Figure 1 - available from: Maternal and Child Health Journal
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Distribution of total gestational weight gain, by pre-pregnancy body mass index and time period
Source publication
Objective To examine whether an electronic medical record “best practice alert” previously shown to improve antenatal gestational weight gain patient education resulted in downstream effects on service delivery or patient health outcomes. Methods This study involved secondary analysis of data from an intervention to improve provider behavior surrou...
Citations
... Almost all the studies were based on the implementation of an intervention (new or refined) into a clinical setting (35/36, 97%) with 1 qualitative analysis of EMRs by clinicians [36]. Most studies were quality or process improvement based (28/36, 78%) [33][34][35]37,[39][40][41][42][43][44][45][47][48][49]51,52,54,55,58,59,[61][62][63][64][65][66][67] or best practice/evidence-based intervention related (27/36, 75% for both) [33][34][35]37,38,[40][41][42]45,47,48,50,[52][53][54][55][56][57][58][59][60][62][63][64][65][66]70]. Over half of the studies examined EMR elements such as order sets (23/36, 64%) [33,34,[36][37][38][40][41][42]46,47,[49][50][51]52,54,55,58,60,61,[64][65][66]70] and care pathways/treatment plans (22/36, 61%) [33][34][35][36][39][40][41][42][43][46][47][48]50,52,54,58,60,62,63,65,66,70]. ...
... Almost all the studies were based on the implementation of an intervention (new or refined) into a clinical setting (35/36, 97%) with 1 qualitative analysis of EMRs by clinicians [36]. Most studies were quality or process improvement based (28/36, 78%) [33][34][35]37,[39][40][41][42][43][44][45][47][48][49]51,52,54,55,58,59,[61][62][63][64][65][66][67] or best practice/evidence-based intervention related (27/36, 75% for both) [33][34][35]37,38,[40][41][42]45,47,48,50,[52][53][54][55][56][57][58][59][60][62][63][64][65][66]70]. Over half of the studies examined EMR elements such as order sets (23/36, 64%) [33,34,[36][37][38][40][41][42]46,47,[49][50][51]52,54,55,58,60,61,[64][65][66]70] and care pathways/treatment plans (22/36, 61%) [33][34][35][36][39][40][41][42][43][46][47][48]50,52,54,58,60,62,63,65,66,70]. ...
... Most studies were quality or process improvement based (28/36, 78%) [33][34][35]37,[39][40][41][42][43][44][45][47][48][49]51,52,54,55,58,59,[61][62][63][64][65][66][67] or best practice/evidence-based intervention related (27/36, 75% for both) [33][34][35]37,38,[40][41][42]45,47,48,50,[52][53][54][55][56][57][58][59][60][62][63][64][65][66]70]. Over half of the studies examined EMR elements such as order sets (23/36, 64%) [33,34,[36][37][38][40][41][42]46,47,[49][50][51]52,54,55,58,60,61,[64][65][66]70] and care pathways/treatment plans (22/36, 61%) [33][34][35][36][39][40][41][42][43][46][47][48]50,52,54,58,60,62,63,65,66,70]. Many papers addressed the minimization or elimination of a particular drug prescription/use (17/36, 47%) [39,40,45,46,49,[51][52][53][54]57,58,60,63,[65][66][67]70]. ...
Background
The use of electronic medical records (EMRs)/electronic health records (EHRs) provides potential to reduce unwarranted clinical variation and thereby improve patient health care outcomes. Minimization of unwarranted clinical variation may raise and refine the standard of patient care provided and satisfy the quadruple aim of health care.
Objective
A systematic review of the impact of EMRs and specific subcomponents (PowerPlans/SmartSets) on variation in clinical care processes in hospital settings was undertaken to summarize the existing literature on the effects of EMRs on clinical variation and patient outcomes.
Methods
Articles from January 2000 to November 2020 were identified through a comprehensive search that examined EMRs/EHRs and clinical variation or PowerPlans/SmartSets. Thirty-six articles met the inclusion criteria. Articles were examined for evidence for EMR-induced changes in variation and effects on health care outcomes and mapped to the quadruple aim of health care.
Results
Most of the studies reported positive effects of EMR-related interventions (30/36, 83%). All of the 36 included studies discussed clinical variation, but only half measured it (18/36, 50%). Those studies that measured variation generally examined how changes to variation affected individual patient care (11/36, 31%) or costs (9/36, 25%), while other outcomes (population health and clinician experience) were seldom studied. High-quality study designs were rare.
Conclusions
The literature provides some evidence that EMRs can help reduce unwarranted clinical variation and thereby improve health care outcomes. However, the evidence is surprisingly thin because of insufficient attention to the measurement of clinical variation, and to the chain of evidence from EMRs to variation in clinical practices to health care outcomes.
... Findings from two interventions [41,62,63,71] suggest that to have an effect on women's weight gain, considerable practice changes are needed. In the Mighty Mums study, midwives received training, resources for themselves and the women, weighed women in longer than normal appointments and could refer women to other diet and physical activity services [62,63]. ...
... In a different study, Lindberg and colleagues implemented a 'best practice alert' into their electronic medical record where the woman's weight gain was calculated and a conversation and related documentation was prompted regarding gestational weight gain and helped the healthcare professional refer to appropriate services such as gestational diabetes testing. Together, this led to better documentation regarding women's weight [41] and more women met the IOM guidelines for gestational weight gain [71]. These findings are in line with other research where changes to the practice environment has improved documentation of weight [72••] and where changes within electronic medical records show most potential [73••]. ...
Purpose of review
The aim of this review was to summarise recent evaluations of healthcare professional training regarding gestational weight gain and provide recommendations for future training.
Recent findings
A number of evaluated healthcare professional training sessions regarding gestational weight gain show promising results in terms of increased participant confidence and knowledge and impact on women’s outcomes. It is clear that the interventions which have also implemented resources in the practice environment to support training are the ones most likely to influence gestational weight gain.
Summary
Support from healthcare professionals are key to influence pregnant women’s weight gain and should be offered within the standard curriculum and through mandatory training. Factors influencing this support include women’s and healthcare professional characteristics, interpersonal and healthcare system and policy factors. All of these need to be considered when developing healthcare professional training to support women with their gestational weight gain.
... The physician alone should not be the single resource to help and advise these women; dietitians, nurses, midwives, behaviorists and exercise therapists may often be in a much better position to provide appropriate advice and counselling [47]. Therefore, more research is needed to identify the provider barrier to addressing GWG not only during pregnancy but also before and after pregnancy, as well as how to overcome those barriers [48]. ...
Background
Prenatal care has been validated to provide medical and educational counselling intended to reduce the risk of adverse pregnancy conditions and improve the maternal and fetal outcomes. Prenatal targeted information regarding nutrition, lifestyle, and weight gain is predictive of meeting Institute of Medicine (IOM) 2009 gestational weight gain (GWG) guidelines. There is limited information about women’s experiences with these prenatal counselling domains, particularly in women who do not meet GWG recommendations. The objective of this study was to evaluate the impact of women’s recall of prenatal counselling and its effect on meeting their GWG within guidelines in a prospective, community-based pregnancy cohort.
Methods
A sample of 2909 women with singleton pregnancies was drawn from the prospective community-based pregnancy cohort All Our Families from Alberta, Canada. Women were stratified into three GWG groups, adequate, inadequate, and excessive GWG, based on pre-pregnancy BMI and the adherence to the Institute of Medicine weight gain in pregnancy guidelines. At less than 25 and 34 to 36 weeks’ gestation, maternal socio-demographic information and women’s recall of prenatal counselling experiences was collected through self-administered questionnaires. Multivariate logistic regression analyses tested GWG strata impact on women’s recall of the prenatal counselling advice in eight domains of nutrition, lifestyle, and weight management during pregnancy.
Results
Adequate GWG was reached by 35.9% of women, 46.5% gained excessive and 17.6% gained inadequate weight. Women who were overweight and obese prior to pregnancy were more likely to gain excessive weight than women who were normal weight (OR 3.3, 95% CI 2.6–4.1; and OR 2.9, 95% CI 2.1–3.9, respectively). Most women reported having no difficulties in finding prenatal care, felt comfortable with their health care provider and were satisfied with the answers received. There was no difference in the recall of prenatal advice received in any of the eight domains of prenatal counselling assessed among women with appropriate and non-optimal GWG.
Conclusion
Women with adequate and non-optimal GWG received comparable prenatal counselling on nutrition, weight gain, and lifestyle modifications. There remain missed opportunities in targeting prenatal counselling advice to women at risk for suboptimal or excessive GWG.
Electronic supplementary material
The online version of this article (10.1186/s12884-019-2283-x) contains supplementary material, which is available to authorized users.
... As EHR implementation becomes more widespread, 10 the use of BPAs to notify EHR users when a particular element of a patient's care needs additional attention is increasing. Several studies have demonstrated improved HTN control and clinical outcomes when a BPA is utilized in a number of clinical situations [11][12][13][14][15][16][17][18][19][20] The results specific to BPAs for HTN management are mixed. Studies by Shih We evaluated the implementation of a BPA targeting HTN in a large Midwestern primary care practice and its relationship with follow-up for patients with an elevated BP at an initial visit and if their BP was controlled at follow-up. ...
Background:
Inadequately treated hypertension leads to considerable morbidity and mortality. Despite many treatment options, blood pressure (BP) control is suboptimal. Missed opportunities due to the growing complexity of primary care office visits contribute. Electronic health records (EHRs) offer best practice advisory (BPA) tools to support clinicians in identifying poor BP control. BPAs have demonstrated effectiveness for other health outcomes.
Methods:
EHR data was collected for patients ≥ 18 years old seen for primary care office visits prior to, during, and after the BPA active period and used to identify patients for whom the BPA fired, or would have fired during control periods. Logistic regression examined the association of BPA activation with follow-up BP check within 14-90 days and with BP control at follow-up, controlling for demographics and health conditions.
Results:
The BPA active period was associated with reduced patient follow-up, however a number of covariates were predictive of increased follow-up: Black non-Hispanics, Hispanics, patients on the Chronic Kidney Disease, Hypertension, or Diabetes registries, as well as the morbidly obese, insurance status, and seasonal factors. For those who did follow up, BPA activation was associated with improved BP control.
Conclusions:
BPA activation was associated with worse patient follow-up but improved BP control. Some subgroups had significantly different rates of follow-up and BP control. This study did not have an experimental design as the BPA was a quality improvement initiative. These results highlight the critical importance of planning experimentally designed organizational initiatives to fully understand their impact.
... One prior study examined an EHR "best practice alert" intervention designed to improve provider communication regarding GWG recommendations. Although not a randomized trial, that intervention was associated with a 7% increase over time in the proportion of women who met IOM guidelines for total GWG, supporting our findings that health systems can leverage the EHR to promote healthy pregnancies (27). ...
Objective:
Evaluate whether a tailored letter improved gestational weight gain (GWG) and whether GWG mediated a multicomponent intervention's effect on postpartum weight retention among women with gestational diabetes mellitus (GDM).
Research design and methods:
A cluster-randomized controlled trial of 44 medical facilities (n = 2,014 women) randomized to usual care or a multicomponent lifestyle intervention delivered during pregnancy (tailored letter) and postpartum (13 telephone sessions) to reduce postpartum weight retention. The tailored letter, using electronic health record (EHR) data, recommended an end-of-pregnancy weight goal tailored to prepregnancy BMI and GWG trajectory at GDM diagnosis: total GWG at the lower limit of the IOM range if BMI ≥18.5 kg/m2 or the midpoint if <18.5 kg/m2, and weight maintenance if women had exceeded this. The outcomes for this study were the proportion of women meeting the Institute of Medicine (IOM) guidelines for weekly rate of GWG from GDM diagnosis to delivery and meeting the end-of-pregnancy weight goal.
Results:
The tailored letter significantly increased the proportion of women meeting the IOM guidelines (72.6% vs. 67.1%; relative risk 1.08 [95% CI 1.01-1.17]); results were similar among women with BMI <25.0 kg/m2 (1.07 [1.00-1.15]) and ≥25.0 kg/m2 (1.08 [0.98-1.18]). Thirty-six percent in the intervention vs. 33.0% in usual care met the end-of-pregnancy weight goal (1.08 [0.99-1.18]); the difference was statistically significant among women with BMI <25.0 kg/m2 (1.28 [1.05-1.57]) but not ≥25.0 kg/m2 (0.99 [0.87-1.13]). Meeting the IOM guidelines mediated the effect of the multicomponent intervention in reducing postpartum weight retention by 24.6% (95% CI 11.3-37.8%).
Conclusions:
A tailored EHR-based letter improved GWG, which mediated the effect of a multicomponent intervention in reducing postpartum weight retention.
... We have limited population-level estimates on how much information patients receive from clinicians regarding GWG using the most recent IOM guidelines. However, recent research has shown that improving clinician knowledge and effort to address appropriate GWG has been effective in helping women gain within IOM recommendations (Lindberg et al., 2016;Wilkinson et al., 2016). In addition, strategies such as meeting dietary and physical activity goals have been shown to help women gain within IOM recommendations (Muktabhant et al., 2015). ...
Objective:
To estimate the percentage of infants with large birth size attributable to excess gestational weight gain (GWG), independent of prepregnancy body mass index, among mothers with preexisting diabetes mellitus (PDM).
Study design:
We analyzed 2004-2008 Florida linked birth certificate and maternal hospital discharge data of live, term (37-41weeks) singleton deliveries (N=641,857). We calculated prevalence of large-for-gestational age (LGA) (birth weight-for-gestational age≥90th percentile) and macrosomia (birth weight>4500g) by GWG categories (inadequate, appropriate, or excess). We used multivariable logistic regression to estimate the relative risk (RR) of large birth size associated with excess compared to appropriate GWG among mothers with PDM. We then estimated the population attributable fraction (PAF) of large birth size due to excess GWG among mothers with PDM (n=4427).
Results:
Regardless of diabetes status, half of mothers (51.2%) gained weight in excess of recommendations. Large birth size was higher in infants of mothers with PDM than in infants of mothers without diabetes (28.8% versus 9.4% for LGA, 5.8% versus 0.9% for macrosomia). Among women with PDM, the adjusted RR of having an LGA infant was 1.7 (95% CI 1.5, 1.9) for women with excess GWG compared to those with appropriate gain; the PAF was 27.7% (95% CI 22.0, 33.3). For macrosomia, the adjusted RR associated with excess GWG was 2.1 (95% CI 1.5, 2.9) and the PAF was 38.6% (95% CI 24.9, 52.4).
Conclusion:
Preventing excess GWG may avert over one-third of macrosomic term infants of mothers with PDM. Effective strategies to prevent excess GWG are needed.
Objective:
To determine if a best-practice alert (BPA) implementation increases the rate of smoking cessation during pregnancy, and affects pregnancy outcomes associated with smoking Methods: This was a pretest-posttest study design where a BPA was added to electronic medical records (EMR) of pregnant persons who reported active smoking. The BPA provided the 5A's method to conduct counseling on smoking cessation. The rates of smoking cessation during pregnancy were compared 1.5 years before and after implementation of the BPA. Secondary outcomes examined whether counseling on smoking cessation was done, the number of the counseling sessions during pregnancy, and obstetric outcomes associated with maternal smoking.
Results:
After implementation of the BPA, the rate of smoking cessation in pregnancy increased from 17.5% prior to BPA implementation to 54.9% after BPA implementation (p<0.001). The rate of counseling on smoking cessation increased from 66.6% prior to BPA implementation to 95.6% after BPA implementation, with an increase noted also in the number of smoking cessation counseling sessions. In multivariate analyses, after controlling for maternal demographic and clinical factors, BPA implementation was significantly associated with higher rates of smoking cessation (adjusted odds ratio (aOR) 3.44, 95% confidence interval (CI) 2.17-5.51),higher rates of documented smoking cessation counseling in the EMR (aOR 12.44, 95% CI 6.06-25.64) , and higher odds of conducting the counseling more than once (aOR 6.90 95% CI 4.45-10.88).
Conclusion:
The rate of smoking cessation and number of times pregnant persons were counseled increased after implementation of a BPA. The BPA could be a useful EMR tool to increase smoking cessation rates during pregnancy.
Importance:
Ten years have passed since the Institute of Medicine (IOM) released its recommendations for gestational weight gain (GWG), based on a woman's prepregnancy body mass index. Despite this, the majority of women do not gain the appropriate gestational weight; most women gain too much weight, and a small but substantial number gain too little.
Objective:
We review the literature concerning GWG, the opinions and practices of clinicians in managing their patients' weight, and how these practices are perceived by patients. We also review several randomized control trials that investigate the efficacy of clinical intervention in managing GWG.
Evidence acquisition:
A literature review search was conducted with no limitations on the number of years searched.
Results:
The number of clinicians who are aware of and use the IOM recommendations has increased, but the prevalence of inappropriate GWG has not decreased. Clinicians report feeling less than confident in their ability to have an impact on their patients' weight gain, and there are discrepancies between what clinicians and patients report regarding counseling. Many randomized control trials demonstrate a beneficial impact of clinical intervention, highlighting the importance of collaboration and technology to provide educational information and support throughout a pregnancy.
Conclusions:
Pregnancy provides an opportunity for clinicians to have open and direct conversations with their patients about their weight. Providing clinicians with the tools, skillset, and confidence to assist in the management of GWG is essential to the health of women and their children, and warrants further investigation.
Objective
This study aimed to understand physical, knowledge, psychological, and lifestyle factors associated with planned excess gestational weight gain (GWG), a strong and potentially modifiable predictor of actual excess GWG, which contributes to maternal and child obesity along with other adverse maternal and fetal outcomes.
Methods
This is a secondary analysis of data from a prospective cohort study where women completed a questionnaire in early pregnancy. Women were asked to report their planned GWG, which was then categorized as above, within, or below the Institute of Medicine (IOM) guidelines. Univariable and multivariable analyses were performed to identify variables associated with planned excess GWG.
Results
Of 970 women included in the analysis, 300 reported a planned GWG above the IOM guidelines. Predictors of excess planned GWG included reporting healthcare provider recommendations to gain weight above the guidelines (adjusted odds ratio [aOR], 62.17; 95% confidence interval [CI], 13.75–281.03), overestimating first trimester weight gain recommendations (aOR, 1.83; 95% CI, 1.21–2.77), believing in risks to the baby with inadequate GWG (aOR 2.16; 95% CI,1.29–3.60), inaccurate self-perceived prepregnancy body size (aOR, 1.88; 95% CI, 1.22–2.89), low or high emotional suppression (aOR, 1.78; 95% CI, 1.06–2.99; and aOR, 2.57; 95% CI, 1.21–5.45, respectively), physical inactivity (aOR, 1.10; 95% CI, 1.03–1.17), and overweight or obesity (aOR, 5.76; 95% CI, 3.70–8.98; and aOR, 11.46; 95% CI, 6.54–20.06, respectively). Protective factors against planned excess GWG included increased maternal age (aOR, 0.95; 95% CI, 0.92–0.99), and believing in risks to themselves with inadequate GWG (aOR 0.64; 95% CI, 0.42–0.97) or believing in risks to the baby with excess GWG (aOR, 0.49; 95% CI, 0.27–0.88).
Conclusions
Women with overweight or obesity are at greater risk of prospectively planning excess GWG, and may especially benefit from healthcare provider counseling on appropriate GWG. Other modifiable factors for planned excess GWG included knowledge about risks of inappropriate weight gain and physical inactivity.
