26 Aug 2016

Program transforms pre-surgery weight loss care

by Anne Crawford

An educational program developed by Monash University and Alfred Hospital researchers to better prepare patients for bariatric (weight loss) surgery is revolutionising their care, streamlining its delivery and leading to improved weight loss after surgery.

The program was based on a study overseen by Professor Wendy Brown, director of the Centre for Obesity Research and Education (CORE), and Associate Professor Peter Nottle, director of Upper Gastrointestinal Surgery at the Alfred Hospital.

Bariatric surgery is currently the most reliably durable therapy for obesity, which affects around 28% of Australians, yet healthcare priorities mean there is little access to the surgery in the public hospital system, causing long waiting lists.

“Obesity is still not recognised as a disease nor as a large driver of ill health – it’s thought to be a moral failing,” Professor Brown said.

The Alfred Hospital, which has run a successful bariatric surgery program since the 1980s, can have a waiting list of up to seven years. Despite this some 12% of people on the list fail to attend their first appointment. Clinicians decided to investigate a program to better inform patients to improve attendance rates and hopefully lead to better early weight loss after surgery.

When the study commenced in 2012, the Bariatric Surgery Clinic had a waiting list for a first appointment of 653 patients referred by GPs, with a mean waiting period of 4.5 years. After attrition, 229 obese people on the list agreed to participate in the study. (Obese is defined as having a BMI or Body Mass Index of over 30.)

Image courtesy of Michael Leunig
The researchers looked at improving the referrals by GPs – some patients were being directed to the clinic without their weight being mentioned in the referral and were even attending appointments unaware that they were waiting for an operation.

Referring doctors were asked to provide more structured information allowing the team to triage the patient. The patient was quizzed about their understanding of obesity, attended an information seminar then undertook a 16-part education package online or in a booklet in which they learned about obesity, healthy eating, weight loss options, advice on reaching goals, the surgery involved and need for aftercare.

“We tell them that obesity is a disease and what we see as the drivers of this disease, and the behaviourial changes they can make before surgery,” Professor Brown said. “We emphasise that none of the procedures we offer are quick fixes – it’s a life-long commitment.”

An outpatient appointment at a multidisciplinary clinic followed. The patient was monitored for 12 months after surgery and data collated.

The data for the 229 patients (mean BMI nearly 48, average age 49) was compared to that of another group who didn’t undergo the pre-hospital program. The findings showed that failure to attend the first appointment plummeted from 12% to 2.1%. The participants who undertook the new program lost 20.3% of what’s called excess weight (amount of weight over the ideal body weight) while those who didn’t lost 18%.

Researchers were surprised that 52% of the people originally approached about the study decided not to proceed with surgery after receiving the introductory letter, perhaps thinking previously that surgery alone would fix their weight problem. More research was needed into this, Professor Brown said.

All bariatric surgery patients at the Alfred now undergo the educational program on the basis of the study, published in Obesity Surgery earlier this year. The program has attracted attention elsewhere with other public hospitals, private hospitals and insurers, and overseas groups interested in it.

Brown WA, Burton PR, Shaw K, Smith B, Maffescioni S, Comitti B, Cowley MA, Laurie C, Way A, Nottle P. A Pre-Hospital Patient Education Program Improves Outcomes of Bariatric Surgery. Obes Surg. 2016 Feb 6. [Epub ahead of print]

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