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This cohort study of well and sick office visits seeks to determine the factors associated with clinician report of primary care relationship to patient. Over 17,000 children ages 4 to 15 were seen in the primary care offices of 363 clinicians. Clinicians designated patients as 'my primary care patient' or 'in our practice.' Male clinician, multispecialty practice, and reason for the visit were significantly associated with designation. We recommend that practices seeking to enhance primary care focus on systems that support clinician-patient relationships for all visits. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Atherosclerotic cardiovascular disease is the leading cause of death in the United States. Atherosclerosis begins early in life; however, children and young and middle-aged adults are not universally screened for the presence of modifiable cardiovascular disease risk factors. The purpose of this study was to investigate whether cardiovascular disease risk-factor assessment in children can identify families who are at increased risk for cardiovascular disease. PARTICIPANTS AND METHODS: Family Strategies Concentrating on Risk Evaluation is a community-based participatory research study designed to stratify cardiovascular disease risk in a cohort of children and their parents. Eligible families, consisting of > or = 1 child and > or = 1 biological parent, are recruited through community and faith-based educational and screening programs. In a single, fasted study visit, participants undergo assessment of cardiovascular disease risk factors: obesity, hypertension, dyslipidemia, and metabolic syndrome. Associations of cardiovascular disease risk factors between children and their parents were assessed. RESULTS: Data were analyzed from 94 families: 108 parents (mean age: 38.5 +/- 7.5 years), 141 children (mean age: 10.5 +/- 3.4 years), and 170 child-parent pairs. Child-parent association was strong for many risk factors: BMI, waist circumference, systolic blood pressure, triglycerides, and total cholesterol. Several discrete-defined risk factors in children were found to be significant predictors of the presence of the same risk factors in their parents. Parents of children with hypertension, obesity, or hypertriglyceridemia had 15 times, 6 times, or 5 times increased odds, respectively, of having the same risk factors. CONCLUSIONS: Identification of several clinically apparent and silent cardiovascular disease risk factors in children predicts elevated cardiovascular disease risk in their parents. Because children access primary care more frequently than adults, children can potentially serve as the index case to identify families at increased risk for cardiovascular disease. [ABSTRACT FROM AUTHOR]

BACKGROUND: The rapidly increasing prevalence of obesity among children is one of the most challenging dilemmas facing pediatricians today. While the medical community struggles to develop effective strategies for the treatment of this epidemic, timely identification of obesity by pediatric health care providers remains the crucial initial step in the management of obesity. OBJECTIVE: Direct assessment of pediatric clinicians' performance in identifying and managing obesity in clinical practice has not been conducted to date. The objective of this study was to determine rates of identification of obesity by pediatric residents, nurse practitioners, and faculty members in an academic primary care setting and to describe the actions taken by these providers in their evaluation and management of obesity. DESIGN: A retrospective medical record review of all health supervision visits for children 3 months to 16 years of age, examined between December 1, 2001, and February 28, 2002, was performed. For children <5 years of age, a weight >120% of the 50th percentile of weight-for-height was defined as obese. For children > or =5 years of age, a body mass index of >95th percentile for age and gender was defined as obese. SETTING: A large, primary care practice located in a tertiary-care, academic, pediatric hospital, which serves a predominantly urban, minority (70% African American), Medical Assistance-insured (90%) population. PARTICIPANTS: Primary care providers, including pediatric residents, nurse practitioners, and faculty physicians. RESULTS: Of the 2515 visits reviewed, a total of 244 patients met the study definition of obesity, yielding an estimated prevalence of obesity visits of 9.7% among health supervision visits for children 3 months to 16 years of age. This prevalence of obesity visits cannot be used to estimate the population prevalence of obesity, given the skewed distribution of visits toward very young children. For all children who met the study definition of obesity, providers documented obesity in their assessments in only 53% of the reviewed visits (129 visits). Although the majority of charts (69%) contained an adequate dietary history, only 15% included a description of the child's activity level or television viewing. Obesity was noted in the physical examination in 39% of cases. For children for whom obesity was identified as a problem by their clinicians (129 patients), 81% of charts contained an adequate dietary history, whereas 27% contained a description of the child's activity level or television viewing. Obesity was noted in the physical examination in 64% of cases. Most children identified as obese by their providers received some management specific to their obesity, including education, screening, and specialist referral. Dietary changes were recommended for 71%, increased activity for 33%, and limitation of television viewing for only 5%. Eighty-three percent of providers recommended close follow-up monitoring. Other recommendations included referral to a dietitian (22%), screening laboratory studies (13%), a food diary (9%), endocrine referral (5%), or preventive cardiology referral (3%). Provider identification of obesity was affected by the age of the patient and by the degree of obesity. Obesity identification was lowest among preschool children (31%) and highest among adolescent patients (76%). Providers evaluating older and heavier children were also more likely to obtain activity histories, note obesity in the physical examination, recommend changes in activity, refer the patient to a nutritionist, obtain screening laboratory studies, and recommend close follow-up monitoring. Identification of obesity and other outcome variables were not significantly influenced by the level of provider training or patient gender. CONCLUSIONS: Although the prevalence of childhood obesity has now reached epidemic proportions, it was under-recognized and under-treated by pediatric primary care providers in our study. Providers identified obesity as a problem for only one-half of the obese children examined for health supervision. The lowest rates of obesity identification occurred among children <5 years of age and those with milder degrees of obesity. Identification did not improve with additional years of pediatric training. Even for the subset of children identified as obese by their providers, evaluation and treatment often were not consistent with current recommendations. For example, more attention was given to the role of diet, compared with activity, in the evaluation of obesity. In particular, only a small number of providers (5%) recommended a decrease in television viewing to their obese patients, despite evidence linking television viewing and pediatric obesity. This finding is of concern, because obesity is known to be a multifactorial disease that responds only to significant changes in both dietary and activity behaviors. Only 13% of providers requested laboratory studies as part of their recommendations. The American Academy of Pediatrics currently recommends obtaining a lipid profile, total cholesterol level, and screening test for type 2 diabetes mellitus as part of the evaluation of obesity. The majority of clinicians who requested laboratory studies included thyroid function tests, which are not recommended by the American Academy of Pediatrics because of the very low likelihood of hypothyroidism as a cause of obesity. Although the extent of evaluation and management for children who were recognized as obese did not meet current guidelines, it was far better than that for patients who were not identified as obese by their providers. This demonstrates the importance of timely identification as the crucial initial step in the management of obesity. The results of this study are disheartening, especially as evidence mounts regarding the importance of early intervention in preventing the medical and psychosocial sequelae of obesity, as well as the persistence of obesity into adulthood. This study highlights the need for increased awareness and identification of obesity in the primary care setting, especially among younger children and those with mild obesity. [ABSTRACT FROM AUTHOR]