1 Weight Loss Surgery DA participants- 18 months later By: Caitlyn Patrick and Evan Morgan
2 Outline Background Obesity Comorbidities Treatments Barriers to care Kylee Miller s work PDSA Plan: Systematic follow up of patients who viewed DA Do: WebCIS chart review of patients for weight loss outcomes and methods Study: Analyzed data based on type of intervention vs. change in weight Act: Discussion of results, ideas for the future
3 Obesity Trends
4 Obesity Trends
5 Obesity Trends By 2004 all states had more than 15 percent obesity. All but 6 states reported more than 20 percent obesity while 9 states reported more than 25 percent obesity.  There appears to be a changing perception of obesity. In a population survey study, fewer overweight and obese individuals defined themselves as overweight in 2007 when compared to 1999, despite a significant increase in the prevalence of obesity.  Lifetime risk: Based on data from the Framingham Heart Study, the 30-year risk was 1 in 2 (50 percent) of developing overweight (BMI >25 kg/m), was 1 in 4 (25 percent) of developing a BMI >30 kg/m and 1 in 10 (10 percent) of developing a BMI >35 kg/m. 
6 Economic Impact According to a study of national costs attributed to both overweight (BMI ) and obesity (BMI greater than 30), medical expenses accounted for 9.1 percent of total U.S. medical expenditures in 1998 and may have reached as high as $78.5 billion ($92.6 billion in 2002 dollars) (Finkelstein, Fiebelkorn, and Wang, 2003). Estimated percentages and expenditures attributed to overweight/obesity by state ( ): In North Carolina- 6% of the total population estimated to cost $2,138,000,000 with 7% of the Medicare population costing $448,000,000 and 11.5% of Medicaid costing $662,000,000. (Finkelstein, Fiebelkorn, and Wang, 2004)
7 Relation between mortality and body mass index At a body mass index below 20 kg/m2 and above 25 kg/m2 there is an increase in relative mortality for men and women. Data from Lew, EA. Ann Intern Med 1985; 103:1024. (similar results from study done in Lancet in 2009)
8 Relative Risk of Co-morbidities Increasing body-mass index (BMI kg/m2), even within the normal range of BMI (21 to 24.9), is associated with an increased risk of type 2 diabetes, hypertension, coronary heart disease, and cholelithiasis Data from Willett, WC, Dietz, WH, Colditz, GA. Guidelines for healthy weight. N Engl J Med 1999; 341:427.
9 Co-morbidities Diabetes mellitus- More than 80 percent of cases of type 2 diabetes can be attributed to obesity Hypertension- A review from the Framingham Heart Study, in which participants were prospectively followed for up to 44 years, estimated that excess body weight (including overweight and obesity) could account for up to 26 percent of cases of hypertension in men and 28 percent in women OSA Osteoarthritis Dyslipidemia Heart disease Coronary disease Heart failure Myocardial steatosis Atrial fibrillation/flutter Gout Venous thrombosis Dementia Hepatobiliary disease GERD/esophageal cancer Cancer (endometrial colon, gallbladder, kidney, breast) Endocrine changes Reproductive complications Depression
10 Treatment options Behavioral Modification, Diet, Exercise Weight Loss Meds Sibutramine- sympathomimetic drugs reduce food intake by causing early satiety but may increase BP Orlistat- intestinal lipase antagonist, need fat soluable vitamin (A,D,E) replacement. Antidepressants- Fluoxetine and Sertraline lead to short term weight loss
11 Treatment options cont. Bariatric Surgery For patients with BMI >40 or >35 with serious comorbitities, ages 18-60, well-informed, and motivated, and have failed lifestyle interventions Medicaid requires 6 months PCP/Nutrition visits focused specifically on weight loss Weight Loss Surgery DA- reviews BMI, how the surgery works, risks and complications, and life after surgery. Also brief section on nonsurgical options
12 Barriers to Weight loss Dr. Rometo made an extensive list of barriers to weight loss in his PDSA cycle. System Barriers (eg. Inaccuracy of BMI recording) MD Barriers (knowledge of treatments, acknowledgement of problem) Patient Barriers (financial, acknowledgement of problem)
13 Kylee Miller s Work with the WLS DA Total 39 people who viewed all/some video in clinic and responded to survey. 46% decided not to have surgery; 49% were undecided/did not respond 15% liked receiving the materials a little 49% liked receiving the materials a lot Knowledge (4 questions) 22% all questions correct
14 Plan: Our PDSA: Cycle 1 Aim: Assess the outcomes of patients that viewed the WLS DA in clinic Questions: 1) Did the pts who viewed the DA seek some sort of intervention (saw surgeon, had surgery, saw nutritionist, weight loss program) for their weight and what were the outcomes as measured by change in weight? 2) What happened to the patients who viewed the entire video compared to those that only partially viewed the video? 3) Did patients initial BMI affect their decision about which intervention to pursue?
15 Our predictions 1)Those patients that said they would not want weight loss surgery following the viewing will be less likely to chose surgery over those that were undecided/did not respond 2) Those patients with higher BMIs will have been more likely to undergo surgical intervention. 3) Those who answered knowledge questions correctly will be less likely to choose surgery. 4) We hope to see an overall average decrease in the weight of the patients who viewed the decision aid regardless of the intervention they chose.
16 Methods Who: 39 Obese patients who viewed the WLS DA in the ACC clinic What: WebCIS Chart review of the clinic notes of these patients. Will record data on # visits, length of follow-up, types of interventions, most recent BMI/weight, and change in weight since viewing DA. When: Patients who saw video 11/2007-1/2008 and had at least 1 follow-up visit more than a week after the viewing and before 8/03/2009.
17 Who were they? 36 Internal Medicine patients who had been shown the decision aid by Kylee Miller Time period 11/16/2007-8/3/2009 Average BMI: Average Number of F/U: 8.8 Excluded: 3 patients were excluded from original data set. 2 due to lack of follow up 1 patient s actual BMI was 29 and didn t qualify for weight loss surgery when she saw the video *Note one patient was pregnant at last F/U visit
18 What happened to them? Intervention N Nutrition Consult 16 None 16 Gastric Bypass 1 Self 2 Self/Nutrition 1 N =3 6 44% 3% 6% 3% 44% Nutr ition Consult None Gastr ic Bypass Self Self / Nutr ition
19 What happened to them? Average Change in Weight (Kg) Nutrition Consult None Gastric Bypass Self Self/Nutrition Intervention
20 There are Nutrition Consults and then there are Nutrition Consults Average change in w eight (Kg) > or = 3 visits <3 visits N=17 Number of Nutrition Consults 5 > or = 3 vi si ts <3 vi si ts 12
21 Revisiting Initial Data N? Response rate Average knowledge score Watched entire video Didn't watch entire video (average view time 11.4 min) 19 84% % 2.1
22 Viewing versus intervention? N=19 N=17 42% 5% 16% 44% 0% 17% 5% 32% 11% 28% Had Weight Loss Surgery Nutrition Consults >or= 3 Nutrition Consults <3 Self None Had Weight Loss Surgery Nutrition Consults >or= 3 Nutrition Consults <3 Self None Note: Of patients who viewed the entire video 2 were referred and seen by surgeons, whereas only one person who didn t watch the entire video was referred to a surgeon but never was seen. Of two patients still desiring weight-loss surgery one watched the entire video and the other didn t
23 Viewing versus outcome? Average change in weight (kg) watched entire video didn't watch entire video (average view time 11.4 min) Excluding the 1 patient who had by-pass average weight loss entire video viewers was (Kg)
24 BMI versus intervention BMI N=8 38% 0% BMI N=25 0% 62% 48% 4% 12% Had Weight Loss Surgery Nutrition Consults >or= 3 Nutrition Consults <3 Self None 28% 8% BMI >60 N=3 Had Weight Loss Surgery Nutrition Consults >or= 3 Nutrition Consults <3 Self None 33% 0% 0% 67% Had Weight Loss Surgery Nutrition Consults >or= 3 Nutrition Consults <3 Self None
25 BMI versus outcome Average change in weight (Kg) >
26 Individual Observations 2 patients said yes to Do you plan on having Bariatric Surgery? Patient #1 - viewed 0 minutes of the video - answered 4/4 questions correctly - gained 3.4 Kg - had no intervention (couldn t afford nutritionist) - still desires WLS Patient #2 - watched the entire video - answered 1/4 knowledge questions correctly - gained 8.9 Kg - had no intervention - had 9 follow up visits
27 Individual Observations 2 patients were seen by surgeons - One was undecided and one did not respond to Do you plan on having bariatric surgery?
28 General Observations Obesity was rarely mentioned explicitly in the clinic notes. BMIs were often inaccurate due to misreporting of height. No one had used medications for weight loss as an intervention*.
29 Critiques of our own methods Successful outcomes of the video are not easily measured. - The role of the video is not to encourage people to lose weight or have weight loss surgery, therefore outcomes of this video can t be measured with change in weight or number of people being referred for, seen by, or undergoing surgery.
30 The weight loss surgery decision aid of the future The knowledge questions may need to be adjusted to better reflect understanding of the video*. Alternatively there may be a key part of the video that can convey the same knowledge and reduce viewing time, there by increasing viewability Weight-loss surgery decision aids could be distributed with information about other weight loss programs.
31 The questions Are the questions meaningful? In other words, does a correct response to the questions reflect an understanding of the decision aid s message or just whether or not the video was seen? Are the questions being asked possibly biased about WLS?
32 The questions 4. How many people regain most or all of the weight they lose after weight loss surgery? About half About 20% Less than 2% I am not sure 5. What number of people die within the month after having weight loss surgery? About 25% About 10% About 2% - Video actually says 1% I am not sure
33 The questions 6. Generally how much of a person's excess weight is lost after weight loss surgery? More than 75% Between 50 and 75% Between 25 and 50% I am not sure 7. Which statements about weight loss with weight loss surgery and weight loss without surgery are true Both are best accomplished when both diet and activity level changes are made. After weight loss surgery, you can lose weight without watching what you eat and increasing your activity level. The only way to lose weight permanently is to have weight loss surgery. I am not sure
34 Future question ideas Question 7 seem to be more target toward the video s message. Other examples of questions that seem to be more focused on the message rather than the content of the video may be questions like: How much can someone eat following weight loss surgery? The most important factor in determining whether or not to have weight loss surgery is: A. How over weight I am B. Whether or not I have diabetes, HTN, OSA, or OA C. Whether or not I know the risks and benefits and believe that it is the right choice for me at this time.
35 Future question ideas More questions about the benefits of WLS as opposed to questions just about the risk True/False Weight loss surgery is the most effective way to lose weight. Weight loss surgery may dramatically improve my diabetes/ HTN/ OSA/arthritis if they impeding my quality of life Realistic goals for weight-loss with out surgery.
36 Future cycles using the WLS DA Target populations based on BMI>35 with comorbidities. Using more sophisticated surveys to measure patient perception of their obesity and obesity related co morbidities and comparing it to their satisfaction with and reasoning for decision to seek or not seek surgical methods of weight loss. Pre-test vs. Post-test knowledge questions (only to test effectiveness of video)
37 Thank you Allison Brenner Dr. Carmen Lewis Kim Young-Wright Andrew Sampson Dr. Pignone
38 References 1. State-specific prevalence of obesity among adults--united States, MMWR Morb Mortal Wkly Rep 2008; 57: Johnson, F, Cooke, L, Croker, H, Wardle, J. Changing perceptions of weight in Great Britain: comparison of two population surveys. BMJ 2008; 337:a Vasan, RS, Pencina, MJ, et al. Estimated risks for developing obesity in the Framingham Heart Study. Ann Intern Med 2005; 143:473.