f2 karen barclay - bariatric surgery: improving quality by addressing psychosocial factors

Bariatric Surgery: Improving Quality by Addressing

Psychosocial Factors

BCPSQC Quality Forum 2013

March 1st Breakout Session F2

Karen Barclay, OT

Robyn Emde, OT

Richmond Hospital Bariatric Surgery Program

2

Disclosure Statement

Both presenters are employees of Vancouver Coastal Health and declare no potential conflicts of interest.

3

Background

In order to understand bariatric surgery, we need to understand the context...

4

Obesity is …

• a complex health problem

• a major contributor to chronic disease including:

• hypertension

• diabetes

• arthritis

• sleep apnea

• cancer

• reducing health related quality of life for thousands of individuals

5

Mokdad et al, 2003, JAMA Katzmarzyk, 2002, Can Med Assoc J Credit to Dr. JJ Sidhu and Dr. Saradh Sampath

No Data <10% 10%-14% 15-19% 20%

Obesity Trends Among Canadian and U.S. Adults, 1990

6


Mokdad et al., 2003, JAMA Katzmarzyk, 2002, Can Med Assoc J

No Data <10% 10%-14% 15-19% 20%

7


No Data <10% 10%-14% 15-19% 20%

Obesity Trends Among Canadian and U.S. Adults,1996

8


Mokdad et al., 2003, JAMA Katzmarzyk, 2002,Can Med Assoc J

No Data <10% 10%-14% 15-19% 20%

9



No Data <10% 10%-14% 15-19% 20%

10


Mokdad, A., CDCShields, M., Statistics Canada, 2005

10%-14% 15-19% 20% 25% 30%

11

Obesity is ...

• placing a growing strain on our provincial health care system:

People with chronic conditions represent approximately 34% of the B.C. population, and consume approximately 80% of the combined physician payment, PharmaCare and acute (hospital) care budgets.1

1. Province of British Columbia, Ministry of Health Services 2010/11-2012/13 Service Plan, p.7

12

Bariatric surgery is...

• surgery to restrict and/or re-route the digestive tract

• increasing in British Columbia, with over 100 surgeries per year performed at Richmond Hospital

• the most efficient weight loss option for people with a body mass index (BMI) ≥ 40 and people with BMI ≥35 who have serious comorbidities

however....

13

The issue is...

Bariatric surgery remains effective over the

long term only if accompanied by

significant lifestyle modification.

It is only one tool in a comprehensive

obesity strategy.

14

What factors influence weight loss?

0-3 months post op

4 months post op and beyond

15

Why is lifestyle modification difficult?

16

Bariatric surgery candidates... • have severe obesity which impairs health and function

• have struggled to lose weight for years

• face stigma from society

• have high rates of concurrent depression, anxiety and eating disorders1

• tell us they need support with their eating behaviour2

1. 19-42% have eating disorders (Franks & Kaiser, 2008)

2. Eating behaviour support is associated with weight loss maintenance (Ogden et al., 2011)

17

What was happening in Richmond?

Spring 2011: highly skilled surgical technique thorough dietary assessment & education access to medical specialists & exercise physiology

BUT...•patients requesting “more emotional support” •long waitlist for limited psychiatry sessions

18

Patient and Family Focus Group

June 2011

Participants told us they wanted information AND:

• Assistance to navigate the emotional roadblocks

• Skills to make the necessary lifestyle changes and stick with them

• Strategies to improve daily function & community participation

19

Literature Review1. Surgery is usually effective, but unaddressed

psychosocial issues are associated with1:

• Surgical Rupture • Inadequate Weight Loss & Weight Re-gain• Cross Addiction • Decreased Quality of Life

2. “Psychosocial support” recommended by the American Bariatric Surgery Guidelines2

1. Lepage, 2010; Livhits et al., 2010; McMahon, et al., 2006; Kofman, et al., 2010

2. Mechanick et al., 2009

20

Barriers

Did everyone need a psychiatry consult?x Expensive x Lack of availability: wait list impeding pt. flowx Consultation alone isn’t enough...

Psychiatrist noted that only 40% needed his service & advocated that best practice should include treatment: cognitive behavioural group therapy and skill application.

“Support Groups” aren’t adequate1

1. Sadock, et al., 2007

21

Supportive Factors:

Surgeon “champion”

Encouraging professional practice leadership

Collaborative interprofessional team

Responsive administration: heard the evidence and supported a trial solution

22

GoalCreate a service model that ensured equal access to quality psychosocial assessment and treatment by:•referring to psychiatry services only when clinically indicated; therefore,

•creating timely access for those patients who need psychiatry services the most

•providing evidence based treatment to support lifestyle modification

23

Program Design

Adding a part time (0.4) occupational therapist to the program enabled:

•reliable mental health risk screening, functional analysis and collaborative goal setting

•timely referral to the psychiatrist when indicated

•evidence-based psychosocial treatment

•the link between education and real life

24

Screening & Outcome Measures

Mood: Beck Anxiety Inventory (BAI) & Beck Depression Inventory (BDI)

Self Esteem: Rosenberg Self Esteem Scale (RSES)

Eating Behaviour: Eating Disorders Examination Questionnaire (EDE-Q)

Function: Canadian Occupational Performance Measure (COPM)

25

Intervention: Group Therapy11-week group therapy program based on:

1. Changeways® Cognitive Behavioural Therapy (CBT)

2. Occupational Therapy Theory

• Improved function through engagement in meaningful activities & roles

Purpose: Identify and counteract distorted and negative thinking Goal setting related to daily self-care, productivity & leisure Stress management Healthy and sustainable lifestyle modification

26

Intervention: Maintenance Group

• Available to‘graduates’of group therapy• One hour group, once a month

Purpose:Skill refresherTalk about challengesGenerate solutionsGet support from others

* Minimal cost to screen for dangerous set-backs

27

ResultsAt one year1 (unpublished QI data July 2011-12):•160 received OT psychosocial assessment•47 referred for full psychiatry consult•106 group therapy candidates•4 11-week groups (n=35), 46 on waitlist•25 out of town candidates (Telehealth?)

Clinically significant improvement across all 5 measures for group therapy participantsPost-group satisfaction surveys overwhelmingly positive

1. Now approaching 2 years, numbers on track to be doubled

28

Case Study: “Heather”1

Referred February 2012• 30 years old• Single mom of 2 children (ages 8 & 10)• Weight: 345 lbs, Height: 5’9” inches = BMI 50.9

Already tried: Weight Watchers (lost & regained 40 pounds multiple times over 6 years), Dr. Bernstein (lost and gained 55 pounds, 3 times), LA Weight Loss, Community fitness programs, appetite suppressants (lost and then regained 95 lbs), Cabbage soup diet, South Beach (lost and regained 12 pounds) ...

1. Pseudonym: all identifying information has been changed

29

Heather’s lived experience

“I am embarrassed by my size. I am ashamed when people look at my groceries.”

“My back is always aching, my ankles hurt, and sometimes give out going down stairs.”

“I don’t take my kids out socially. I don’t work out because I feel people are disgusted by me.“

Heather’s Goals: • Do more with my kids• Be a positive role model• Improve health & mobility • Participate in sports

30

Heather’s Assessment

• Food addiction: hiding food from family • Emotionally-driven eating patterns• Low self esteem: using food as a reward• Depressive symptoms: impairing socialization • Difficulty prioritizing herself: “I don’t have fun”

Motivated to live a different life

Recommendation: Address the psychosocial factors through therapy prior to

surgery

31

Heather’s Treatment

Group therapy addressed the psychosocial barriers that were holding her back from her good intentions:

Learned to recognize negative thinking

Developed new non-food coping strategies

Improved her stress management skillsLearned how to prioritize her needs

Started a positive cycle of socialization

Motivation + Skills = Ability to maintain lifestyle modification

Ready for surgery

32

Heather’s Outcome

February 2013:• BMI: 39 (down to 275 lbs.)

Improved self esteem

Goes out with friends

Bought a home gym (with saved drive-thru $!)

Positive role model for her children

33

Short term Program Outcomes

High quality service: Assessment & Treatment

Satisfied patients

Improved access to psychiatry consult

Improved patient flow

34

Anticipated Long Term Impacts

Reduced need for surgical revisions

Better weight loss maintenance

Improved patient-reported quality of life

Lower chronic disease-related health care costs

35

Sustainable Weight Loss and Functional Lifestyle

Sustainable Weight Loss and Functional Lifestyle

Mental Health and Self-

Management Skills

36

Key Messages:

1. Involving patients and families in program planning is highly advantageous

1. Surgery is just one component in a successful obesity strategy

1. Proactive attention to psychosocial needs improves quality outcomes

37

Acknowledgements

Ms. Mary Flesher, RDN, Manager

Dr. Nam Nguyen, Surgeon

Dr. Monica Redekopp, Professional Practice Director

Dr. Sharadh Sampath, Surgeon

Dr. Jesse Sidhu, Psychiatrist

Thank you!

38

Questions?

Karen Barclay, Practice Coordinator, Occupational Therapy VCH – RichmondRichmond [email protected]

Robyn Emde, Occupational Therapist

VCH – Richmond

Garratt Wellness Centre

604-278-9711 extension 4341

[email protected]

39

References

Franks S., & Kaiser K. (2008). Predictive factors in bariatric surgery outcomes: What is the role of the preoperative psychological evaluation? Primary Psychiatry. 15(8): 74-83.

Katzmarzyk, P. (2002). The Canadian obesity epidemic, 1985-1998. Canadian Medical Association Journal. 166(8): 1039-40.

Kofman, M., Lent, M. & Swencionis, C. (2010). Maladaptive eating patterns, quality of life, and weight outcomes following gastric bypass: Results of an internet survey. Obesity. 18(10): 1938-43.

Lepage, C. (2010). The Lived Experience of Individuals following Roux-en-Y Gastric Bypass Surgery: A Phenomenological Study. Bariatric Nursing and Surgical Patient Care. 5 (1), 57-64.

Livhits M., Mercado C, Yermilov I., Parikh JA, Dutson E., Mehran A., et al. (2012). Preoperative predictors of weight loss following bariatric surgery: Systematic review. Obesity Surgery. 22(1): 70-89.

40

References

McMahon, M., Sarr, M., Clark, M., Gall, M., Knoetgen, I., Service, F., Laskowski, E. & Hurley, D. (2006). Clinical management After Bariatric Surgery: Value of a Multidisciplinary Approach. Mayo Clinic Proceedings. 81(10, suppl), S34-S45

Mechanick J., Kushner R., Sugerman, H., Gonzalez-Campoy, J., Collazo-Clavell, M., Spitz, A., et al. (2009). American association of clinical endocrinologists, the obesity society, and American society for metabolic & bariatric surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Obesity. 04(17 Suppl) 1:S1

Mokdad, A., Ford, E., Bowman, B., Dietz, W., Vinicor, F., Bales, V. & Markus, J. (2003), Prevalence of obesity, diabetes and obesity-related risk factors. JAMA. 289(1): 76-79.

Ogden J., Avenell S. & Ellis G. (2011). Negotiating control: Patients' experiences of unsuccessful weight-loss surgery. Psychological Health. 26(7): 949-64.

41

References

Paterson, R. (2007). Changeways Core Program: Evidence-based group treatment for depression. Clinicians Guide ©

Province of British Columbia (2010) Ministry of Health Services: 2010-11-2012/13 Service Plan. Retrieved from: http://www.bcbudget.gov.bc.ca/2010/sp/pdf/ministry/hserv.pdf

Sadock, B., Kaplan, H. & Sadock, V. (2007). Kaplan & Sadock’s Synopsis of Psychiatry, 10th Edition. Philadelphia: Wolter Kluwer/Lippincott Williams & Wilkins.

f2 karen barclay - bariatric surgery: improving quality by addressing psychosocial factors

Documents