Implementation of a model of care for obese patients requiring weight loss prior to elective surgery

Aim

Obesity is a major health problem in Australia, and the numbers of obese patients requiring elective surgeries is increasing. Patients are being declined surgery due to their body weight and associated risks. A successful model of care to help patients achieve safe weight loss prior to surgery is vital for the future of public healthcare. Prior to the implementation of this model of care, patients did not have access to a structured model which could provide a successful means of weight loss and proceeding to surgery. This model could mean safer, shorter operations, cost reduction for health services, and improved access to elective surgery.

Benefits

Evaluation of VLCD Clinic after Allied Health - Translating Research Into Practice (AH-TRIP) implementation (n=45 patients):

• Average weight loss 8.7kg (7% body weight), 64% of patients achieved weight loss required for surgery
• 91% of patients were set a weight loss target by surgeon, in line with new criteria
• Average wait six weeks for surgery post weight loss
• 12 surgeons were surveyed: 83% believed VLCD treatment made surgery easier, 75% believed it shortened the operating time, 100% satisfied with VLCD Clinic
• Indirect results: Recognition received by dietitian - ‘Team Spirit’ award and Board Chair’s Awards nomination. The dietitian now plans to undertake a prospective control trial.

Background

A literature review was performed. Three systematic reviews (30 studies total) on VLCD prior to bariatric surgery, and eight studies VLCD prior to non-bariatric surgery were found, which showed:

• Successful weight loss with a structured VLCD is achievable (1.3 – 27% body weight loss)
• Patient adherence to highly structured intervention protocols was high
• VLCD is safe with no change to nutritional parameters prior to surgery, and that 10% body weight loss is a feasible weight loss goal
• Monitoring of blood tests is needed for safety of treatment
• Treatment led by a health professional appears to enhance success
• There have been no studies completed examining a model of care using VLCD prior to surgery.

Evaluation and results

Further evaluation of a larger group of patients (n=78) has shown an increased success rate of patients achieving the required weight loss to proceed to surgery – increased to 71% (n=78) from 64% (n=45) of patients. This highlights the feasibility of the implemented model. 91% of referrals also have a weight loss target, showing that this requirement is being fulfilled. Relationships with key stakeholders - surgeons, anaesthetics and theatre bookings - are still strong, and agreements to offer surgery dates promptly (median wait time = six weeks) are being met. Dietitian is successfully still ordering and viewing blood tests as required. Research publication due to be released mid-late 2020.

Lessons learnt

1. Translation takes time, and relationships drive the change to practice.
2. Regular communication to stakeholders about any changes to practice, and why. Giving regular presentations citing research done previously helped to get surgeons on board.
3. Stick to the eligibility criteria. Better referrals = more successful patients. More successful patients = more appropriate referrals. Surgeons saw results and were then motivated to send more appropriate patients to the clinic.
4. Engagement with those who make the calls (e.g. theatre bookings) is essential. Getting buy-in from a passionate colleague who works closely with them was invaluable in overcoming this barrier.