Bariatric Care in the Community: Recognizing and Addressing Barriers to Long-term Follow-up Care for Bariatric Surgery Patients

| June 16, 2010

by Karen O’Donnell, RN; James Cavanagh, MBBS, MRCGP; Carel le Roux, MBBS, PhD, MRCPath; and Ahmed R. Ahmed, MBBS, BSc (Hons), FRCS

Ms. O’Donnell is Clinical Nurse Specialist for Imperial Weight Centre, Charing Cross Hospital, London, United Kingdom. Dr. Cavanagh is from Brook Green Medical Centre, London. Dr. le Roux is Consultant Metabolic Physician for Imperial Weight Centre, Charing Cross Hospital. Dr. Ahmed is Clinical Lead of Bariatric Surgery for Imperial Weight Centre, Charing Cross Hospital.

Bariatric Times. 2010;7(6):22–23

Abstract
The incidence of obesity is increasing worldwide and, subsequently, the number of patients undergoing bariatric surgery is also on the rise. In the United Kingdom and elsewhere, hospital-based bariatric surgery departments have traditionally been responsible for the preoperative work up and postoperative follow up of bariatric surgery patients. However, with rising numbers, this will become increasingly difficult. In particular, life-long follow up may become impossible as the number of patients having undergone surgery rises year after year. In this article, we propose and analyze the effects of offering two programs for bariatric care in the community. In the first program, patients are seen preoperatively for assesments and optimization in the primary care setting, and only present to the hospital for surgery. In the second program, postoperative patients are followed up with by their primary care physicians who are ultimately responsible for all aspects of their care, including gastric band adjustments and nutritional management.

Introduction
In the United Kingdom, the incidence of obesity in adults has trebled during the past 25 years. About two-thirds of the adult population (almost 24 million adults) were either overweight or obese in 2004.[1] The National Health Service (NHS), England’s national healthcare system, is funded by the taxpayer through the Department of Health. The Department of Health in the United Kingdom realizes that although the upfront cost of bariatric surgery may be high, there is increasing evidence of the financial benefits in addition to the personal health benefits of surgery in the long term; hence, the NHS covers all costs of treatment for obesity. To help primary care trusts (PCTs) make decisions regarding who should get treatment, the Department of Health has a separate organization, the National Institute for Clinical Excellence (NICE).

The NICE guidelines from 2006 state that obesity in adults should be managed at two levels: 1) through general advice, from public education on healthy living to the public at large by primary care physicians (family practioners) and from specific personal advice to targeted individuals by a family practitioner or practice nurse on weight control, diet, and physical exercise. This advice is aimed at influencing lifestyle, supported by drug therapy prescribed by the family doctor, if appropriate; and 2) through onward referral to a weight loss specialist for treatments involving surgery. The referral guidelines for bariatric surgery in the United Kingdom are similar to the National Institute of Health (NIH) criteria used in the United States and elsewhere.[2]

This article reviews our center’s solutions to addressing barriers to care in patient follow up and effective management of obesity in adults.

Addressing barriers to care
In the United Kingdom, a number of barriers exist to the effective management of obesity in adults, notably in relation to family practitioners reporting uncertainty about the following three areas:
1.    the effectiveness of lifestyle interventions
2.    the appropriateness and effectiveness of drug therapy
3.    the criteria for referral for specialist opinion.[1]

The Imperial Weight Centre at Charing Cross Hospital, London, was recently designated by the Surgical Review Corporation (SRC) as an International Centre of Excellence for Bariatric Surgery. Our unit has had a significant increase in the numbers of patients referred for bariatric surgery. On average, we receive 120 referrals to the centre every month for patients requiring specialist input for weight management. The majority opt for bariatric surgery, and the unit currently performs 600 cases per year, which will will soon increase to 900 cases per year. Any unit offering bariatric surgery needs to have systems in place for regular life-long follow up of patients. Adherence to long-term follow up is vital, as nutritional and metabolic problems can be easily treated or avoided.[3] It will be evident that with such high referral rates, regular follow up for all patients in the hospital setting becomes a daunting, if not impossible, proposition. With increasing numbers of patients undergoing bariatric surgery, physicians other than the initial surgeon will need to become involved in the follow up of bariatric patients. The family physician may be the only medical professional involved years after the surgery is performed who can ensure that patients meet their overall nutritional needs.[4] Furthermore, many of the presurgical assessments that currently take place within the hospital setting take time and manpower and utilize scarce resources that may otherwise be used more effectively in other parts of the surgical pathway.

We recognized these challenges and realized that more needs to be done in the community setting both in the pre- and postoperative settings. Therefore, in January 2010, we launched an innovative program of providing bariatric surgery outpatient care at Brook Green Medical Centre Family Practice. This involves staff from the Imperial Weight Centre working alongside family practitioners in the community. The objective was to provide high-quality, local care for bariatric surgery patients as well as increase knowledge of obesity and its management in a family practice setting. We designed two separate programs in an attempt to reduce the burden on our hospital systems and improve the patient pathway by transferring most of the care back to the community setting, and thus, reducing time, effort, and costs for our patients from commuting to and from the hospital.

The first program looks at identifying those patients in the community who are interested in bariatric surgery and making sure they have access to surgery. It involves family practioners providing preoperative medical assessments, optimizing any existing comorbidities, and also giving dietary advice to patients seeking bariatric surgery. The first pilot study began in the summer of 2009 and examined a specific group of bariatric patients within the practice population. The group participants had 1) a body mass index (BMI) of 35 or greater, 2) type 2 diabetes, and 3) no previous bariatric intervention. Using these criteria, 24 patients were offered preoperative counseling and assessments that would normally have happed in the bariatric surgery department at the hospital. Five out of these 24 patients opted to have surgery. Three patients had adjustable gastric bands put in place and will be returning to the family practice for postoperative care where validated assessment tools will be used to measure both the impact of the operation on the patients’ health and satisfaction with the service. Complications will also be noted and, if necessary, patients can easily be referred back to the hospital.

The second program supports family practitioners in providing postoperative management of patients following bariatric surgery procedures, such as gastric banding, including adjustments of gastric bands, and follow up of patients after sleeve gastrectomy and gastric bypass surgery. The family practitioners have received specialist training from the bariatric team and continue to have support in the form of a clinical nurse specialist who attends the clinic. The service follows the same protocols and pathways as the hospital setting. The clinics are currently funded by the bariatric surgery department. The next stage will involve working with local health service commissioning teams to have the funding of this community service taken over by the local health care provider.

Dr. James Cavanagh, family practioner from Brook Green Medical Centre, London, United Kingdom, said, “The feedback we have received so far from patients has been very positive. The clinics are a fantastic opportunity for us family practitioners to learn from specialist colleagues, which will benefit many patients, not just those attending the obesity clinics.” Karen O’Donnell, clinical nurse specialist, notes that patients like being able to receive care from hospital specialists in a community setting and from specifically trained family practitioners because the surroundings are more convenient and the doctors are more familiar to them. The clinics are modelled on diabetic care in the United Kingdom, which is largely provided in the community.

Summary
We hope that the program will allow us to see 15 to 20 patients per week in the community setting. If the service proves effective, we envisage that approximately 80 percent of our pre- and postoperative follow-up care could be facilitated in the community. The benefits to the NHS would be that the same quality of care will be provided to patients in a local setting at a fraction of the cost.

References
1.    National Institute for Health and Clinical Excellence Clinical Guidance 43, 2006. Obesity: Guidance on the prevention, identification, assessment, and management of overweight and obesity in adults and children. http://www.nice.org.uk/
nicemedia/pdf/CG43NICEGuideline.pdf Accessed April 21, 2010.
2.    Gastrointestinal surgery for severe obesity. Proceedings of a National Institutes of Health Consensus Development Conference. March 25-27, 1991, Bethesda, MD. Am J Clin Nutr. 1992. 55(2 Suppl):487S–619S.
3.    Fujioka K. Follow-up of nutritional and metabolic problems after bariatric surgery. Diabetes Care. 2005;28(2):481–484.
4.    Virji A, Murr M. Caring for patients after bariatric surgery. Am Fam Physician. 2006;73(8):1403–1408.

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