Shared Decision Making for Bariatric Surgery in Patients with Severe Obesity David Arterburn Joe Nadglowski President/CEO, Obesity Action Coalition Senior Investigator, Kaiser Permanente Washington @JNadglowskiOAC @davearterburn 9/19/19
David Arterburn Disclosures Rela latio ionship ip Company ny(ies es) Speakers Bureau None Advisory Committee None Board Membership None Consultancy NIH grants Review Panel NIH PCORI Funding PCORnet Bariatric Study Honorarium IFSO Latin American Chapter (conference travel) Ownership Interests None 2
Joe Nadglowski Disclosures: Joe Nadglowski is an employee of the Obesity Action Coalition(OAC). OAC policies do not permit him to have any direct financial relationships with any outside funders. Any such funds provided by any relationship, including the PCORnet Bariatric Study, are provided to OAC and not Mr. Nadglowski. Rela latio ionship ip Company ny(ies es) Speakers Bureau None Advisory Committee None Board Membership None Consultancy None Review Panel None PCORI Funding None Honorarium None Ownership Interests None 3
Bariatric Surgery for the Treatment of Obesity and Obesity Related Complications • Bariatric surgery is usually performed on patients with a BMI ≥40 or ≥35 if they have obesity related complications such as diabetes, etc. 1 • 9.7% of US Adult women and 5.6% of men in the United States have a BMI of 40 or above. 2 • According to the American Society for Metabolic and Bariatric Surgery (ASMBS), 228,000 bariatric surgery procedures were performed in 2017. 1 1. The American Society for Metabolic and Bariatric Surgery (ASMBS) 2. National Center for Health Statistics 4
Why Do People Seek Bariatric Surgery? • Primary reason is to improve health (controlling of medical problems); but people also desire to improve quality of life, mental health, and appearance. 1,2 • Family history of obesity and its related complications also plays a big role. 3 • Utilization remains low with less than 1% of eligible recipients seeking surgery. 4 1 Pearl, SOARD , 2019; 2 Munoz DJ, Obes Surg. 2007; 3 da Silva PT, Arq Bras Cir Dig . 4 Imbus J, Surg Obes Relat Dis . 2018 5
Barriers to Surgery • Obesity de-prioritized by healthcare providers. • Obesity not recognized as a disease by some providers. • Provider deferring to patient to suggest treatment agenda or initiate referral. • High societal stigma around obesity and seeking help for one’s obesity. • Belief that lifestyle change is most effective method to treat obesity. • Lack of Insurance coverage (procedures excluded) and/or difficult pre-authorization requirements. • Fear of surgery 1. Imbus JR, Surg Obes Relat Dis . 2018 6
Mixed Messages Weight Loss Surgery – It’s Safe. It Works. It’s Not a Last Resort. Drug, A Alc lcohol l Dea eaths S Soa oar A After Weig ight-Loss S ss Sur urger ery
Replace Hype with Patient Centered Evidence • PCORnet Bariatric Study compared the benefits and harms of the 3 most common types of weight loss surgery (Gastric Bypass, Sleeve Gastrectomy and Adjustable Gastric Band). • Evaluated 65,000 patients who have had bariatric surgery at 41 healthcare systems across the US. • While data was primarily available on adults, more than 700 of these patients were adolescents from 12 – 19 years of age. • Compared each type of weight loss surgery at 1, 3, and 5 years to see: • How much weight people lost and regained over time. • What happened to people with diabetes – remission, relapse, control. • How often people had major complications – reoperation, hospitalization 8
Clear differences in weight loss and regain… PCORnet Bariatric Study, Arterburn et al, Annals of Internal Medicine. Oct 30, 2018 9
Diabetes remission…. and relapse… 10 Unpublished results. Do not cite or distribute without permission from authors.
And the risk of reoperation and rehospitalization through 5 years. Unpublished results. Do not cite or distribute without permission from authors. 11
The need for shared decision making (SDM) • No one bariatric procedure is “right” for all patients. • Patients and their physicians need to consider the complex trade offs between the risks and the benefits of each procedure: • Gastric bypass has the best weight loss and diabetes outcomes • Sleeve gastrectomy has the lowest rate of reoperation and hospitalization • Adjustable banding has lowest early risk, but highest long-term risk • Patients and providers need help with these conversations. 12
Goals of new project • Incorporate PCORI comparative effectiveness evidence from the PCORnet Bariatric Study into an existing bariatric surgery decision aid • Implement the updated strategy into two health care systems: Kaiser Permanente Washington (KPWA) and UPMC in Pennsylvania. • The SDM Approach will address two preference-sensitive decisions for patients with severe obesity (defined as a body mass index or BMI ≥40 or a BMI ≥35 with obesity -associated health conditions): 1) Whether to undergo bariatric surgery, and 2) Which bariatric procedure to undergo 13
Decision Aid: Weight Loss Surgery: Is it Right for You? • Developed in 2005 - 2006 in collaboration with Health Dialog and the Informed Medical Decisions Foundation • Using IPDAS standards; systematic review; focus groups & interviews with patients and providers; updated biannually • Tested in a randomized, controlled trial* including 152 patients • ½ pre-op bariatric referrals; ½ general medical patients • DA significantly increased patients’ knowledge of their health condition, reduced their decisional conflict, and improved outcome expectancies • Decision aid is being updated to include 5 -year data from PBS *Arterburn D, et al. Obesity, 2011 14
Existing SDM Infrastructure • KPWA: began its large- scale SDM implementation effort in 2009* • Has distributed more than 50,000 decision aids and trained more than 1000 providers in SDM within their system since that time. • The prior KPWA SDM implementation work was not focused on bariatric surgery, so this is an opportunity to expand our established SDM program. • UPMC: relatively SDM-naïve environment (i.e., there have been no formal efforts to implement a broad-scale SDM Approach at UPMC) • We will test the ability to spread the KPWA SDM Approach into a traditional fee-for-service health care environment (different from the KP model) • Has a world-renowned bariatric surgical program (UPMC has one of the largest and oldest bariatric programs in the United States) 15 *Arterburn D, et al. Health Affairs, 2012; Moulton B, et al. Health Affairs, 2013. Hsu C, et al. Med Dec Making , 2013 & 2017.
What work was done at implementation sites to get them on board and help assure the success? • At KPWA, we engaged SDM experts and quality leaders, and we engaged primary care leaders and bariatric surgeons in design of the project; obtained letters of support and commitment of resources • At UPMC, we engaged leaders in quality and IT, and we engaged primary care leaders, and bariatric surgeons in design of the project; obtained letters of support and commitment of resources 16
The EPIS implementation conceptual model will guide our project Aarons GA, et al. Implement Sci. 2012;7:32. 17
The Six Steps of Shared Decision Making 1. Invite patient to participate 2. Present options 3. Provide information on risks and benefits 4. Elicit patient preferences 5. Facilitate deliberation and decision making 6. Assist patient with implementing decision 18
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