P2.190: Assessing alignment of referrals with guidelines for the treatment of children with obesity: Examination of electronic medical record data from a multi-state health system in the Upper Midwest USA

Background: Over 14 million children and adolescents in the United States are affected by obesity, approximately 20% of the pediatric population. Connecting families to effective treatments is a public health and health equity issue given the social, economic, and geographical influences on the development of obesity and access to care. The AAP Clinical Practice Guideline (CPG) for the Assessment and Treatment of Children with Obesity recommends health behavior and lifestyle treatment (HBLT) for all children with obesity and consideration of pharmacological and surgical interventions. Study aims were to quantify referrals from primary care aligning with CPG recommendations and to identify factors associated with likelihood of referral within a large health system.

Methods: This cross-sectional study examined electronic medical record data abstracted from Mayo Clinic and the Mayo Clinic Health System located in the Upper Midwest, USA. Inclusion criteria were patients aged 2-17 years seen for a well-child visit in 2022 and/or 2023 with BMI ≥ the 95th percentile. The primary outcome was whether an order for an obesity-specific appointment order was placed in the calendar year of the child’s well visit. We categorized orders as Health Behavior Referral (dietitian, behavioral health, and/or HBLT), Medical Referral (endocrinologist, the service providing pharmacological and surgical interventions at time of study), or Any Referral (all types combined ). Multivariable logistic regression models tested associations of referral placement with child characteristics (presence of severe obesity defined as BMIp95 ≥ 120 or BMI ≥ 35 kg/m2, age, gender, race and ethnicity), Area Deprivation Index, and practice site (proximal or regional to tertiary care site).

Results: Of 15,424 unique patients (M = 9.8, SD = 4.3 years of age; 45.3% female) with BMI-defined obesity, 604 (3.9%) received any referral, and some received multiple. Specifically, 3.7% of patients received one or more Health Behavior Referral (519 dietitian, 69 behavioral health, 70 HBLT) and 1.6% received a Medical Referral. Table 1 summarizes characteristics of patients with and without a referral. Odds of any referral were associated with presence of severe obesity; older age; self-identification as Hispanic/Latinx, Black/African American, or Asian; and proximity to the tertiary medical center (Table 2). Similar patterns were observed for the likelihood of Medical Referrals and Health Behavior Referrals.

Conclusion: This study revealed a large gap to successful implementation of the CPG treatment recommendations. Findings suggest delays in referral to recommended obesity care when children are older and face greater disease morbidity, and that distance from specialty care may hinder likelihood of referral. Further research is needed to understand factors underlying higher likelihood of referral among children with minoritized racial and ethnic identities. Overall, findings highlight the importance of understanding barriers to referral and for clinical innovation and advocacy to connect children and their families with evidence-based treatments.