of the
following variables: BMI, height, weight, waist circum-
ference, diagnosis of overweight/obesity, and counseling
regarding diet, physical activity, and behavioral modifi-
cation. A significant improvement was found for BMI
(χ 2 (1) = 26.228, p < .0001), height (χ 2 (1) = 30.599, p <
.0001), diagnosis of overweight/obesity (χ 2 (1) = 5.784,
p < .05), diet counseling (χ 2 (1) = 8.379, p < .05), and
physical activity counseling (χ 2 (1) = 8.400, p < .05)
(Table 2).
Documentation of guideline compliance among quality
indicators improved by 41.5% for BMI, 5.2% for height,
2.8% for weight, 13.3% for waist circumference, 31.4%
for diagnosis of overweight/obesity, and counseling re-
lated to diet, physical activity, and behavioral modifica-
Discussion
Clinical guideline adherence is an effective method
for ensuring quality patient care (Melnyk & Fineout-
Overholt, 2011). Similar to previous research, the find-
ings suggest overweight/obesity management in the
primary care setting is sub-optimal. The average com-
pleteness scores in pre- and post-CE encounter notes
were 2.6 and 4 out of 8, respectively. Documentation
of height and weight, necessary to obtain a BMI calcu-
lation, were consistently recorded prior to the CE session,
with 93.8% and 96.2% compliance, respectively. Identifi-
cation of overweight and obesity through BMI calculation
or a diagnosis in the patient’s medical record occurred in
only 37.1% and 23.8% of the records reviewed prior to
the CE session, respectively. To assist with this diagnosis,
a waist circumference was obtained in only 0.05% of the
records reviewed. Furthermore, prior to the CE session,
counseling regarding diet, physical activity, and behav-
ioral modification was present in 8.6%, 4.8%, and 1%
of encounter notes, respectively. These results are con-
sistent with a recent cross-sectional analysis of the 2005
and 2006 National Ambulatory Medical Care Survey in
which obesity screening, diagnosis, and counseling were
assessed. Key information regarding height and/or weight
necessary to calculate BMI was missing in 46–54% of
visits examined. Obese individuals lacked a diagnosis of
obesity in 70% of the visits, and 63% lacked receipt of
counseling for diet, physical activity, or weight manage-
ment (Ma, Xiao, & Stafford, 2010). Similarly, Noel et al.
(2010) found that 28% of obese patients had a diagno-
sis of obesity and 34% of the obese patients received
education and counseling regarding nutrition, exercise,
and weight management. The need for improvement

5
Assessment of provider adherence N. Farran et al.

Table 2 Association of guideline adherence pre- and post-CE session

100%

90%

80%

70%
% Adherence

60%

50%

40%
Pre-CE
30%
Post-CE
20%

10%

0%

Note. CE, continuing education; pre-CE, patient information obtained between January and March of 2011; post-CE, patient information obtained between
May and July of 2011. Pre-CE BMI was unable to be determined in 11 of the encounter notes. Statistical significance with a p < .05 and p < .0001 are
indicated by ∗ and ∗∗∗ , respectively. χ2 scores were: 26.228, 30.599, 0.080, 0.161, 5.784, 8.379, and 8.400, respectively.

Figure 1 Change in overweight/obesity qual-

ity indicators pre- and post-continuing educa-
tion (CE) session. Pre-CE, patient information
obtained between January and March of 2011.
Post-CE, patient information obtained between
May and July of 2011. p < .05 as compared to
baseline data prior to the CE session for BMI,
height, diagnosis of overweight/obesity, and
counseling related to diet and physical activity.

strategies pivoting on quality indicators is supported by
both the existing literature and the present study.
There is limited research examining the proposed in-
dicators as evaluators of the quality of care provided
to overweight/obese adults (Laiteerapong et al., 2011;
Hopkins, Agarwal, & Dolovich, 2010). The present study
supports the utilization of such indicators as a feasible
method to systematically assess care provision. These in-
dicators are easily implemented, uniformly measured,
and should be routinely utilized in the clinical setting. Ad-
ditionally, these measures are able to be collected quickly
and unobtrusively. Use of the proposed quality indicators
can highlight care gaps and inform improvement projects
related to weight management.

6
N. Farran et al. Assessment of provider adherence

Table 3 Change in completeness scores

Mean Completeness Score Change

4.5
4
4

3.5

3 Pre-CE : 210
2.6
Encounters
2.5
Post-CE: 210
2 Encounters

1.5

0.5

0
Mean Completeness Score

Note. CE, connuing educaon. Pre-CE, paent informaon obtained between January and
March of 2011. Post-CE, paent informaon obtained between May and July of 2011. Pre-CE
Standard Deviaon, 94276, Standard Error Mean= .06506. Post-CE Standard Deviaon,
1.39528, Standard Error Mean, 09628

Completeness Score Change By Encounter

180
159***
160

140

120
Encounters

Improved
100
Declined
80
No Change
60
38
40

20 13

0
Completeness Scores Pre- and Post-CE N= 210

Note. CE, connuing educaon. Pre-CE, paent informaon obtained between January and
March of 2011. Post-CE, paent informaon obtained between May and July of 2011.
P < .0001 as compared to baseline data prior to the CE session. Stascal significance with a
p < .0001 is indicated by ***.

Weight management in primary care may improve
through quality improvement initiatives that increase
guideline education and integration of findings in the
clinical setting. In the present study, overall over-
weight/obesity guideline compliance significantly im-
proved, with a 35% increase in completeness scores from
pre-CE values. Specifically, documentation of height,
BMI, diagnosis of overweight/obesity, and counseling
related to diet and physical activity made statistically
significant gains. These findings echoed the limited
previous research. In a year-long quality improve-
ment study among residents, overweight/obesity man-
agement was improved after brief interventions to im-
prove evidence-based care, as evidenced by increased
rates of height, weight, and BMI documentation, corre-
lated with improved diet and physical activity counseling

7
Assessment of provider adherence N. Farran et al.

Table 4 Mean change in completeness score by patient characteristics adherence to overweight/obesity clinical guidelines and
Patient Mean change in Standard
would allow the scope of the study to be expanded to
characteristic completeness score deviation determine if statistically significant weight reduction oc-
curred. A more normalized distribution of patient demo-
Gender
graphics would improve the generalizability of findings.
Male 1.539 1.306
Lastly, one auditor performed all data collection. Multiple
Female 1.314 1.511
Insurance auditors with independent verification of findings would
Medicare 1.063 0.929 ensure the validity and reliability of data. However, the
Medicaid 1.482 1.451 structure of data collection methods reduced the risk of
Commercial 1.449 1.482 bias and confounding.
Self-pay 1.182 1.250
Body mass index
25–29 1.204 1.369 Interpretation
30–34 1.149 1.411
35–39 1.576 1.621 The findings were consistent with expected outcomes.
40 and above 1.674 0.993 Specifically, assessment of the quality of care delivery to
Age overweight and obese adults can occur by systematically
18–29 1.483 1.639 measuring guideline adherence. Additionally, improve-
30–41 1.397 1.392 ment in compliance with quality indicators is achieved
42–53 1.509 1.756
following a CE session with primary care providers and
54–65 1.265 0.884
clinical support staff, with a goal of reducing patient risk
Note. There was no statistically significant difference found in complete- related to obesity. Primary care is the appropriate location
ness score change by patient characteristics. for the present intervention as these quality measures
should be routinely assessed in this setting. Guideline
implementation in clinical practice requires sustained ef-
(Laiteerapong et al., 2011). Similarly, BMI documenta- forts to promote staff familiarity with recommendations,
tion was improved after efforts were undertaken to in- as well as create practice structure support and contin-
crease identification of overweight and obese patients in ued skill building among clinical staff to ensure trans-
primary care (Gance-Cleveland et al., 2010). lation of evidence in practice. Identification of barriers,
Primary care providers have a critical role in identifying such as lack of guideline familiarity and ability to rapidly
and managing overweight and obese adults. However, measure BMI, can facilitate change. Improved identifica-
the study findings indicate that primary care providers tion and management of overweight/obese adults is fea-
may provide suboptimal weight-related care. Quality im- sible through brief quality improvement initiatives, sug-
provement projects, such as the current study, may high- gesting that evidence-based practice can enhance care
light practice areas requiring improvements. Researchers delivery. Further study of these quality indicators in a
can assess practice habits and trends in care delivery larger segment of the primary care community over a
through the evaluation of guideline adherence via the use longer duration would ensure generalizability of find-
of quality indicators. Evidence-based initiatives, including ings. Future research should explore opportunity costs re-
continued provider education and organizational change lated to the time constraints of performing medical record
strategies, can assist clinicians with guideline integration audits.
in care delivery, with the potential to improve the quality
of care provided to overweight/obese adults.
Conclusions
Primary care providers have the opportunity to re-
Limitations
duce the obesity epidemic and the impact of related
A study limitation was the retrospective design with comorbidities through care provision to individuals in
pre- and post-CE session evaluation of documented care. need of weight-related interventions. Care delivered
A real-time audit would allow for provider feedback to overweight/obese adults is systematically assessable
and may influence guideline adherence. Additionally, the through identifying measurable quality indicators derived
study included locations in a single metropolitan area, from the clinical guidelines. Quality indicators can track
representing the care of seven providers over a short pe- provider performance to identify quality gaps for future
riod of time. A larger sampling with a greater number of improvement interventions. As the goal is to reduce pa-
providers and patients, over an extended period, would tient risk related to obesity, previous research has evi-
more realistically reflect the primary care community’s denced that improved patient outcomes can result from

8
N. Farran et al.
effective weight management based on the clinical guide-
lines (Schuster, Tasosa, & Terwoord, 2008).
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Supporting Information
Additional Supporting Information may be found in the
online version of this article.
Supplement A. Overweight and obesity decision sup-
port tool.
Supplement B. Practice recommendations.
Please note: Wiley-Blackwell is not responsible for the
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