The Potential Impact of Clinical Pathways for Bariatric Surgery

Dana A Telem

Obesity has reached a crisis point in the United States, and is now regularly classified as an epidemic.1 The proportion of obese adults now comprises one-third of the US population, according to data from the Centers for Disease Control and Prevention.2 Additionally, more than 12 million children are obese, which represents 17% of the population between the ages of 2 and 19 years.3 Although the overall proportion of obese individuals in United States has remained relatively stable throughout the past decade, percentages continue to rise among certain ethnic and minority groups, including African Americans, Hispanic Americans, and Mexican Americans.4

Obesity is defined as possessing a body mass index (BMI) of 30 or greater.5 Individuals with a BMI of 40 or greater are considered severely or extremely obese. Obesity and a sedentary lifestyle have been linked to numerous health conditions, including type 2 diabetes, cardiovascular disease and complications, and high blood pressure.6 Research conducted by the SEARCH for Diabetes Youth Study Group has shown that the growing population of overweight and obese children and adolescents are partly responsible for the influx of type 2 diabetes diagnoses among younger individuals.7

Medical professionals, nutritionists, and lifestyle coaches advocate a number of strategies for combatting overweight and obesity, including improved diet, regular physical activity, and community programs focused on healthy living education.8 Bariatric surgery has also emerged as a leading weight management tool for severely obese individuals, individuals with at least two obesity-related comorbid conditions, and individuals who have not achieved a sustained weight loss through nonsurgical methods.9 Surgical weight loss procedures include gastric bypass, in which the small intestine is divided and connected to a newly created stomach pouch, which regulates food intake; sleeve gastrectomy, in which approximately 80% of the stomach is removed, reducing the amount of food that can be tolerated; and adjustable gastric band surgery, in which an inflatable band is inserted around the upper portion of the stomach, thus creating a smaller stomach pouch.10 Approximately 196 000 individuals underwent bariatric surgery in the United States in 2015, according to data from the American Society of Metabolic and Bariatric Surgery (ASMBS).11

Journal of Clinical Pathways spoke with Dana A Telem, MD, MPH, associate professor of surgery and director of the comprehensive hernia program at University of Michigan and chair of ASMBS’s Quality Improvement and Patient Safety Committee, to get a better understanding of the role clinical pathways can play in standardizing bariatric surgery practices. Dr Telem and colleagues recently published a paper in Surgery for Obesity and Related Diseases regarding the nationwide application of clinical pathways, finding considerable variation in the adoption of pathway programs and individual recommendations.12 Dr Telem spoke about how ASMBS continues to improve the nationwide quality of weight loss surgery, and what individual surgeons and practices can do to ensure that their patients receive the best possible care.

Generally speaking, how can clinical pathway programs improve treatment and practices in the area of bariatric surgery?

I think that in bariatric surgery, there is a lot of variability as to how we do workups on patients, how we perform surgery, and how we manage patients after surgery. There is also a strong body of evidence from other literature that variability isn’t always a good thing, and can result in health care inequity and increased cost expenditures. It can also potentially impact outcomes downstream. We hope that developing care pathways that can guide physicians and surgeons based on the best evidence available will help close some of those gaps. Ideally, we would hope to create a care model that would improve the long-term outcomes of patients, and allow for the best value and equity of care.

Your paper in Surgery for Obesity and Related Diseases showed that variability remains common among bariatric surgeons. Why do you think that is?

There are two things to talk about here. First, bariatric surgery represents an incredible example of a field with dynamic and continuous quality improvement. In the late 1990s and early 2000s, bariatric surgery really was the Wild West. We were seeing high mortality rates and high complication rates, to the point where there was almost a moratorium issued on the procedure. Those of us performing these procedures banded together because we wanted to do all we could to improve outcomes, and now bariatric surgery is one of the safest procedures that you can get. Right now, it is safer than cholecystectomy or a hip replacement. A lot of that has to do with establishing standards, requiring accreditations, and monitoring outcomes.

We now have a national accreditation program called the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, which is administered through the ASBMS. As part of accreditation, a program has to have a particular pathway program in place regarding patient and complication management. The variability comes from there being no national or central body dictating what was going to be in those pathways, which were by and large serving local goals. There is also the fact—which we acknowledge is a limitation of our study—that just because something is not written on paper doesn’t mean it isn’t done. We can only account for what is dictated on paper. The variability in some programs or among some surgeons may not be as vast as it seems. The variability may also relate to how thoroughly a pathway was put together.

What do you think standardization would look like?

Based on our data, we actually just put together a national pathway program for sleeve gastrectomy that was approved by ASMBS, and which we hope will be published soon and available on ASMBS website. Based on the identified issues in the variability study, we conducted an extensive, evidence-based literature review to figure out the best practices in the pre-interim and postoperative phases. This really gave us a good idea of what we are doing well and what we should be doing better. It also identified key gaps where we really don’t have a concrete answer, and where we need to drive further research to figure out those grey areas that still exist.

There were a few variables identified in the paper that already have high concordance rates. Why do you think those specific practices are more widely adopted?

I think because there is more standardization and more available literature in those areas. Some of them conform to guidelines and metrics that are reimbursed, or that are frequently discussed within our professional organization, such as prophylaxis for deep vein thrombosis. Those highly concordant variables were probably just more present on the minds of the people who were developing the pathways.

What are the next steps for pathways in the field?

One of the key metrics of implementation sciences is figuring out where the gaps exist. Not understanding the levels of variability within practice makes it hard to determine where pathways need to be directed for evidence-based behavioral changes. So, I think it is crucial that we know where the gaps exist. If our study showed that there was no variability between pathways, it would beg the question of whether we really needed to do anything. Knowing where the gaps are helps direct our next moves and helps us when we design pathways, how best to make things better.

No pathway is static—these are dynamic programs that need to be continually updated based on our knowledge of best practices. The end goal would be to turn something from a grey area to an area where we know what we need to be doing. This is what I think we have done with our forthcoming guidelines on sleeve gastrectomy, and we hope to create guidelines for a wide variety of other areas, including gastric bypass, weight regain after bariatric surgery, and revisional procedures. The opportunities are endless, but I would encourage anyone interested in doing something like this to determine the levels of variability first. There are still a lot of opportunities to learn and grow, even in a field that is safe and relatively stable. We cannot let things get out of date, because that isn’t impactful. 

We also have to correlate with outcomes, and ask whether something makes a difference. The last piece of the puzzle is, what are the downstream effects? So, we have to ask how we measure these interventions. We should look at adherence, surgeon and patient satisfaction, and the hardcore outcome metrics to show what is making a difference. These are sometimes the hardest elements to gauge, but they are so important to the overall understanding of what is best practice. 

References

1.    Mitchell N, Catenacci V, Wyatt HR, Hill JO. Obesity: overview of an epidemic. Psychiatr Clin North Am. 2011; 34(4):717-732.

2.    Overweight & Obesity. Centers for Disease Control and Prevention website. https://www.cdc.gov/obesity/. Accessed January 26, 2017.

3.    Childhood overweight and obesity. Center for Disease Control and Prevention website. https://www.cdc.gov/obesity/childhood/index.html. Accessed January 26, 2017.

4.    An epidemic of obesity: US obesity trends. Harvard TH Chan School of Public Health website. https://www.hsph.harvard.edu/nutritionsource/an-epidemic-of-obesity/. Accessed January 26, 2017.

5.    Defining adult overweight and obesity. Centers for Disease Control and Prevention website. https://www.cdc.gov/obesity/adult/defining.html. Accessed January 26, 2017.

6.    Understanding the American obesity epidemic. American Heart Association website. http://www.heart.org/HEARTORG/HealthyLiving/WeightManagement/Obesity/Understanding-the-American-Obesity-Epidemic_UCM_461650_Article.jsp#.WItRArYrL-Y. Accessed January 26, 2017.

7.    Search for Diabetes in Youth Study Group. The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth study. Pediatrics. 2016;118(4):1510-1518.

8.    Promote health through diet and exercise. University of Utah School of Medicine website. http://library.med.utah.edu/WebPath/TUTORIAL/OBESITY/OBESITY.html. Accessed January 26, 2017.

9.    Who is a candidate for bariatric surgery? American Society for Metabolic and Bariatric Surgery website. https://asmbs.org/patients/who-is-a-candidate-for-bariatric-surgery. Accessed January 26, 2017.

10.    Bariatric surgery procedures. American Society for Metabolic and Bariatric Surgery website. https://asmbs.org/patients/bariatric-surgery-procedures. Accessed January 26, 2017.

11.    Estimate of bariatric surgery numbers, 2011-2015. American Society for Metabolic and Bariatric Surgery website. https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers. Accessed January 26, 2017.

12.    Telem DA, Majid SF, Powers K, DeMaria E, Morton J, Jones DB. Assessing national provision of care: variability in bariatric clinical care pathways. Surg Obes Relat Dis [published online August 3, 2016]. doi:10.1016/j.soard.2016.08.002