Determining the rate of obesity documentation in a division of general internal medicine at a tertiary care medical center

Background: Obesity is a leading cause of preventable deaths in the United States, likely second only to tobacco-related diseases. However, studies have shown that the formal diagnosis rate is low, at 19.9%. Furthermore, of the patients with a diagnosis of obesity, only 22.6% receive a treatment plan. Objective: The objective was to determine rates of identification and diagnosis of obesity and referral for counseling in an ambulatory general internal medicine practice. Design: The electronic health records (EHR)of patients seen and examined for a 6-month period were searched for obesity-related terms (ORTs) which included: obese, overweight, weight-related issues, and elevated body mass index (BMI). Patients: All patients with a documented BMI of more than 30 kg/m2 who underwent a medical examination in the Division of General Internal Medicine at Mayo Clinic in Rochester, Minnesota, from October 1, 2012, through March 31, 2013, constituted the study population. Main Measures: Of 7484 patients seen for a medical examination, 2044 (27.3%) had a BMI more than 30 kg/m2. Of these, 946 (46.3%) were female. Key Results: The mean BMI was 34.8 kg/m2 (range, 30.0-64.4), and the mean age was 60.7 years (range, 18.5-94.6). Only 473 patients (23.1%) had the International Classification of Disease, Ninth Revision (ICD-9), code for diagnosis of obesity: Class 1 in 192 (41%), class 2 in 162 (34%), and class 3 in 119 (25%). Of the remaining 1571 patients with a BMI more than 30 kg/m2 but without the diagnosis of obesity, 748 (47.6%) had ORTs in their medical notes. Those with an obesity diagnosis were more likely to be referred for nutrition counseling than those with ORTs (9.3% vs. 4.4%; P < 0.0006). Conclusions: Physicians are meaningfully identifying obesity and discussing its health consequences through the use of ORTs, but they are failing to document ICD diagnoses in the medical records. The following core competencies are addressed in this article: Medical knowledge, Practice-based learning, Systems-based practice.