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					CLINICAL AUDIT TOOL:

Weight Management




            1
 Introduction

 This clinical audit tool addresses weight management in the primary care setting. It has a
 particular focus on weight management in the context of cardiovascular risk and diabetes.


 It draws on best practice guidance summarised in the New Zealand Primary Care Handbook
 2102 on cardiovascular risk factor assessment and management and on weight management
 specifically from the source guideline Clinical Guidelines for Weight Management in New
 Zealand Adults (2009).
 See http://www.health.govt.nz/publication/new-zealand-primary-care-handbook-2012 for
 further content from the Handbook.


TOPIC       Weight Management

            Why is this topic of interest or concern?
                 Overweight and obesity increase the risk of mortality and
                    morbidity, particularly from cardiovascular disease and type
                    2 diabetes

            Key information from the guidance:
                   All people with a 5-year cardiovascular risk of more than 10% should
                    receive specific lifestyle assessment and advice, including weight
                    management as indicated, by the primary care team.
                   BMI is not a direct measure of body fat and does not distinguish between
                    ethnic differences in the ratio of fat to lean muscle.
                    People of smaller stature and with a BMI <25 kg/m2 (normal weight), but
                    with a large waist (indicating abdominal fatness) may benefit from weight
                    loss advice.
                   A realistic target for weight loss varies by individual. Benefits start to
                    accrue when 5-10% of initial body weight is lost.
                   Low energy, low glycaemic index/load, and modified macronutrient
                    approaches (i.e. low carbohydrate, low fat, high protein or high
                    carbohydrate diets) are all similarly effective for weight loss providing the
                    diet results in some energy restriction.


                The Clinical Guidelines for Weight Management in New Zealand Adults (2009)
                recommend a stepped approach to assisting people to achieve and maintain a
                healthy weight:
                Step 1 Engage with the person and raise awareness.
                Step 2 Identify need and context for action.
                Step 3 Determine options for action.
                Step 4 Arrange ongoing contact and support (once reach goal weight).




                                                 2
PLAN   Indicators          (elements of practice performance to be measured)


       The practice effectively provides weight management as part of cardiovascular risk
       and diabetes management
       1.   Measure weight and truncal obesity (step 1) as part of cardiovascular risk
            assessment and type 2 diabetes patient review.
       2.   Identify need for intervention – those with BMI >30 or BMI ≥25 with risk
            factors or with central fatness – and consider and discuss individuals risk and
            motivation for change (step 2).
       3.   Determine options for action (step 3) for those with BMI >30 or BMI ≥25 with
            risk factors or with central fatness.
            FAB approach is a key intervention for all; a combination of changes to
            food/diet, increased physical activity, behavioural strategies (problem-solving
            and goal setting).
            Consider referral to professional and community providers to support the FAB
            approach.
            Consider how progress will be monitored.

            Other possible interventions that may be considered:
            Anti-obesity drugs for those with BMI ≥30
            Referral for bariatric surgery for those with BMI ≥40 or with a BMI ≥30 with significant
            comorbidities. (Also consider and meet local referral guidelines criteria for bariatric
            surgery.)


       4.   Ongoing contact and support once goal weight is reached to support lifestyle
            change (step 4): brief clinical contact (e.g., practice nurse), family or
            community contact/support.


       Criteria         (how the indicator will be measured)


            1.   Measurement of weight and truncal obesity: weight, height and waist
                 circumference measured & BMI calculated and recorded.
            2.   Patient records for those with BMI >30 or BMI ≥25 with risk factors or with
                 central fatness indicate risks, need and motivation for weight management
                 discussed.
            3.   Patient records indicate those with BMI >30 or BMI ≥25 with risk factors or
                 with central fatness have had brief counselling and an appropriate action
                 plan has been initiated.
                 Target weight/weight loss is recorded in patient records.
                 Approach to monitoring progress (e.g. patient or practice weekly weight
                 measurement) is documented in patient records.
            4.   Patient notes indicate ongoing support for lifestyle change has been
                 discussed/follow-up arranged.




                                                3
        Standards        (the standards to be achieved)


        Note that the focus is on improving standards of clinical practice, with 80%
        achievement identified by the RNZCGP as an appropriate target and 100% as an
        ideal. Individual GPs and practices may choose to set a differing target for a first or
        subsequent audit/s, with a view to increasing standards over time.


            1.   The majority of patients (80%) have BMI and waist circumference measured
                 as part of CVD risk assessment and 80% have measurements recorded in
                 patient records. 80% of patients with type 2 diabetes have BMI and waist
                 circumference measured at least annually and 80% have measurements
                 recorded in patient records.
            2.   80% of patient records for patients with BMI >30 or BMI ≥25 with risk
                 factors or with central fatness indicate weight management discussed.
            3.   80% of patient records for patients with BMI >30 or BMI ≥25 with risk
                 factors or with central fatness indicate one or more appropriate weight
                 management interventions for that individual initiated.
                 80% of patient records document target weight/weight loss.
            4.   80% of patient records document planned follow-up.


DO      Discover what you are doing now                        (collect data)



           Select patient group of interest: Cardiovascular risk assessment/ Type 2
            diabetes review/Other.
           Retrieve records for at least 20 random patients in a selected time period.*
           Review measurement of weight and truncal obesity for all (see Sheet 1).
            For those where weight management is indicated, review weight management
            intervention provided using Sheet 2 for review of patient records. Aim to
            review at least 10 patients.


            *Note – it may be necessary to retrieve more records in order to identify
            sufficient patients requiring weight management intervention.




STUDY   Next steps: what do the results tell you                         (interpret the data)



           Collate the data from patients according to the standards set and compile a
            brief summary for each indicator.
           What are you doing well?
           What needs improving?
           What gaps between standards and performance do you want to close?
           Identify possible solutions.




                                             4
Clinical Audit Tool: Weight Management
Sheet 1: Measurement of Weight & Truncal Obesity


Patient Record Review Sheet                                   Date:_________

CVD Risk Assessment/ Type 2 Diabetes Review/Other _____________ (Circle one)
Patient   Initials/NHI   BMI & waist      Weight               Comments
                         circumference    management
                         (WaC) recorded   follow-up
                                          indicated

                                          BMI >30
                                          BMI ≥25 with risk
                                          factors
                                          Central fatness
1                        BMI/WaC/Both     Yes/No
2                        BMI/WaC/Both     Yes/No
3                        BMI/WaC/Both     Yes/No
4                        BMI/WaC/Both     Yes/No
5                        BMI/WaC/Both     Yes/No
6                        BMI/WaC/Both     Yes/No
7                        BMI/WaC/Both     Yes/No
8                        BMI/WaC/Both     Yes/No
9                        BMI/WaC/Both     Yes/No
10                       BMI/WaC/Both     Yes/No
11                       BMI/WaC/Both     Yes/No
11                       BMI/WaC/Both     Yes/No
12                       BMI/WaC/Both     Yes/No
13                       BMI/WaC/Both     Yes/No
14                       BMI/WaC/Both     Yes/No
15                       BMI/WaC/Both     Yes/No
16                       BMI/WaC/Both     Yes/No
17                       BMI/WaC/Both     Yes/No
18                       BMI/WaC/Both     Yes/No
19                       BMI/WaC/Both     Yes/No
20                       BMI/WaC/Both     Yes/No
Total with BMI & WaC recorded (%)         Total no. requiring follow/up




                                          5
      Clinical Audit Tool: Weight Management
      Sheet 2: Weight Management Intervention
      For BMI >30 or BMI ≥25 with risk factors or Central fatness



      Patient Record Review                                           Date:_________

      CVD Risk Assessment/ Type 2 Diabetes Review/Other _____________ (Circle one)
Patient   Initials/NHI   Weight management     One or more            Planned      Comments
                         discussed             weight                 follow-up
                                               management             documented
                                               interventions
                                               initiated
                                               (Note - FAB
                                               approach
                                               counselling and
                                               referrals
                                               appropriate for all)
1                        Yes/No/Don’t know     F      Yes/No          Yes/No
                                               A      Yes/No
                                               B      Yes/No
2                        Yes/No/Don’t know     F      Yes/No          Yes/No
                                               A      Yes/No
                                               B      Yes/No
3                        Yes/No/Don’t know     F      Yes/No          Yes/No
                                               A      Yes/No
                                               B      Yes/No
4                        Yes/No/Don’t know     F      Yes/No          Yes/No
                                               A      Yes/No
                                               B      Yes/No
5                        Yes/No/Don’t know     F      Yes/No          Yes/No
                                               A      Yes/No
                                               B      Yes/No
6                        Yes/No/Don’t know     F      Yes/No          Yes/No
                                               A      Yes/No
                                               B      Yes/No
7                        Yes/No/Don’t know     F      Yes/No          Yes/No
                                               A      Yes/No
                                               B      Yes/No
8                        Yes/No/Don’t know     F      Yes/No          Yes/No
                                               A      Yes/No
                                               B      Yes/No
9                        Yes/No/Don’t know     F      Yes/No          Yes/No
                                               A      Yes/No
                                               B      Yes/No

                                               6
10          Yes/No/Don’t know   F   Yes/No   Yes/No
                                A   Yes/No
                                B   Yes/No
11          Yes/No/Don’t know   F   Yes/No   Yes/No
                                A   Yes/No
                                B   Yes/No
12          Yes/No/Don’t know   F   Yes/No   Yes/No
                                A   Yes/No
                                B   Yes/No
13          Yes/No/Don’t know   F   Yes/No   Yes/No
                                A   Yes/No
                                B   Yes/No
14          Yes/No/Don’t know   F   Yes/No   Yes/No
                                A   Yes/No
                                B   Yes/No
15          Yes/No/Don’t know   F   Yes/No   Yes/No
                                A   Yes/No
                                B   Yes/No
16          Yes/No/Don’t know   F   Yes/No   Yes/No
                                A   Yes/No
                                B   Yes/No
17          Yes/No/Don’t know   F   Yes/No   Yes/No
                                A   Yes/No
                                B   Yes/No
18          Yes/No/Don’t know   F   Yes/No   Yes/No
                                A   Yes/No
                                B   Yes/No
19          Yes/No/Don’t know   F   Yes/No   Yes/No
                                A   Yes/No
                                B   Yes/No
20          Yes/No/Don’t know   F   Yes/No   Yes/No
                                A   Yes/No
                                B   Yes/No
Total (%)




                                7
           RNZCGP Summary Sheet
  Continuous Quality Improvement (CQI) Activity


Topic:   Weight Management
Doctor's name:
______________________________________________________________


First cycle


Data: Date of data collection:
Check: Describe any areas targeted for improvement as a result of analysing the data collected.




Action: Describe how these improvements will be implemented




Monitor: Describe how well the process is working. When will you undertake a second cycle?
Second cycle


Data: Date of data collection:
Check: Describe any areas targeted for improvement as a result of analysing the data collected.




Action: Describe how these improvements will be implemented.




Monitor: Describe how well the process is working.




Comments:




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posted:6/10/2014
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