Telemedicine and Face-to-Face Care for Pediatric Obesity

Background

The Institute of Medicine reports that the prevalence of childhood obesity has doubled among children 2–5 years old and tripled in children 6–11 years old in the past 30 years. ¹ Obesity is particularly challenging in rural areas where patients experience lower access to healthcare along with an increased high fat and calorie diet. ² The University of California Davis Medical Center (Sacramento, CA) has pioneered the use of telemedicine in its approach to childhood obesity to cover more than 20 rural clinics in California. ³ In our study, we compared the outcomes of the Telemedicine Weight Management Clinic (TM) with those of its face-to-face (FTF) Weight Management Clinic counterpart over the last 5 years, predicting the results to be equivalent or in favor of TM.

Subjects and Methods

All children seen in the TM clinic from June 2006 to June 2011 were included (n=121), and encounter notes in medical records were reviewed. For comparison, an equivalent sample of FTF patients was selected from that time frame (n=122). Data that were also abstracted from the medical record included age at first visit, gender, race, referral site, and comorbid diagnoses. The body mass index (BMI) z-score, also known as the BMI standard deviation score, was used as a measure of BMI because the patient's age and gender were factored into the calculation. ⁴ First, we studied outcomes that compared the management of clinicians in both clinics. These included the following: (1) changes or additions to patient diagnosis, (2) changes or additions to diagnostic evaluation (laboratory investigations or imaging), and (3) changes or additions to treatment (dietary counseling, activity recommendations, or medications). Second, we evaluated patient outcomes for those patients who attended more than one TM or FTF consultation. These included the following: a qualitative, patient-reported (1) improvement in patient diet, (2) increased activity level, or (3) decrease in screen time (includes both television and computer use) or (4) a quantitative, physician-reported weight status (weight maintenance, weight loss, or slowing of the rate of weight gain). Telemedicine and in-person consultations consisted of interdisciplinary evaluations provided by a general pediatrician with additional training and expertise in childhood weight management and a registered dietician. Although physicians used the same practice management guidelines, a major limitation of the study was that most clinical care (97%) was performed by one of two physicians, one of whom only worked in FTF. The patient populations for the two groups differed significantly on several important measured characteristics and likely differed on several important unmeasured characteristics, such as socioeconomic status and other unique issues that contrast urban and rural lifestyles, for which we are unable to adjust. Therefore, unadjusted frequencies are presented here for the purpose of informing future studies.

Results

The final sample included 122 FTF patients and 121 TM patients (Table 1). The average age of children in both groups was approximately 11 years, and both groups had average BMI values that were approximately 2.5 standard deviations above the reference mean for the patients' age and gender. The two study groups differed significantly on the number of clinical consultations and race/ethnicity. When comparing patients with more than one visit, n was 41 for TM and 63 for FTF. A few records were unavailable for practitioner outcomes, resulting in slightly decreased numbers of patients available for the frequencies.

Discussion

Our findings demonstrate that telemedicine is a feasible strategy to increase access to high-quality care for childhood obesity in underserved rural communities with promise for future studies that may suggest outcomes equivalent or superior to FTF care.

Patients seen at FTF and TM had differing demographic characteristics. The FTF group was composed of more African Americans and fewer Latinos than the TM group, which is possibly because of TM serving primarily rural patients and FTF serving a more urban demographic. These communities differed in various ways that were relevant to obesity, ranging from access to nutritious foods to cultural practices. Patient demographic data we collected and our smaller sample size did not allow a subgrouping, but future studies would benefit from controlling for such a disparity. The TM group also had significantly fewer patients who attended more than one visit, and the TM patients who attended multiple visits tended to participate in more frequent consultations (greater than five). This may have selected for a more motivated group of subjects in the TM group in the analyses restricted to patients with more than one consultation.

We noted fewer changes in diagnostic evaluation as a result of consultation in the TM group. This could possibly be associated with differences in consultation styles between TM and FTF but is more likely a result of limited access to diagnostic evaluation tools in rural areas. Because the TM group tended to have more patients who participated in a greater number of visits, continuity of care and frequent follow-up could be successfully maintained in a TM consultation framework.

One weakness of our study was the small number and unbalanced distribution of consulting physicians between the two groups. However, all physicians who provided clinical consultations to patients in this study utilized uniform practice guidelines and were familiar with both FTF and TM visits. Future studies that compare the outcomes of TM and FTF visits should address ways to provide a more balanced distribution of visits among physicians. Despite this challenge, our study suggests that telemedicine can serve as a practical strategy to increase access to medical care for childhood obesity in rural communities and to promote changes in lifestyle with the goal of maintaining a healthy weight. We acknowledge that obesity is a multifactorial disease process and that medical care is just one part of the complex model of ensuring healthy weight maintenance. However, our findings suggest that telemedicine is a feasible tool to provide high-quality care for childhood obesity.