Pediatric Psychologists Involved in National Obesity Initiative

Wendy L. Ward, PhD, Arkansas Children’s Hospital/University of Arkansas for Medical Sciences College of Medicine
Meredith L. Dreyer, PhD, Children’s Mercy Hospitals and Clinics; University of Missouri-Kansas City School of Medicine
Elizabeth Getzoff, PhD, Mt. Washington Pediatric Hospital, Inc.
Jane Gray, PhD, Dell Children’s Medical Center/University of Texas at Austin
Texas Child Study Center, Texas Center for the Prevention and Treatment of Childhood Obesity
Bethany Sallinen, PhD, C.S. Mott Children’s Hospital, University of Michigan
Laura Shaffer, PhD, University of Louisville School of Medicine

Background

Several psychologists participated in NACHRI’s Focus on a Fitter Future I in 2008-2009. This was a multidisciplinary group of experts from 15 Children’s Hospitals that met three times in person and numerous additional times via interactive webinar. The goal was to develop recommendations for children’s hospitals and prevention/treatment programs hosted in children’s hospitals. A brief executive summary was provided to the administrative liaisons at each hospital (copies provided for Div 54 board members today). In addition an 8 chapter supplement in the Journal of Pediatrics was published in September 2011 addressing hospital environment policy, reimbursement difficulties with hospital toolkit for pursuing better funding from state insurance companies, evidence-based practice guidelines, guidelines for adolescent bariatric surgery (adopted by the American Society of Metabolic and Bariatric Surgery ASMBS), etc. One difficulty from a pediatric psychology perspective was that there were not enough of us to serve on all committees and when results were presented there were some statements made that were not advantageous to our discipline or its needs. We were successful in advocating for our discipline at that point so that the end product was reasonable. But it heightened the need for adequate representation on the subcommittees.

Currently: NACHRI decided that FFF I was so successful, that they wanted to do a FFF II with the goal of more detailed impact on hospital environment. In addition, continued efforts in the areas of reimbursement, creating a research network consortium for multi-site clinical trials, creating a national patient registry, stronger statements regarding public policy/advocacy, recommendations for retention of patients in programs, and writing more detailed treatment guidelines. This time, 25 hospitals were accepted as participants with 3-4 person teams. There are 14 pediatric psychologists heavily involved in each of the new subcommittees with the goals of policy statements.

Participants

• Healthy Hospitals: Meredith Dreyer

• Research Network: Wendy Ward, Eli Getzoff, Melissa Santos

• Treatment Guidelines: Jane Gray, Wendy Ward, Emily Israel, Bethany Sallinen, Melissa Santos, Eli Getzoff, Laura Shaffer

• Reimbursement: Jane Gray

• Patient Retention: Bethany Sallinen, Emily Israel, Melissa Santos

• Public Policy: Meredith Dreyer, Laura Shaeffer

• Patient Registry: Eli Getzoff, Wendy Ward

Summary of Activities

The Reimbursement Subcommitee of FFII has been focusing on the billing and reimbursement of non-physician health professionals involved in multidisciplinary weight management clinics, including psychologists, dieticians, and exercise physiologists. The subcommitee decided to focus on messaging to three key audiences: government relations representatives at hospitals and related institutions, executive committees of hospitals and related institutions, and clinician colleagues. Psychology has been creating brief messaging to illustrate the need for pediatric psychology in weight management clinics, as wells as the need for attention to billing for psychologist services. The focus has been educating the three audiences on the availability of the Health and Behavior Codes as an option for reimbursement.

The Patient Retention Subcommittee has developed a semi-structured interview to examine the perspectives of parents whose children have not completed Stage III treatment programs. Specifically, the interview will assess parental reasons for discontinuing treatment and determining what program practices could be put in place to prevent patient attrition in the future. Currently, 11 children’s hospitals have either obtained IRB approval or are in the process of obtaining approval. Programs are identifying patients who completed less than 25% of program visits in the past year or who did not return for a follow up visit within 6 months and contacting parents for phone interviews. Following data collection, the subcommittee plans to submit results for publication and presentation at national conferences.

The Public Policy Subcommittee has been working on two main projects: the creation of a pediatric obesity value piece and a pediatric obesity policy resource guide. As psychologists on the subcommittee, we have worked to make sure psychology is represented in the value piece that will be available to advocates to take with them when they visit legislators to explain the childhood obesity epidemic and how children’s hospitals are addressing this problem. Psychologists contributed to the development of the resource guide by sharing our knowledge of research coalitions and national resources that would be helpful to include. In addition, we advocated for better psychology funding in the subcommittee’s collaborations with the Payment subcommittee in efforts to promote payment for all services recommended by NACHRI in the treatment of childhood obesity.

The Patient Registry subcommittee is committed to beginning a national register for all obese youth. They are starting with a small 2 yr retrospective 7 or 8 sites collecting data with a small set of variables to see if it is feasible to do such a registry. If successful they hope to broaden the scope to a prospective study with more sites and more variables. The psychology subcommittee recommended 2 measures for them to consider for prospective study (PSC-17 and the SMU).

Research Network aka COMPASS (Childhood Obesity Multi-Program Analysis and Study System) has begun the steps including a rules of governance to become a multisite network of clinical pediatric obesity researchers to encourage cross-institutional collaboration and lead to study sample sizes that enable them to answer challenging research questions. Objectives of network include to provide an evidence base to guide the prevention, evaluation and treatment of childhood obesity through a multi-disciplinary collaboration between network of children’s hospitals, create supporting research that improves the quality and effectiveness (administrative cost, clinical outcome) of care delivered to obese children, support research studies that provide data for benchmarking and provision of best practices and support research that will inform N.A.C.H. on policy matters relevant to childhood obesity legislation at the national and state level.

Psychologists working with the Treatment Guidelines subcommittee focused their efforts on the creation of two major work products, expert consensus guidelines on psychological assessment and treatment of children and adolescents in pediatric obesity specialty clinics. We created a detailed outline of important areas to cover in clinical interview as well as more general recommendations for the use of objective measures. The treatment guidelines provide commonly used interventions for all children and adolescents as well as developmentally specific considerations and recommendations for the treatment of specific concerns such as binge eating, nighttime eating syndrome, and food aversion. Though there are not yet empirically supported assessments and treatments for pediatric obesity, the consensus among the 12 (?) psychologists drawing from other aspects of the pediatric literature was remarkable.

The current Healthy Hospital Environment subcommittee was charged with building upon the foundation of work from the previous focus on a Fitter future subgroup. The first group developed expert guidelines for a healthy hospital environment to care for obese patients and families. In our current group, we have taken their work, and expanded to create a brief readers' poll to determine hospital employee interest and readiness to make changes to the hospital environment. A matrix was developed to allow hospitals to self-assess their progress across domains of a healthy hospital, ranging from Green initiatives, emotional safety, physical safety to food service. Finally, vignettes were sought that outlined successful implementation of healthy hospital practices, so that these stories and strategies can be utilized by other hospitals interested in making the same types of changes. These vignettes covered topics such as employee wellness, breastfeeding promotion for employees, elimination of sugar-sweetened beverages throughout the hospital, vending machine changes, and many more. Our group is looking for ways to disseminate these best practices to other hospitals.

Conclusion and Future Directions

Coordination of psychology involvement in all of the subcommittees has been successful this past year, and the group plans to continue coordinating efforts in the next year’s activities. The group continues to engage in activities and use language that is supportive of APA and Div 54 objectives. Toward that end, we have contacted APA officials and spoken to the Div 54 board about our activities and are willing to hear any suggestions, concerns, or queries. Future goals include 1) lending psychology’s perspective to the national initiatives toward obesity prevention, treatment and toward research into pediatric obesity, 2) communicating what is happening in each of the subcommittees among the group of psychologists and assist each other in promoting discipline-specific issues and 3) collaborating together toward the presentation of standard of practice guidelines for the assessment and treatment of overweight youth (including a web-published written guideline, national interactive webinar, and journal publication).