MS. FOXHALL is a contributing editor for <i>Contemporary Pediatrics.</i>

Kathryn Foxhall

There are a number of studies showing that some school-based interventions for the prevention of childhood obesity can be effective, says a draft review from the Agency for Healthcare Research and Quality (AHRQ), the key federal agency charged with improving quality and effectiveness in health care. 

Childhood Obesity Prevention Programs: A Comparative Effectiveness Review and Meta-analysis

, "Modest evidence shows that school-based interventions could prevent childhood obesity." 

However, the agency could find only 2 studies on primary care-initiated activities to include in its recent review and only 1 small diet intervention study showing a significant change in body mass index (BMI).			

The draft report, published by the Effective Health Care Program of the AHRQ, examined 27,916 citations in the medical literature but excluded all but 113 intervention studies. Eighty-two of those studies tested school-based interventions, although some also included activities in the home or other settings. 

One study demonstrating effectiveness in the primary care setting was by Marian Tanofsky-Kraff, PhD, and colleagues, reported in the December 2010 

International Journal of Eating Disorders

. That study randomized 38 girls aged 12 to 17 years and at risk for obesity to interpersonal psychotherapy or standard-of-care health education. 

It found that over a year, the girls in the interpersonal psychotherapy group were less likely to increase their BMI as expected for their age and BMI percentile. 

In response to the AHRQ review, Stephen Pont, MD, MPH, chair of the American Academy of Pediatrics (AAP) Provisional Section on Obesity, says that there is a growing research base on dealing with obesity in primary care. But one reason so little study has been completed in that setting is the lack of coverage for interventions by private insurance and Medicaid. 

 (125[4]:596-604) states that only 10 state Medicaid programs appear to cover obesity-related treatment in children and "most states are not regulating the insurance market with regard to use of obesity in medical underwriting."			

Pont notes that Medicare now pays for interventions for obesity, and sometimes Medicaid follows Medicare's lead, "but it's not a done deal." He also says AAP will be coming out with new tools to help combat obesity beginning this fall. 

In regard to the finding that most studied programs are based in the schools, Pont says there is often a "spectacular opportunity" for physicians to serve as health advocates in that setting. He says that physicians often communicate with the schools about children's medications and other issues anyway. And, they can reinforce the idea that children who are obese may not do as well in school or on standardized tests. 

The AHRQ report says that although its review looked at changes such as dietary intakes and physical activity, it did not look at psychosocial or environment outcomes. A better understanding of enabling factors might allow for better-designed interventions. 

The review finds strong support for effectiveness in school-based efforts targeting physical activity and those targeting diets. Head-to-head tests were rare, however, so it's unknown whether one focus is better than the other.  

The report concludes that there should be more attention and resources going to disseminate successful intervention programs and to their evaluation. 

Articles

A number of studies show that some school-based interventions for the prevention of childhood obesity can be effective, says a draft review from the Agency for Healthcare Research and Quality (AHRQ), the key federal agency charged with improving quality and effectiveness in health care.

AHRQ says obesity-related interventions understudied

We live in a time of such potential for vaccine development that it's difficult to know where to put resources. However, those decisions could make a huge difference in numbers of lives saved and costs avoided, among other things. 

As the Institute of Medicine (IOM) report 

Ranking Vaccines: A Prioritization Framework-Phase I: Demonstration of Concept and a Software Blueprint

 shows, most vaccines have been created within living memory, and the last 2 decades have been rich with introductions, from cholera to rotavirus vaccine. 

The report also estimates that manufacturers in wealthier countries invest $500 to $900 million over 10 to 15 years to develop 1 new vaccine. 

Should we emphasize benefits for pregnant women, children, or adults? Should the targets be diseases of poverty, emerging infections, or diseases affecting people with chronic conditions? 

At the request of the Department of Health and Human Services, IOM has actually created software to help analyze the many factors. The next step will be to get feedback from stakeholders on the model and to test more vaccine candidates with it. 

The software, called SMART Vaccines, will use data and other user-supplied entries to compare different potential vaccines according to attributes such as cost effectiveness, numbers of cases and premature deaths prevented, health care costs saved, and work productivity gained. 

Among other steps, the user will make crucial decisions on which of 29 attributes to consider and in what order to rank them with a drag-and-drop function. 

Users will also be able to change their priorities instantly to see how that changes the scores for the potential vaccines. 

Charles Phelps, PhD, University of Rochester professor and a key developer of the model, noted that previous IOM reports on vaccine priorities used single characteristics for ranking their importance. In one case it was health benefit, and in another it was efficiency benefit. 

With this model, Phelps said, "We wanted something that would allow people to bring in a wider array of attributes of vaccine programs and we wanted users to be able take their own perspectives in setting out their priorities."			

"SMART Vaccines is intended to serve only as a decision-support tool for vaccine prioritization and not to be used as a decision maker," stressed the report. 

A manufacturer, a wealthy country, a developing country, and an organization such as the Pan American Health Organization may all use the tool to come up with different priorities, the report indicated. 

Because the IOM Committee on Identifying and Prioritizing New Preventive Vaccines for Development wanted the model to be as transparent as possible so that people can understand what is happening, Phelps said the hope is that the software will lead stakeholders to fruitful conversations about where their differences lie and also create interest in gathering more data where it is needed. 

The SMART Vaccines Beta, on which the current IOM report is based, is not available for public use, but SMART Vaccines 1.0 will be released to the public sometime next year after completion of phase 2 of the work, when it will be fully operational. 

The committee is beginning phase 2 now and plans a workshop to gather public feedback in September. 

The report, along with software screen shots and a Webinar, is available free at 

									http://www.iom.edu/reports/2012/ranking-vaccines-a-prioritization-framework-phase-I.aspx

We live in a time of such potential for vaccine development that it's difficult to know where to put resources.

IOM committee mulls future direction

The Federal Employees Health Benefits Program (FEHBP) is moving its considerable influence behind the concept of the medical home. In its annual call in March for benefit and rate proposals from various health plans, FEHBP emphasized that it has a key interest in advancing coordinated care. 

Christine Hunter, MD, chief medical officer of the US Office of Personnel Management (OPM), which oversees the FEHBP, says, "Right up front is the patient medical home as the nexus of care coordination." 

The FEHBP is often looked to as a model for insurance coverage because it covers 8 million lives across the age spectrum and offers choices of 91 health plans. 

"We hope that we will be leaders in specifying what employers want on behalf of their employees with respect to the patient-centered medical home," she said. 

Each insurance plan that operates under the program will have to report the percentage of practices in their network that have achieved medical home status. "And we want to see that number go up," said Hunter. 

The OPM will also ask the plans to report the number of their patients who are enrolled in medical homes, as well as the plans' criteria for recognizing a practice as a medical home, such as the standards available through the National Committee for Quality Assurance, URAC, and the Joint Commission. 

"Then we want the plan to give us a breakdown of which provider payment incentives have they found most useful. We understand that one needs to pay differently for this care. And we want to include it in our premium negotiations," Hunter stated at the meeting. 

The OPM also wants to know how the plans are marketing medical homes, she said. So it will ask how the plans are going to do outreach to tell members there is an opportunity to do things better or that there are new services to help the employees and their families stay healthy. 

Hunter wants to ask, "How are patients going to be informed of the quality outcomes that are associated with a patient-centered medical home?" She cited Web sites, provider directories, patient newsletters, secure email messaging, or text messaging as possible avenues. 

The OPM wants to support other medical home pilots initiated by different segments of the federal government and state governments, she said, pointing to efforts such as work on various aspects of care coordination and fitting medical homes into accountable care organizations. 

If carriers can bring their federal employee population in addition to their Medicare or Medicaid populations to one of these pilots, they are invited to propose that to OPM, Hunter said at the meeting. 

In its recent guidance letter, the OPM, which covers 2,800 births a week, told carriers about its special focus on maternity and neonatal care. Pointing to guidelines from the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics that seek to eliminate elective delivery before 39 weeks' gestation, OPM asked for related program information. 

The guidance also notes that plans are required to cover contraceptive services at no cost sharing for plan year 2013, in line with regulations on preventive services from the Department of Health and Human Services. 

The Federal Employee Health Benefits Program is moving its considerable influence behind the concept of the medical home.

Federal Employees Health Benefits Program, Office of Personnel Management push idea of medical home

Through an intense process, a subcommittee advising the federal government has selected 24 areas by which to measure healthcare quality for children covered by Medicaid and the Children's Health Insurance Program (CHIP). Now the Department of Health and Human Services is asking for comments on this initial, core set of measures, which is for voluntary use by the state programs, health insurance issuers, and managed care entities that contract with Medicaid and CHIP and providers of items and services under these programs. 

Although the measures are voluntary now, the hope is that most states will eventually use them, said Xavier Sevilla, MD, chair of the American Academy of Pediatrics (AAP) Steering Committee on Quality Improvement and Management. The idea, he said, is to select a key set of measures agreed on nationally. Sevilla, who served on the selection subcommittee, said that it would be a good idea to take a look now at how your practice is doing with these measures because in the future, the measures may be used to evaluate pediatric practices. 

A subcommittee of the Agency for Healthcare Research and Quality (AHRQ) advisory council selected the measures, which were mandated by last year's CHIPreauthorization legislation. That panel included pediatricians, provider groups, experts in quality measurement, state Medicaid officials, and other stakeholders. 

The measures include, for example, the extent to which children reaching their second birthday have had recommended immunizations; the number of children 2 to 18 years old who have had an outpatient visit with a primary care provider or ob/gyn during the measurement year who had a recorded body mass index assessment; the extent to which newborn children through 36 months old are screened for social and emotional development with a standardized, documented tool or set of tools; and the extent to which children get well-child visits at various age levels.

The legislation called for a selection of measures currently in use and, for example, 14 of them are from the Healthcare Effectiveness Data and Information Set (HEDIS) measures reported by Medicaid managed care plans. 

The current set serves as a first step. The background document says that there are topics "for which currently available, valid and feasible measures could not be identified." These include measures of the medical home, "more valid measures of availability of services," and "a core measure of duration of enrollment and coverage for use in quality reporting." The legislation calls for an enhanced set by January 1, 2013. 

The question of when the measures might come into use is still to be answered, said Sevilla. States vary a great deal in their status in using measures, he noted, and much will depend on states' budgetary status and on what happens with healthcare reform. 

Rita Mangione-Smith, MD, MPH, who cochaired the subcommittee selecting the measures, also led the 2007 

 study of 1,500 children's records that showed they received about 46.5% of indicated care. The background note stated, "Little is known about the magnitude of deficits in the quality" of children's care. 

Comments on the proposed measures are due March 1. Information is in the December 29, 2009, 

 The AAP is also asking pediatricians to provide input on the quality measures so that the association can formulate its comments to AHRQ before March 1. Comments should be directed to 

Through an intense process, a subcommittee advising the federal government has selected 24 areas by which to measure healthcare quality for children covered by Medicaid and the Children's Health Insurance Program.

Committee proposes quality measures for Medicaid, children's insurance

At the same time, the lead researcher notes that most communities don't have science-based approaches, but that pediatricians can be critical in moving their localities to programs proven to work.

In a webinar with federal officials showcasing the research, the new administration's drug czar Gil Kerlikowske said, "We know that evidence-based prevention programs can be very effective. We know that they can save money. For instance, for every dollar invested in prevention programs, you could get up to a $10 savings in substance abuse treatment."

The rates were also significantly lower for alcohol and smokeless tobacco use in the last 30 days, binge drinking in the last two weeks, and delinquent behavior over the last year.

However, even with the positive outcomes, it was tough to make a difference in some areas, according to the study results. There were no significant differences in the levels of adolescents beginning to use marijuana or inhalants. Also, the percentages of students who had used cigarettes, inhalants, marijuana, prescription drugs, and other illicit drugs in the last 30 days (as opposed to having ever used them) were lower in the CTC communities, but not significantly.

The CTC approach differs from some programs tackling adolescent problems, NIH notes. In CTC, trained coalitions of community stakeholders use epidemiological data to assess their own prevention needs, including elevated risk factors and depressed preventive factors, then choose from a list of tested programs that target those needs, and finally evaluate the progress via surveys.

The list of programs includes, for example, prevention of drug and alcohol use and violence, reducing family conflict, life skills training, HIV/AIDS prevention, dating safety, tobacco control, and anger management.

Lead researcher David Hawkins, PhD, said, after children are first surveyed, "If academic failure or low commitment to school was a risk factor, [communities] might choose individual tutoring for young people falling behind in school. If they found rebelliousness or children needing more skills to resist drug offers was a problem, they might implement life skills training or the Olweus bullying prevention program in the schools."

Frances Harding, the head of the Center for Substance Abuse Prevention, said, "We know that one size doesn't fit all. The science has helped us to focus in on the individual issues that each community presents." Her agency funds several evidence-based prevention programs.

Hawkins also stressed the need for repeated surveys on how the programs are working: "So if we have been trying to target poor family management as a risk factor, and still a large proportion of kids say, 'My parents don't know where I am and who I am with when I am not at home,' that means that we are not really being successful yet with our programming."

He also said, "Pediatricians can be big leaders in this," whether by becoming directly involved in the community coalitions, sponsoring the workshops in their clinics, or simply stating their support. It's one thing to hear about such a program from a family services program. "When pediatricians say to parents of kids who are entering middle school, 'You know, we want all the parents in this community to participate in this effective parenting program that will help you as your child enters adolescence to reduce risk for health problems during adolescence,' parents are much more likely to listen."

He indicated that because pediatricians are opinion shapers, it's even more important that they push for the science-based programs. When community people say they already have a great parenting program, Hawkins said doctors should ask, "What's the scientific evidence that this works?...Shouldn't we be doing something that we know has been tested and shown to be effective?'"

A companion editorial to the study did assert there is a "pressing need" for training centers to help policymakers and practitioners, "to avoid correctional quackery and to undertake effective interventions."

Hawkins also said that the best list of tested programs are the "Blueprints for Violence Prevention," which also includes substance abuse prevention. It is available from the University of Colorado at Boulder's Center for the Study and Prevention of Violence, available online at 

									http://www.colorado.edu/cspv/blueprints/

Communities that use science-based approaches to problem behaviors in adolescents, including alcohol and tobacco use, are more likely to see positive results.

A 'scientific' approach to keep kids off drugs