Anda di halaman 1dari 22

Cost-Effectiveness of a Clinical

Childhood Obesity Intervention


Mona Sharifi, MD, MPH,a Calvin Franz, PhD,b Christine M. Horan, MPH,c Catherine M. Giles, MPH,d
Michael W. Long, ScD,e Zachary J. Ward, MPH,d Stephen C. Resch, PhD,f Richard
Marshall, MD,g Steven L. Gortmaker, PhD,d Elsie M. Taveras, MD, MPHc,h

OBJECTIVES: To estimate the cost-effectiveness and population impact of the national abstract
implementation of the Study of Technology to Accelerate Research (STAR) intervention
for childhood obesity.
METHODS: In the STAR cluster-randomized trial, 6- to 12-year-old children with obesity
seen at pediatric practices with electronic health record (EHR)-based decision support
for primary care providers and self-guided behavior-change support for parents had
significantly smaller increases in BMI than children who received usual care. We used a
microsimulation model of a national implementation of STAR from 2015 to 2025 among all
pediatric primary care providers in the United States with fully functional EHRs to estimate
cost, impact on obesity prevalence, and cost-effectiveness.
RESULTS: The expected population reach of a 10-year national implementation is ∼2 million
children, with intervention costs of $119 per child and $237 per BMI unit reduced. At
10 years, assuming maintenance of effect, the intervention is expected to avert 43 000
cases and 226 000 life-years with obesity at a net cost of $4085 per case and $774 per life-
year with obesity averted. Limiting implementation to large practices and using higher
estimates of EHR adoption improved both cost-effectiveness and reach, whereas decreasing
the maintenance of the intervention’s effect worsened the former.
CONCLUSIONS:A childhood obesity intervention with electronic decision support for clinicians
and self-guided behavior-change support for parents may be more cost-effective than
previous clinical interventions. Effective and efficient interventions that target children
with obesity are necessary and could work in synergy with population-level prevention
strategies to accelerate progress in reducing obesity prevalence.
NIH

aDepartment of Pediatrics, Section of General Pediatrics, Yale University School of Medicine, New Haven, What’s KnoWn on this subject: Excess health
Connecticut; bEastern Research Group Inc, Lexington, Massachusetts; cDivision of General Academic
Pediatrics, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, Massachusetts;
care costs attributable to obesity demand effective
Departments of dSocial and Behavioral Sciences and hNutrition, and fCenter for Health Decision Science, and efficient strategies. To facilitate appropriate
Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts; eDepartment of resource allocation, economic evaluations can aid
Prevention and Community Health, Milken Institute School of Public Health, George Washington University, explicit assessments of intervention efficiency and
Washington, District of allow for comparisons between interventions. Such
Columbia; and gDepartment of Pediatrics, Harvard Vanguard Medical Associates and Atrius Health Inc, Boston,
Massachusetts
analyses are lacking in pediatric obesity
management.
Dr Sharifi conceptualized and designed the study, drafted the initial manuscript, and reviewed
and revised the manuscript; Dr Franz assisted with the cost analysis of the Study of Technology What this study adds: A childhood obesity
to Accelerate Research (STAR) trial and critically reviewed and revised the manuscript; intervention involving electronic decision support
Ms Horan assisted with the acquisition of cost data for the STAR trial and critically reviewed the in primary care improved BMI at a cost of $119
manuscript; Ms Giles and Drs Long, Resch, and Marshall contributed to the conceptualization per child and $237 per BMI unit reduced. National
and design of the study and critically reviewed and revised the manuscript; Mr Ward contributed implementation over 10 years could reach >2
to the conceptualization and design of the study, conducted the microsimulation modeling, and million children and avert 43 000 obesity cases.
critically reviewed and revised the manuscript; Dr Gortmaker contributed to the conceptualization
and design of the study, led the Childhood Obesity Intervention Cost-Effectiveness Study as
to cite: Sharifi M, Franz C, Horan CM, et al. Cost-
Effectiveness of a Clinical Childhood Obesity
Intervention. Pediatrics.
2017;140(5):e20162998
PEDIATRICS Volume 140, numberD5o, Nwonvleomadbedr 2fr0o1m7:eh2t0t1p6:/2/9p9e8diatrics.aappublications.org/ by guest article
on November 20, 2017
tabLe 1 Components of the STAR Intervention, Including Point-of-Care Electronic Decision Support care, when seen at pediatric primary
for Clinicians and Self-Guided Behavior-Change Support for Parents
care practices randomly assigned

2 Downloaded from http://pediatrics.aappublications.org/ by guest on November 20, 2017 SHARIFI et al


Intervention Details to an intervention that included
Components electronic clinical decision support
EHR modifications Best Practice Advisory in the Epic EHR (CDS) for pediatricians and self-
Alerts pediatrician of BMI ≥95th percentile when height and weight are guided behavior-change support for
measured and documented into the EHR for children ages 6–12 y parents.15,16
Includes links to the following:
1. A prepopulated SmartSet order entry and note template (see below Clinicians, administrators, and policy
for details) makers face increasing demands
2. Centers for Disease Control and Prevention growth charts
on time and resources to achieve a
3. Evidence-based childhood obesity screening and management
guidelines2, broad range of child health goals.
4 Economic evaluations of proven
4. The STAR study Web site, which housed: interventions empower decision-
Printable patient-education handouts on obesity-related behavior change makers with the information needed
A list of local weight management programs
to prioritize interventions that
Searchable database of local physical activity programs near a given
address provide the best value to patients and
Training materials on the EHR tools and how to use them the health system. To date, there are
Additional resources to aid clinicians during follow-up obesity visits few such analyses of interventions
(an outline for how to structure visits) to manage children with obesity in
SmartSet well child visit order entry and note template specific for obesity
clinical settings. A recent systematic
that facilitates:
Documentation and coding of BMI percentile categories and nutrition and review of primary care–based
physical activity counseling (to comply with HEDIS recommendations) as well interventions for childhood obesity
as obesity and obesity-related comorbidities calls into question their value in
Referrals to weight management programs, nutritionists, or producing clinically meaningful
subspecialty clinics (eg cardiology and endocrinology)
outcomes and highlights the
Orders for obesity-related screening laboratory tests, if appropriate
Text on healthy behaviors for inclusion in the after-visit summary importance of examining financial
routinely provided to families costs from both the individual
Clinician training On-site presentations to pediatric practices to demonstrate EHR and societal perspectives.17 In
modifications and resources this study, we examined the costs
Biweekly performance feedback e-mails regarding adherence to HEDIS
associated with the STAR clinical
performance measures
Materials for Posters displayed in pediatric practices promoting health behavior change
Materials mailed to families quarterly, including 4 newsletters and 4
childhood obesity intervention
families
magazines about healthy eating with the following 2 goals: (1) to
HEDIS, Healthcare Effectiveness Data and Information Set. inform clinicians and policy makers
about what investment would be
Clinical interventions to manage required to adopt this intervention
demands for screening and
childhood obesity have the potential in other pediatric primary care
prevention that exceed what they can
to reduce the prevalence of obesity settings, and (2) to evaluate the cost-
feasibly manage within the limits of
in adults, improve long-term effectiveness and population impact
well-child care.9–12
quality of life, and reduce health of the intervention if implemented
care costs.1 Both a 2010 report of nationally.
The use of electronic health records
the US Preventive Service Task
(EHRs) has increased rapidly over
Force2 and a Cochrane review3 the last half-decade, likely fueled Methods
concluded that comprehensive, high- by federal financial incentives.13,14
intensity behavioral interventions EHR functionality can be leveraged to intervention and effect estimate
for childhood obesity, compared facilitate childhood obesity The modeled intervention was based
with usual pediatric clinical care, management by prompting diagnosis on the STAR cluster-randomized
could reduce the prevalence and providing decision support and clinical trial conducted from 2010 to
of overweight among children. electronic resources for evaluation, 2013 at Harvard Vanguard Medical
However, the adoption of expert management, and follow-up care. In Associates and Atrius Health Inc, a
recommendations4 and nationally the recent Study of Technology to multisite group practice in eastern
standardized performance measures5 Accelerate Research (STAR) clinical Massachusetts.15,16 Intention-to-treat
for childhood obesity management trial, 6- to 12-year-old children with analyses demonstrated a smaller
in pediatric primary care has been obesity had a smaller increase in BMI increase in BMI over 1 year among
limited.6–8 Clinicians face competing after 1 year, compared with usual 194 children ages 6 to 12 years

PEDIATRICS Volume 140, number 5, DNoovwemnlboearde2d01f7rom http://pediatrics.aappublications.org/ by guest on 3


November 20, 2017
tabLe 2 Population Reach, Cost, and Effectiveness Results From a 10-Year Microsimulation Model EpicCare ambulatory EHR software
of the National Implementation of the STAR Clinical Childhood Obesity Intervention, 2015–
(Epic Systems, Verona, WI). Table
2025
1 summarizes the intervention’s
Population Reach Mean 95% UI components, which are reported in
10-y reach, millions 2.0 1.8 to 2.2 detail elsewhere.15,16
First-year reach, millions 0.6 0.5 to 0.6
Intervention effect
1-y BMI change −0.5 −0.9 to −0.1 Modeling Framework
Intervention costs
The Childhood Obesity Intervention
10-y total cost, $ (millions) 239 186 to 292
Annual costs, $ (millions) 24 19 to 29 Cost-Effectiveness Study (CHOICES)
Cost per child 119 94 to 145 has been described in detail
10-y totals (2015–2025) previously.18 In brief, this modeling
Years with obesity averted, thousands 226.0 56.6 to 323.7 framework builds on the Australian
Obesity costs averted, $ (millions) 64 16 to 92
Assessing Cost-Effectiveness
Net costs difference, $ (millions) 175 105 to 263
Health care costs saved per dollar invested, $ 0.27 0.06 to 0.45 intervention19,20 in obesity21 and
2025 projected obesity prevalence prevention22 methodologies to
Overall obesity prevalence reduction, % 0.01 0.00 to 0.02 evaluate the national implementation
Cases of obesity averted, thousands 42.8 9.8 to 63.9
of childhood obesity interventions in
Child obesity prevalence reduction, % 0.05 0.01 to 0.08
Cases of child obesity averted, thousands 37.9 9.0 to 55.5 the United States through a rigorous,
Cost-effectiveness ratios,a $ stakeholder-informed process. The
Intervention cost per BMI unit reduction per child 237 106 to 1276 CHOICES microsimulation model is a
Net cost per year with obesity averted 774 327 to 3763 stochastic, discrete-time, individual-
Net cost per case of obesity averted 4085 1691 to 20 550 level model programmed in Java
Costs are in 2014 dollars and discounted at 3% per year.
a
that simulates an open cohort of
Incremental cost-effectiveness ratios comparing the intervention with usual care.
the US population from 2015 to
2025. The model estimates the cost-
tabLe 3 Projected Component Costs for the STAR Intervention Implemented Nationally Among effectiveness of obesity interventions
Pediatric PCPs With Fully Functional EHRs, 2015–2025
through their impact on BMI, obesity
Intervention Costs 10-y Total Costs, $ Per Child Costs, $: Mean Percent of
(Millions): (95% UI) Total Costs prevalence, and obesity-related
Mean (95% UI) health care costs over the 10-year
Total cost 239.0 (185.7 to 292.3) 119.4 (94.13 to 145.18) 100 simulation ending in 2025 and
Start-up costs 9.7a 4.84 (4.47 to 5.29) 4.1 following guidelines of the first
EHR modifications 2.7a 1.33 (1.22 to 1.45) 1.1
US Panel on Cost-Effectiveness in
Web site development 5.3a 2.65 (2.45 to 2.90) 2.2
PCP training 0.5a 0.27 (0.25 to 0.30) 0.2
Health and Medicine.23 We report
Material development 1.2a 0.59 (0.55 to 0.65) 0.5 cost per unit change in BMI, per
Ongoing costs 229.3 (176.0 to 282.6) 114.56 (89.19 to 140.26) 95.9 case of obesity averted, and per year
PCP training, 3.5a 1.75 (1.62 to 1.91) 1.5 with obesity averted as the primary
performance feedback measures of cost-effectiveness.
Web site maintenance 9.4a 4.72 (4.36 to 5.16) 4.0 Additional details about the model,
Additional PCP time per 30.6 (−8.5 to 64.5) 15.31 (−4.42 to 32.61)
12.8 including the logic pathway linking
child
Mailings to families 185.7 (152.3 to 216.5) 92.78 (77.54 to 106.80) 77.7 the STAR intervention to change in
a Based on deterministic estimates from the STAR trial and dissemination.
obesity-related outcomes and health
care costs (as well as the model
parameters), are provided in the
with BMI ≥95th percentile seen at at the point of care to promote
Supplemental Information.
the 5 practices randomly assigned recognition and recommended
to the intervention (−0.51 [95% management of obesity among 6- to
Population Reach
confidence interval, −0.91 to −0.11]) 12-year-old children during pediatric
compared with 184 children seen at well-child care. Parents also received The target population for the
the 4 practices randomly assigned materials by mail 4 times during the intervention scaled to the national
to usual care, adjusted for clustering 1-year intervention to support self- level is all children in the United
by practice site and for patient and guided health behavior change for States ages 6 to 12 years with a
parent demographic characteristics. their children. The EHR modifications BMI ≥95th percentile seen by
included diagnosis and screening pediatric primary care providers
The intervention involved EHR-based prompts and decision support for (PCPs) who have “fully functional”
CDS and training for pediatricians obesity management using the EHRs24,25 capable of the type of
among US children with a BMI ≥95th
percentile.18

Measuring costs

To estimate costs associated with


national implementation, we
followed standard guidelines28–31
and adopted a modified societal
perspective, which includes direct
medical costs and nonmedical
costs (such as postage for mailings,
refreshments for physician trainings,
etc) but excludes the opportunity
cost of time spent by families
making lifestyle changes. See
Supplemental Table 4 for details of
the cost analysis. Cost calculations
were in 2014 dollars, adjusted for
inflation by using the US Bureau
of Labor Statistics Consumer
Price Index, and discounted at
3% per year. We assessed 1-time,
start-up intervention costs of
modifications to the EHR, Web site
development, PCP training, and the
development of materials for self-
FiGuRe 1 guided behavior-change support
Cost-effectiveness planes showing the mean intervention costs and effectiveness estimates from for parents; we treated start-up
10-year microsimulation models of the STAR clinical childhood obesity intervention, with varying
scenarios of national implementation by practice type and by using different estimates for EHR costs as capital costs annualized
adoption (2015–2025). HHS, Health and Human Services. All metrics are reported for the over a 10-year period. We used
population over a 10-year period (2015–2025) and discounted at 3% per year. cost data from the dissemination
of STAR to another practice setting
decision receiv one-year To various ion to s, or per
-support ed a BMI calculat practice to conserv labor child
settings estimate atively atory , (2)
tools health change e the
the estimate order per
used in benefi observed target (eg,
interventi the s PCP,
STAR. t from in the populat solo or
on’s program betwe (3)
Supplem the STAR ion and 2-
reach ming en the per
ental interv trial the provid
costs interv grou
Figure 3 ention would be interve er
associat entio p of
displays (the reproduc ntion’s practic
ed with n and pedi
a benefi ible in potenti es,
the EHR usual- atric
hierarch ting other al reach multis modifica care PCPs
ical popul pediatric (Supple pecialt tions. childr shari
represe ation) primary mental y We en ng a
ntation were care Table group calculate durin fully
of the equal. settings. 4), we or d g the func
interven We first health ongoing yearlo tion
tion’s furthe approxi mainte costs of ng al
target r mated nance continue trial EHR
populati assum the organi d (E.M.T syste
on. ed proport zation training ., m,
Because that ion of practic and unpu and
the all all US es, perform blishe (4)
effect pedi childre etc)25 ance d per
estimate atric n ages 6 and feedbac data). PCP
used to PCP to 12 the k to We prac
calculat grou years averag PCPs, scaled tice
e health ps (per 2010 e Web site estim shari
benefits with US census numbe mainten ated ng a
was fully estimates r of ance, interv physical
childre addition entio location
based funct ) seen for
al n (see
on ional well-child n ages
clinical costs Suppleme
intentio EHRs care by 6 to 12
time to the ntal
n-to- woul pediatric years
old spent by natio
treat d PCPs with
seen the PCPs nal
analyses impl fully
per level
from the eme functional by
child, on the
STAR nt EHRs. To pediat
and basis
trial, we the do this, ric
mailings of
assume inter we PCPs
to w
d that venti collected in each
parents. he
the total on published of
We th
number with estimates these
did not er
of high of the practic observe co
children fideli number e differen sts
reached ty of setting ces in w
by the and pediatric s.27 We the er
interven that PCPs in used frequen e
tion (the the the this cy of in
intent- inter United propor follow- cu
to-treat venti States26 tion in up rr
populati on with fully the visits, ed
on) and effec functional micros clinical (1
who ts on EHRs in imulat referral )
Table 4 for details). Finally, health in Supplemental Table 4.25 To would cost $239 million (95% UI,
care cost savings because of the account for the likely continued $186 million to $292 million), or
intervention were modeled over the uptake of EHRs from 2012 to our $119 (95% UI, $94 to $145) per child
10-year simulation period based on simulation period of 2015 to 2025, reached (Table 2). Relative to usual
associations between obesity and we considered 2 additional scenarios care, the intervention could reduce
health care costs from national data, with higher estimates of EHR mean per capita BMI by 0.5 U (95%
as previously detailed.18,32 adoption (Supplemental Table 4). UI, 0.1 to 0.9) among those reached,
In the first, we assumed the pace with an estimated intervention cost
uncertainty and sensitivity analyses of increase in EHR adoption per of $237 (95% UI, $106 to $1276) per
We conducted probabilistic year observed from 2009 (range BMI unit reduced. Over 10 years, the
uncertainty analyses by 3.5%–14.5%) to 2012 (range 3.3%– BMI reductions would avert ∼$64
simultaneously sampling parameter 30.1%)25 continued through 2015 million in health care costs (95% UI,
values from predetermined (range 3.3%–45.7%). We applied $16 million to $92 million), partially
distributions. We report mean values these estimates to model national offsetting the intervention cost and
and 95% uncertainty intervals (UIs) implementation among all practices resulting in a 10-year net cost of
using Monte Carlo simulations over and then among large practices only. $175 million (95% UI, $105 million to
1000 iterations of the model for a Next, we modeled a more ambitious $263 million). At 10 years, assuming
population of 1 million individuals scenario, assuming 65% fully the BMI reductions during the
scaled to the national population functional EHR adoption among PCPs intervention persist, the intervention
size. In addition to the probabilistic at large practices in 2015 based on would avert 42 900 (95% UI, 9800 to
sensitivity analysis, we evaluated the fiscal year 2014 target for EHR 63 900) cases of obesity and 226
the impact of varying the model’s adoption among office-based PCPs 000 (95% UI, 56 600 to 323 700)
assumptions. defined by the US Department of life- years with obesity at a net cost
Health and Human Services.33 of
Varying Implementation Based on $4085 per case (95% UI, $1691 to
Practice Size Varying Maintenance of the $20 550) and $774 per year (95% UI,
To examine potential economies of Intervention’s Effect $327 to $3763) with obesity averted.
scale, we conducted a scenario Finally, given uncertainty around our Table 3 shows the total, start-up, and
analysis limiting the implementation assumption of effect maintenance, ongoing costs of the intervention
of the intervention to large we examined the impact of the in detail. The majority of the
practices only, ie, multispecialty linear decay of the intervention intervention costs are attributable
group practices and medical effect over various time frames (10, to the mailings of newsletters and
school– and hospital-based clinics. 7, 5, and 3 years), in which weight magazines to families (78%) and
These large practices likely have gradually reverts back to the baseline additional time spent by PCPs during
more information technology trajectory over the specified time clinical visits (13%).
infrastructure and established period.
relationships with their EHR vendors, Figure 1 displays the results of the
which would potentially diminish scenario analyses (detailed results
the costs of making modifications to ResuLts shown in Supplemental Table 5).
their EHRs. To estimate information Limiting the implementation of
The national implementation of a the intervention to large practices,
technology programming costs
clinical childhood obesity including multispecialty group
in these scenarios for the EHR
intervention with EHR-based CDS for practices and medical school– and
modifications, we used direct cost
clinicians and self-guided behavior- hospital-based clinics, reduced the
estimates from the STAR trial
change support for families from projected population reach by 25%
conducted in a multispecialty group
2015 to 2025 would affect >6000 to 1.5 million (95% UI, 1.4 million to
practice with a well-established EHR.
pediatricians with fully functional 1.7 million) children but also reduced
Varying Estimates of EHR Adoption EHRs who provide care to 10.5% of the net cost of the intervention by
Among PCPs the 24.6 million children ages 6 to 12 29% to $124 million (95% UI, $71
years in the total US population. million to $191 million). Increasing
In the base case, we modeled the
impact of the intervention among Table 2 displays the results of the the estimates of fully functional
PCPs with fully functional EHRs microsimulation. Over 10 years, EHR adoption among pediatricians
using conservative estimates of the intervention would reach ∼2 expanded the intervention reach and,
EHR adoption based on a 2012 million (95% UI, 1.8 million to 2.2 in turn, population health benefits.
survey of pediatricians, as detailed million) children with obesity and If federal goals for EHR adoption33
were achieved among pediatric PCPs,
the intervention could reach 3.7 settings only versus all pediatric subsidies for advertising unhealthy
million children (95% UI, 3.4 million primary care practices with fully food to children ($0.66), and
to 4 million), even if limited to large functional EHRs). These per-child nutrition standards for all other food
practice settings, and potentially costs are lower than the $196 and beverages sold in schools ($6.10)
avert 79 200 (95% UI, 20 000 to per-child incremental cost (2011 are much less than for bariatric
114 900) cases of obesity. surgery ($1600).18,39 Preventing
US dollars) reported in the only
Finally, Supplemental Fig 4 shows previous US study that examined obesity among children requires
the cost-effectiveness outcomes (cost relatively small changes in energy
the cost of a primary care–based
per case of obesity averted and cost balance, an average reduction of
intervention for childhood obesity
per year with obesity averted) when 64 kcal per day in the youth daily
among preschool-aged children,
we vary our assumption regarding energy gap would meet Healthy
a trial that did not demonstrate a 40–42
People 2020 goals. However,
how long the intervention's effect is significant effect on BMI.34 Notably,
maintained. We observed an inverse, far more substantial energy deficits
this previous cost analysis did not are necessary to reduce BMI among
linear relationship between the
include the costs of clinician training children who already have obesity.
duration of effect maintenance and
but did include estimates of family The projected impact of the STAR
the cost-effectiveness estimates.
time and out-of-pocket costs because intervention on the prevalence of
For example, the cost per year
with obesity averted changes from the intervention involved additional, obesity is high and intervention
$774 (95% UI, $327 to $3763) in study-specific visits (unlike STAR). costs are low when compared with
the base case to $3543 (95% UI, Another US study of family-based other clinical interventions, such as
$2214 to $11 154) assuming 3-year group treatment of parents and bariatric surgery.18
maintenance of effect. 8- to 12-year-old children with
overweight or obesity estimated Our examination of intervention
that the intervention cost $1448 costs revealed that direct mailings
discussion per family and $209.17 per percent to families would account for
The national implementation of reduction in BMI percentile over the 78% of the costs associated with
the STAR clinical childhood obesity 95th percentile (currency year not national implementation. Newer
intervention over 10 years could reported).35 The lack of comparable approaches using remote and
reach a projected 2 million 6- to strategies to estimate both costs mobile technologies, such as patient
12-year-old children with obesity. and outcomes makes comparisons portals and text messaging, might
Intervention costs were ∼$119 per between studies difficult, especially substantially lower ongoing costs
child and $237 per unit change in because many studies are from and allow for dissemination of
BMI under our baseline assumptions outside the United States. Yet, among tailored materials that may further
for national implementation. At 10 the cost-effectiveness analyses of improve outcomes.43,44 Additional
years, assuming maintenance of the primary care–based interventions time spent by PCPs during clinical
intervention effect, the intervention that have been conducted in other visits with each child accounted for
could avert 43 000 cases of obesity countries, the adjusted mean ∼13% of total costs. These costs
and >226 000 life-years with obesity. difference in BMI of the STAR was were based on our conservative,
Limiting the implementation to greater in magnitude than those stakeholder-informed estimates and
large practice settings with potential reported for these other studies, 36–38 not on actual data from time studies
economies of scale improved and the per-child cost of STAR with clinicians. It is feasible that
measures of cost-effectiveness, and appears to be lower.34 improved integration of CDS tools
higher national EHR adoption would into clinician workflows could reduce
increase population reach up to 3.7 Supplemental Table 6 compares these time costs and further improve
million children. More conservative STAR with 13 other childhood cost-effectiveness.
estimates around the maintenance obesity interventions using the
CHOICES microsimulation model. Despite rapid increases in EHR
of the intervention’s effect worsened
Projected reductions in childhood adoption nationally, most of the
cost-effectiveness projections.
obesity prevalence are more development, research, and funding
The per-child incremental cost of the substantial with cost-saving, of EHR-based CDS has been focused
modeled STAR intervention population-level strategies than on adult patients, and well-developed
compared with usual care ranged clinical interventions. For example, features tailored to pediatric settings
from $113 to $119 depending on the the cost per BMI unit change for have lagged behind.45 Although
implementation scenario considered sugar-sweetened beverage taxes office-based pediatricians report
(ie, implementation at large practice ($2.49), the elimination of tax rates of EHR adoption comparable
to estimates for all office-based available. Second, the model carries of implementation because we
physicians (79% with any EHR in the base case assumption that the assumed that each health system
2012), only 1% of pediatricians intervention effects on 1-year weight would implement the intervention
reported having fully functional changes that are observed in the independently and create materials
EHRs with pediatric-supportive STAR trial will be (1) maintained and and resources de novo when, in fact,
features (“weight-based medication stable beyond 1 year and (2) resources developed for the STAR
dosing, tracking recommended reproducible study are available for dissemination.
well-child visits and immunizations, in other pediatric primary care Therefore, the projected benefits may
calculating catch-up immunizations, settings. Given the lack of long- be an underestimation, and true
and plotting growth charts and term follow-up of clinician practice costs may be lower.
computing BMI”).25 In response, and child BMI to support the first
federal standards were released in assumption, we present sensitivity
2013 to encourage the development analyses with varying maintenance concLusions
of pediatric-supportive EHR features of the intervention’s effect. For the Implementing electronic decision-
with plans to include them in second, implementation success at support tools to facilitate obesity
future criteria for meaningful use other practice settings will management in pediatric primary
incentives.46 Our sensitivity analyses certainly be modified by the unique care may be a more cost-effective
demonstrate greater population features of the patient population, strategy than previous clinical
reach with higher rates of fully clinicians, and the practice overall, interventions, although it may be less
functional EHR adoption, and the such as regional variations in care cost-effective than policies such as
integration of pediatric-supportive delivery and obesity prevalence. taxes and school-based interventions.
features into existing EHR platforms However, High-quality and efficient clinical
will likely further reduce the costs continued training and performance interventions that target children at
associated with implementation. feedback efforts included in our high risk who already have obesity
implementation scenario may support are necessary and could work in
This study has several limitations.
long-term fidelity of the intervention. synergy with population-level,
First, the effect and cost
Lastly, our base case model uses primary prevention strategies to
estimates used in our model are
2012 data on EHR adoption among accelerate progress in reducing the
based on
pediatric practices.25 To address the prevalence of childhood obesity.
a single study and subject to the
likely higher uptake in 2015 (the
study’s limitations. Although STAR
start of the model’s simulation
was a cluster-randomized trial with
period),
objective growth measures that
we conducted scenario analyses with
ensured high-quality and reliable abbReviations
higher levels of adoption.
results, residual confounding
CDS: clinical decision support
could remain, and results may not We did not consider intervention
CHOICES: Childhood Obesity
generalize to uninsured and lower- impact beyond the 10-year
Intervention Cost-
income populations in different simulations nor the potential collateral
Effectiveness Study
geographic regions. To address benefits,
EHR: electronic health record
the uncertainty around the effect or ripple effects,47 from changes in
PCP: primary care provider
estimate, we conducted probabilistic weight or health behaviors among
STAR: Study of Technology to
sensitivity analyses, and to improve families of children involved in the
Accelerate Research
the generalizability of our estimates intervention. We also did not consider
UI: uncertainty interval
of cost, we used national data to the impact of behaviors promoted by
estimate labor and material costs, if the intervention (improved nutrition,
activity, and sleep) on health
outcomes other than weight
trajectories. The results may
overestimate the cost
principal investigator, and critically reviewed and revised the manuscript; Dr Taveras conceptualized and designed the STAR trial as principal investigator and
critically reviewed and revised the manuscript; and all authors have made substantial contributions to conception and design, acquisition of data, or
analysis and interpretation of data; drafted the article or revised it critically for important intellectual content; and approved the final manuscript as
submitted.
This trial has been registered at www.clinicaltrials.gov (identifier NCT01537510).
doi: https://doi.org/10.1542/peds.2016-2998
Accepted for publication Aug 2, 2017
Address correspondence to Mona Sharifi, MD, MPH, Department of Pediatrics, Section of General Pediatrics, Yale University School of Medicine, 333 Cedar St, PO
Box 208064, New Haven, CT 06520-8064. E-mail: mona.sharifi@yale.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2017 by the American Academy of Pediatrics
FinanciaL discLosuRe: The authors have indicated they have no financial relationships relevant to this article to disclose.
FundinG: The Study of Technology to Accelerate Research was supported by the American Recovery and Reinvestment Act of 2009 (R18AE000026). The
Childhood Obesity Intervention Cost-Effectiveness Study was supported in part by grants from The JPB Foundation, the Robert Wood Johnson Foundation (grant
66284), and the Centers for Disease Control and Prevention (grant U48/DP001946), including the Nutrition and Obesity Policy Research and Evaluation Network.
Dr Sharifi was supported by grants (K12 HS 022986 and K08 HS024332) from the Agency for Healthcare Research and Quality. Dr Taveras was supported by a
National Institutes of Health (NIH) grant (K24 DK10589) from the National Institute of Diabetes and Digestive and Kidney Diseases. This work is solely the
responsibility of the authors
and does not represent the official views of the Centers for Disease Control and Prevention or any of the other funders. Funded by the National Institutes of Health
(NIH).
PotentiaL conFLict oF inteRest: The authors have indicated they have no potential conflicts of interest to disclose.
ReFeRen fi ve st h m 5. a //w
ces n nti at r m Nat n ww
al ve e a en ion d .nc
1.
- Se m n da al qa.
Worl
r rv e e ti Co I or
d
e ic n D on m n g/
Healt
p es t. a s mit f Po
h
o Ta P t fo tee o rtal
Orga
rt sk e a r for r s/0
nizati
- Fo d b tr Qu m /W
on.
a rc i a ea alit a eig
Repo
u e. a s t y t ht
rt of
g Sc tr e m Ass As
the i
u re i S en ura ses
first o
st en c y t nce sm
meeti n
- in s. s of . ent
ng of
2 g 2 t ch We an
the S
0 fo 0 R il igh d
ad e
1 r 1 e d t Co
hoc t
4. ob 0; v an As uns
work
p es 1 . d ses eli
ing
d it 2 2 ad sm ( ng.
grou
f. y 5 0 ol ent H pdf
p on
A in ( 0 es an E .
scien
c ch 2 9 ce d D Ac
ce
c il ): ; nt Co I ces
and
e dr 3 ( ov uns S sed
evide
s en 6 1 er eli ) Se
nce
s an 1 ) w ng pte
for
e d – : ei for mb
endin m
d ad 3 C gh Nu er
g e
J ol 6 D t triti 13,
child a
es 7 0 an on 201
hood u s
l ce 3. 0 d an u 7
obesi
y nt Oud 1 ob d r
ty; 6.
2 s: e 8 es Ph e
June Hu
5 U Lutti 7 ity ysi s
18– ang
, S khui 2 . cal .
20, TT,
2 Pr s H, P Act
2014 4. Bor
0 ev Baur e ivit
; S A ow
Gene en L, di y
1 p v ski
tiv Jans at for
va, 7 ea LA,
e en a
Swit r ri Ch Liu
2. Se H, i
zerla cs ild B,
B rv et B l
nd. . ren et
a ic al. A, a
Avai 2 /A al.
lable r es Inte Ba b
rlo 0 dol Pe
at: t Ta rven l
w 0 esc dia
http o sk tion e
S 7; ent tric
://w n F s
E, 1 s; ian
ww. or for a
Er 2 He s’
who. M ce trea t
vi 0( alt an
int/e ; re ting :
n su hca d
nd- co obe
C, p re fam
chil m sity
U et pl Eff h ily
dho m in
S al 4): ecti t ph
od- en chil S25
. ven t ysi
obes da dren 4–
P R ess p cia
ity/e ti . S28
r ec Dat s ns’
cho- on Coc 8
e o a : we
ight l o Dr 11(1):1 gn ars
11.
- r m ow 8–26 of hall
8. Sharifi Mang
rela e nin the R,
M, ione- 13.
ted c 1 g STA Kl
Rifas- Smith Blumen
car a 9 in R ein
Shima R, thal D.
e of l 9 a ran ma
n SL, DeCri Stimula
chil l 9 sea do n
Marsha stofar ting the
dre o t of mi KP,
ll R, o AH, adoptio
n f h ad zed et
et al. Setodj n of
in d r vic co al.
Evalua i CM, health
the o o e: ntr Co
ting et al. informa
U.S. c u pe oll mp
the The tion
Am t dia ed arat
g imple qualit technol
J o tric tria ive
h mentat y of ogy.
Pre r ian l to eff
2008 ion of ambu N Engl
v c . s acc ect
expert latory J Med.
Me o Arch an eler ive
comm care 2009;36
d. m Pedi d ate nes
ittee delive 0(15):1
201 m atr A 477– ado s of
1;4 recom red to
u Adol me 1479 ptio chil
1(1) mend childr
n esc rica n of dho
:24 ations en in 14.
i Med. n chil od
–32 for the Blumenthal
c 201 Ac dho obe
obesit Unite D.
7. a 2;16 ade od sity
6(4): y d Launching
P t my obe int
317 assess State HITECH.
e i of sity erv
– ment. s. N N Engl
r o Pe com ent
322 Clin Engl J Med.
r n dia para ion
Pedia J 2010;3
i tric 62(5): tive s
tr Med.
n s 382– effe in
o (Phila) 2007;
E pol 385 ctiv pediatr
f . 357(1
M icy enes ic
w 2013; 5):151 15.
, sta s primar
e 52(2): 5– Ta
S te rese y care:
i 131– 1523 ve
k me arc a
g 138 ra
i nts 12. Norlin h. cluster-
h s
9. . C, Con random
n t
Schor Pe Craw E tem ized
n s EL. dia ford M, p clinical
e t Rethink MA, M Clin trial.
r a tri
ing Bell ar Tria
A t cs. JAMA
well- CT, sh ls.
C u 200 Pediatr.
child Shen all 201
, s care. 6;11 2015;1
8(4). g X, R, 3;34 69(6):
S : Pediat
Avai Stein H (1):1 535–
t n rics.
lable MT. or 01– 542
e a 2004;
at: Delive an 108
i t 114(1) 17. Sim
ww ry of C
n i :210– 16. LA,
w.p well- M,
e o 216 T Lebow
edia child et
r n a J,
10. care: al.
M a trics v Wang
Belam a R
J l . e Z,
arich look ati
. t org/ r Koball
PF, inside on
P r cgi/ a A,
Gandi the al
a e cont s Mura
ca R, door. e
r n ent/ d MH.
Stein Acad an
e d full/ E Brief
RE, Pedia d
n s 118 M primar
Racine tr. de
t f /4/e , y
AD. 2011; si
a r 964 M care
obesit i . essin essi c o
y l t E g ng o s
inter d x cost- the s t
venti o
h imple p effec hea t -
ons:
o ment. e tiven lth - E
a
o Health r ess ben e f
met
a- d Aff t in efit f f
anal (Millw R obes fro f e
ysis. o ood). e ity m e c
Pedi b 2015; v (ACE obe c t
atric e 34(11) P - sity t i
s. :1932 h obesi inte i v
s
201 –1939 a ty): rve v e
i
6;13 r an ntio e n
t 19.
8(4) m over ns n e
y Cart
:e20 a view i e s
er R,
160 c of n s s
a Vos
149 o the s
r T,
18. e ACE in i
e Moo c
Gortma c appr obes n
die h
ker SL, o oach ity
M, i
Wang p n , proj
Haby l P
YC, Long r O econ ect.
M, d r
MW, et o u omic Int
Mag r e
al. j t met J
nus e Obe v
T e c hods
A, n s. e
h c o and
Mih 200 n
r t m cost
alop a 6;30 t
e e e resul
oulo n (10) i
e d s ts.
s C. :146 o
R BMC d
Prio 3– n
i e Publi
t rity 147
s. c a
n o setti 5
2 Healt d (
t ng
0 h. o 22 A
e s in
0 200 l . C
r a heal
8 9;9: e Vos E
v v th:
; s T, -
e origi 419
e 8 c Ca P
n ns, 21. rte
( e r
t desc Hab r
m 6 n e
i ripti y R,
o ): t v
o on MM Ba
r 5 s e
n and re
e 9 , n
s appli : nd
3 Vos t
catio re
– T, i
t t n of t gt
6 Ca o
h the h J,
h 1 rte n
a Aus e et
a 7 r R, )
n trali al.
t et :
an 20. A
al. a
Asse Carte s
r t A s F
ssin r R, s
e h ne s i
g Moodi e
d e w e n
Cost e M, s
u y Mark ap s a
- s
c wick pro s l
Effe i
e c A, et ac i
ctive n
o al. h n
ness g R
s A to g
c initi e
t ss ass
h ative C p
o d an J.
r i Tren
t c ds in
. i elect
M n ronic
e e healt
l . h
b R recor
o e d
u c syste
r o m
n m use
e m amon
, e g
A n offic
u d e-
s a base
t t d
r i physi
a o cians
l n :
i s Unite
a f d
: o
Univers r
ity of r
Queensl e
and, p
Brisban o
e and r
Deakin t
Univers i
ity; n
2010
g
23. cost-
Sieg effec
el tive
JE, ness
Wei anal
nste yses.
in JAM
A.
MC,
199
Russ
6;27
ell
6(16
LB, ):13
Gold 39–
MR; 134
Pan 1
el
on 24.
Cost Hs
- iao
Effe CJ
ctiv ,
enes Hi
s in ng
Hea E,
lth A
and sh
Me m
States, 2007-2012. Natl Health Stat Rep. business case. Am J Public Health. obesity: development and validation
2014;(75):1–18 2008;98(3):411–415 of a quantitative mathematical
25. Lehmann CU, O’Connor KG, Shorte VA, 33. U.S. Department of Health and Human model. Lancet Diabetes Endocrinol.
Johnson TD. Use of electronic health Services. Annual performance plan 2013;1(2):97–105
record systems by office-based and report, fiscal year 2016. 2015. 41. Hall KD, Sacks G, Chandramohan D, et al.
pediatricians. Pediatrics. 2015;135(1). Available at: www.hhs.gov/about/ Quantification of the effect of energy
Available at: www.pediatrics.org/cgi/ budget/performance/goal-1-objective- imbalance on bodyweight. Lancet.
content/full/135/1/e7 f/index.html. Accessed September 11, 2011;378(9793):826–837
26. Agency for Healthcare Research and 2015
42. Wang YC, Orleans CT, Gortmaker SL.
Quality. The number of practicing 34. Wright DR, Taveras EM, Gillman MW, Reaching the healthy people goals for
primary care physicians in the United et al. The cost of a primary care- reducing childhood obesity: closing
States: primary care workforce facts based childhood obesity prevention the energy gap. Am J Prev Med.
and stats no. 1. 2014. Available at: intervention. BMC Health Serv Res. 2012;42(5):437–444
www.ahrq.gov/research/findings/ 2014;14:44
43. Sharifi M, Dryden EM, Horan CM, et al.
factsheets/primary/pcwork1/index.
35. Epstein LH, Paluch RA, Wrotniak BH, et al. Leveraging text messaging and
html. Accessed August 7, 2015
Cost-effectiveness of family-based mobile technology to support
27. Bocian AB, Wasserman RC, Slora EJ, group treatment for child and parental pediatric
Kessel D, Miller RS. Size and age-sex obesity. Child Obes. 2014;10(2):114–121 obesity-related behavior change: a
distribution of pediatric practice: a qualitative study using parent focus
36. McCallum Z, Wake M, Gerner B, et al.
study from Pediatric Research in Office groups and interviews. J Med
Outcome data from the LEAP (Live,
Settings. Arch Pediatr Adolesc Med. Internet Res. 2013;15(12):e272
Eat and Play) trial: a randomized
1999;153(1):9–14
controlled trial of a primary 44. Taveras EM, Marshall R, Sharifi M,
28. Russell LB, Gold MR, Siegel JE, care intervention for childhood et al. Connect for health: design of a
Daniels N, Weinstein MC; Panel on overweight/mild obesity. Int J Obes. clinical-community childhood obesity
Cost- Effectiveness in Health and 2007;31(4):630–636 intervention testing best practices of
Medicine. The role of cost- positive outliers. Contemp Clin Trials.
37. Wake M, Baur LA, Gerner B, et al.
effectiveness analysis in health and 2015;45(pt B):287–295
Outcomes and costs of primary care
medicine. JAMA.
surveillance and intervention for 45. Conway PH, White PJ, Clancy C. The
1996;276(14):1172–1177
overweight or obese children: the LEAP public role in promoting child
29. Weinstein MC, Siegel JE, Gold MR, 2 randomised controlled trial. BMJ. health information technology.
Kamlet MS, Russell LB. 2009;339:b3308 Pediatrics.
Recommendations of the panel on 2009;123(suppl 2):S125–S127
38. Wake M, Lycett K, Clifford SA, et al.
cost- effectiveness in health and
Shared care obesity management in 46. Agency for Healthcare Research
medicine. JAMA. 1996;276(15):1253–
3-10 year old children: 12 month and Quality (AHRQ). New children’s
1258
outcomes of HopSCOTCH randomised electronic health record format
30. Gold MR, Siegel JE, Russell LB, trial. BMJ. 2013;346:f3092 announced. 2013. Available at:
Weinstein MC. Cost-Effectiveness in
39. Cradock AL, Barrett JL, Kenney https://archive.ah rq.gov/news/
Health and Medicine. Oxford, United newsletters/research-activities/
EL, et al. Using cost-effectiveness
Kingdom: Oxford University Press; 13mar/0313RA43.html . Accessed
analysis to prioritize policy and
1996 January 15, 2015
programmatic approaches to
31. Drummond M, O’Brien B, Stoddart G, physical activity promotion and 47. Gorin AA, Wing RR, Fava JL, et al; Look
Torrance G. Methods for the Economic obesity prevention in childhood. Prev AHEAD Home Environment Research
Evaluation of Health Care Programmes. Med. Group. Weight loss treatment
2nd ed. Oxford, United Kingdom: Oxford 2017;95(suppl):S17–S27 influences untreated spouses and
University Press; 1997
40. Hall KD, Butte NF, Swinburn BA, Chow the home environment: evidence of a
32. Finkelstein EA, Trogdon JG. Public CC. Dynamics of childhood growth and ripple effect. Int J Obes.
health interventions for addressing 2008;32(11):1678–1684
childhood overweight: analysis of the
Cost-Effectiveness of a Clinical Childhood Obesity Intervention
Mona Sharifi, Calvin Franz, Christine M. Horan, Catherine M. Giles, Michael W.
Long, Zachary J. Ward, Stephen C. Resch, Richard Marshall, Steven L. Gortmaker
and Elsie M. Taveras
Pediatrics 2017;140;
DOI: 10.1542/peds.2016-2998 originally published online October 31, 2017;

Downloaded from http://pediatrics.aappublications.org/ by guest on November 20, 2017


Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/140/5/e20162998
Supplementary Material Supplementary material can be found at:
http://pediatrics.aappublications.org/content/suppl/2017/10/16/peds.2
016-2998.DCSupplemental
References This article cites 38 articles, 10 of which you can access for free at:
http://pediatrics.aappublications.org/content/140/5/e20162998.full#re
f-list-1
Subspecialty Collections This article, along with others on similar topics, appears in the
following collection(s):
Health Information Technology
http://classic.pediatrics.aappublications.org/cgi/collection/health_info
rmation_technology_sub
Electronic Health Records
http://classic.pediatrics.aappublications.org/cgi/collection/electronic_
health_records_sub
Obesity
http://classic.pediatrics.aappublications.org/cgi/collection/obesity_ne
w_sub
Permissions & Licensing Information about reproducing this article in parts (figures, tables) or
in its entirety can be found online at:
https://shop.aap.org/licensing-permissions/
Reprints Information about ordering reprints can be found online:
http://classic.pediatrics.aappublications.org/content/reprints

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2017 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
.

Downloaded from http://pediatrics.aappublications.org/ by guest on November 20, 2017


Cost-Effectiveness of a Clinical Childhood Obesity Intervention
Mona Sharifi, Calvin Franz, Christine M. Horan, Catherine M. Giles, Michael W.
Long, Zachary J. Ward, Stephen C. Resch, Richard Marshall, Steven L. Gortmaker
and Elsie M. Taveras
Pediatrics 2017;140;
DOI: 10.1542/peds.2016-2998 originally published online October 31, 2017;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/140/5/e20162998

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2017 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
.

Anda mungkin juga menyukai