supporting evidence - North of Scotland Planning Group (NoSPG)

Meeting:
NoSPG
Date:
23rd February 2011
Item:
05/11 (iii)
NORTH OF SCOTLAND
PLANNING GROUP
NORTH OF SCOTLAND WEIGHT MANAGEMENT SUB GROUP
EVIDENCE REPORT
Summary of work and evidence submitted to the NoS WMSG
in support of the review of weight management services
in the North of Scotland.
SUPPORTING EVIDENCE DOCUMENTS:
Page
1.
North of Scotland Public Health Network summary report
2.
North of Scotland Public Health Network – Key questions and evidence summaries
15
3.
Obesity Management Service – Patient Involvement Report December 2010
42
(NHS Grampian Better Care Without Delay Team)
2
North of Scotland Public Health Network (NoSPHN) - Weight Management Working Group Draft
report to NoS Weight Management Group
Version 4, 10.02.11
The purpose of this report is to outline the approach and outcomes of the NoSPHN Weight Management
subgroups work to support the NoS Weight Management Sub Group (NoS WMSG) who is conducting a
review of services for people who are overweight and obese in the North of Scotland. This work has been
undertaken against a background of steadily increasing population rates of people who are overweight and
obese, with a resultant increase in demand for bariatric surgery. Limited bariatric surgery service provision;
funding restrictions and increasing waiting times make it crucial to plan for the future ensuring this is in the
context of an overall weight management pathway.
The NoS WMSG commissioned NoSPHN to gather appropriate information and evidence to inform the
development of a regional strategy / delivery plan (the agreed scoping of the NoSPHN work is attached as
Appendix 1). This was achieved primarily through a focused review of literature and a demand and capacity
analysis. The NoSPHN Group have presented evidence and information to the NoS WMSG on an ongoing
basis, and collated and summarised this work in an evidence file (see Key Questions documents attached as
Evidence Document 2). The work of NoSWMG is ongoing and is due to report to NoSPG in February 2011.
The main phase of the NoSPHN activity is complete (although some national data has still to be reported).
This report summarises the key findings of the NoSPHN Weight Management Group.
Introduction
The management of obesity is one of today’s major health care dilemmas. Adult obesity (BMI>30kg/m2)
has increased steadily over the last decade; a trajectory predicted to continue for the foreseeable future.
Approximately 1 in every 4 Scottish adults is obese; by 2030, this is set to rise to 40% of the adult
population.1 An estimated 17,000 people in the North of Scotland currently are morbidly obese (BMI of over
40kg/m2), rising to 25,000 by 2030.2
Existing interventions for significant and sustained weight reduction through diet, exercise, behavioural
change and pharmaceutical means, once someone is obese, have had limited success. Bariatric surgery is
effective in achieving significant weight loss and resolution of some comorbidities, in obese and morbidly
obese people but demand currently outstrips supply. With no sign of let up in the steady rise in levels of
obesity in the future, bariatric surgery can not be viewed in isolation.
In “Preventing Overweight and Obesity in Scotland: A Route Map Towards Healthy Weight” (2010) the
Scottish Government stated: “Obesity cannot be viewed simply as a health issue, nor will it be solved by
reliance on individual behaviour change. A successful approach will require cross-portfolio and cross-sector
1
http://www.scotpho.org.uk – data based on Scottish Health Surveys & Preventing overweight and obesity in Scotland: a Route map
towards Healthy Weight The Scottish Government, Edinburgh 2010
2
http://www.nice.org.uk/usingguidance/commissioningguides/bariatric/assumptions.jsp Assumptions used in Estimating a Population
Bench Mark. NICE 2006
2
collaboration and investment to make deep, sustainable changes to our living environment in order to shift it
from one that promotes weight gain to one that supports healthy choices and healthy weight for all.”
The Route Map highlighted the importance of the core preventative actions we need to take:
•
Energy consumption - controlling exposure to, demand for and consumption of excessive quantities of
high calorific foods and drinks.
•
Energy expenditure - increasing opportunities for and uptake of walking, cycling and other physical
activity in our daily lives and minimising sedentary behaviour.
•
Early years – establishing life-long habits and skills for positive health behaviour through early life
interventions.
•
Working lives - increasing responsibility of organisations for the health and wellbeing of their employees.
The role of the NHS spans from prevention to treatment to palliative care; primary, secondary and tertiary
care pathways need to ensure evidenced based interventions at every level; however obesity is a long term
condition which requires a high degree of self management supported primarily in the community/primary
care.
The Management of Obesity - a national clinical guidance (SIGN 115, 2010) outlines the current
evidence for interventions including bariatric surgery, and emphasises the importance of bariatric surgery as
one element in a weight management care pathway. Planning services for the management of overweight
and obesity must however be set in the context of prevention as an essential step in managing future
service demand both for bariatric surgery but also across health services.3
Efforts thus far have failed to stem the rising prevalence of obesity in the adult population. In the meantime,
the demand for effective interventions, such as bariatric surgery, for the management of those who are
severely obese will continue to rise.
Method
NOSPHN support was commissioned to address specific key questions from the NoSWMG.
questions were used to focus the review of published evidence.
The key
In recent years, numerous systematic
reviews have been published considering the evidence of effectiveness interventions for the management of
obesity and their place in care pathways. Here we restricted our search to systematic reviews for surgical
interventions for obesity and included guidelines from SIGN and NICE (National Institute for Health and
Clinical Excellence (NICE). Additional supplementary searches were done where required.
Information
summaries for each of the key questions were fed back to the working group as a series of “Traffic Light
Summaries” (Evidence Document 2).
Demand and capacity analysis was undertaken to describe the epidemiology (current and future) of severe/
complex obesity; to analyse the current and future demand for bariatric and obesity services. Templates
3
Preventing Overweight and Obesity in Scotland: A Route Map Towards Healthy Weight The Scottish Government, Edinburgh 2010
3
and simple models published by the NICE have been adapted and used to estimate the following for the
North of Scotland Population:
•
obesity and morbid obesity prevalence;
•
demand for bariatric surgery, by applying conversion factors identified through a consensus of expert
clinical opinion to the prevalence figures;
•
NICE benchmark annual number of bariatric surgery procedures from population size;
•
NICE benchmark annual number of bariatric surgery procedures from demand estimates;
•
The annual increase in the severe obesity.
The opportunity was also taken to explore:
•
The proportion of patients undergoing bariatric surgery within Grampian Hospitals who present later for
plastic surgery – NoS figures are awaited from ISD.
•
Prescribing data relating to the treatment of obesity within Primary Care setting in the NoS.
Findings Summary
i) Identifying who should be offered surgery
There is good quality evidence that surgery is a highly effective treatment for achieving significant weight
loss in obesity. In context, where surgery might be expected to achieve 25-75kg weight loss after 2-4 years,
diet/lifestyle interventions might achieve <5kg and pharmacological interventions 5-10kg.4
In 2010, SIGN presented criteria for bariatric surgery based on BMI>35kg/m2; presence of comorbidities
that could be improved with significant weight loss AND, for all patients, the completion of a structured
weight management programme involving diet, physical activity, psychological and drug interventions, not
resulting in significant and sustained improvement.
NICE currently recommend surgery as an option for those with a BMI>40kg/m2 or those with a BMI
of>35kg/m2 plus co morbidities; AND that all have tried all other appropriate weight loss interventions
without success for at least 6 months. For those with a BMI>50kg/m2, NICE recommend surgery as the first
line for treatment.
There was little evidence to support which subgroups of patients might have the most to gain from surgery,
though surgery for those with a BMI of >40kg/m2 and those with comorbidity plus a BMI of 35-40kg/m2 was
the most cost effective.5
Based on a comprehensive literature review of effectiveness of gastric banding, and drawing on outcome
evidence from trials at 2 years, Picot et al 2009 (HTA)7 modelled the average healthcare cost per person
over 20yrs (accounting for surgery, complications, after care and costs relating to diabetes, myocardial
4 Douketis JD, Macie C, Thabane L, Williamson DF. Systematic review of long-term weight loss studies in obese adults: Clinical significance and applicability to clinical
practice. Int J Obes 2005;29(10):1153-67
5
J Picot, J Jones, JL Colquitt, E Gospodarevskaya, E Loveman, L Baxter and AJ Clegg The clinical effectiveness and cost effectiveness of
bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation Health Technology Assessment 2009; Vol. 13:
No. 41
4
infarctions and stroke) – see Table below. Healthcare costs were always higher, even after 20 years, for the
surgical group compared to the non surgical group, but the gains in quality of life adjusted life years were
greater than for non surgical care. The “best value” was observed for adults with a BMI of >40/m2 or a BMI
30-39/m2 plus a comorbidity (only diabetes was included in the model), where for each additional QALY the
additional cost over 20years was estimated to be £1,367-£4,000.
Surgery Healthcare Costs
Treatment Model (20 years)
Gastric Banding versus Non surgical
BMI>40/m2
care
BMI 30-39
BMI 35-
+ type 2
39/m2
DM
Non surgical care
Costs
£13,561
£31,683
£9,311
QALY
10.8
10.39
11.12
Costs
£17,126
£33,182
£14,398
QALY
11.72
11.49
11.52
Incremental cost for health gain achieved
@ 20yrs:
@20yrs:
@20yrs:
(ICER)
£2,000-4,000
£1,367
£12,763
Surgical (banding)
comment
Based on 73%
of patients
having
complete
resolution of
diabetes by
20yrs
QALY: quality adjusted life year – how many extra months or years of life of a reasonable quality a person
might gain as a result of treatment.
ICER:
additional cost for one additional QALY compared to non-surgical management.
There is no specific evidence about the effectiveness of surgery in particular high risk groups but it is worth
noting that the following are all associated with higher levels of obesity: lower socioeconomic status;
ethnicity, specifically black Caribbean, black African and Pakistani; those with learning disabilities; and those
with serious mental health problems. Cardiovascular risk for South Asian men and women is much higher
than general population and any modification of risk factors in this group is likely to have significant health
benefits.6
6
NICE Clinical Guideline No.43 Obesity guidance on the prevention, identification, assessment and management of overweight and
obesity in adults and children. 2006
5
ii) What type of surgery should be offered?
Guidelines support that surgical interventions should be recommended only in the context of lifestyle,
nutritional and psychological support both before and after surgery.
There was insufficient evidence to say which surgical procedure is best and patient choice plus surgeon (and
hospital) experience were identified as important factors in the decision process.
Studies suggest that gastric bypass surgery probably achieves greater long term weight loss and a higher
proportion of patients achieve a BMI of <30kg/m2 but the theatre duration and recovery time in hospital was
longer.
Both procedures have potential complications and the complication rate reporting varied
substantially between studies.7,5
iii) Other issues
a. Role of Intragastric Balloon prior to surgery
There was evidence that intragastric balloon insertion as part of the preparation for surgery was not more
effective than diet alone and was probably not a useful adjunct to diet.
b. Plastic Surgery
Plastic surgery for those patients who achieve major weight loss is an important part of the package of care
but carries with it significant risks with complications occurring in 20-50% of patients. Complications are
lower in those with a >30kg/m2 and some guidelines recommend that a BMI of <27kg/m2 should be
achieved. Smoking also increases the risk of complication.
c. Informed Choice
NICE recommended that advice, treatment and care should take into account people’s needs and
preferences. People should have the opportunity to make informed decisions about their care and treatment,
in partnership with their health professionals. Good communication between health professionals and
patients was essential.
7
Angrisani L, Lorenzo M, Borrelli V. Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5-year results of a
prospective randomized trial. Surg Obes Related Dis 2007;3:127–32.
6
Demand and capacity analysis
Bariatric Service (NICE Guidelines)
NICE estimated that 10 per 100,000 total population would be an appropriate benchmark for the number of
procedures delivered (given appropriate investment over the next 5 years). They acknowledged that this
benchmark would fall short of meeting the demand if their recommendation for bariatric surgery were
applied. Applying this to the NoS population gives an estimated 132 procedures per year. Across the NoS,
the current planned surgical capacity has been increased from 40 procedures per year (all undertaken in
NHS Grampian) to 80 per year (undertaken in NHS Grampian and NHS Tayside – procedures in Tayside for
NHST patients only) i.e. current planned surgical activity is less than the NICE benchmark of 132.
Applying the NICE template and assumptions around surgery to North of Scotland data (key questions 16
and 17) below is an illustration of the numbers of people that might be expected to be eligible for surgery.
Figure 1 NICE Recommended Criteria. Adults with BMI >40kg/m2 plus BMI 35-39 with comorbidity.
If NoS were to use the NICE criteria and benchmark: in addition to the current estimated demand for 132
procedures per year a net annual increase in the queue of 179 would be expected. If NoS were to use the
NICE criteria and the current planned activity of 80 procedures per year then the net annual increase in the
queue would be 231.
7
Figure 2
SIGN Guidelines criteria. Adults with BMI 35-50kg/m2 with comorbiditiy.
If NoS were to use the SIGN criteria and NICE benchmark: in addition to the current estimated demand for
132 procedures per year a net annual increase in the queue of 164 would be expected. If NoS were to use
the SIGN criteria and the current planned activity of 80 procedures per year then the expected net annual
increase in the queue would be 216 patients.
Application of SIGN or NICE criteria to the NoS population and undertaking either the NICE benchmark or
the current planned annual surgical procedure rate would result in an increase in the number of people
eligible, willing and therefore, potentially waiting for surgery.
The application of more stringent criteria
would however potentially enable the pool of people eligible and willing for surgery to be reduced over time
(but would not meet either the NICE or SIGN guidance) – examples are given below.
Caution should however be noted in use of the data because assumptions that go beyond the assumptions
made by NICE have been applied to the second, third and fourth example here.
8
Applying More Stringent Criteria
Figure 3
Criteria: Adults aged 20-44 years with BMI 35-50kg/m2 and comorbidity (example of
applying more stringent criteria, e.g. age range set to account for increased peri-operative risk over the age
of 45).
If NoS were to use the criteria age 20-44 years with BMI 35-50kg/m2 and comorbidity: in addition to the
current estimated demand for 132 procedures per year a net annual reduction in the queue of 12 would be
expected. If NoS were to use the above criteria and the current planned activity of 80 procedures per year
then the net annual increase in the queue would be 41.
Figure 4
Criteria: adults aged 20-44 years with BMI 35-39kg/m2 and comorbidity (example of
applying more stringent criteria e.g. narrowest age and BMI ranges).
9
If NoS were to use the narrowest age and BMI criteria, age 20-44 years with BMI 35-39kg/m2 and
comorbidity: in addition to the current estimated demand for 132 procedures per year a net decrease in the
queue of 92 would be expected. If NoS were to use the above criteria and the current planned activity of 80
procedures per year then queue would be expected to decrease by 40 patients.
Data
There was some exploration of the queue length in NHSG at the final two stages before surgery but it was
identified that the information was not reliable. This highlights a need to improve data management.
Plastic Surgery following Bariatric Surgery (NHSG Hospitals Only)
Fourteen patients have had 19 plastic surgery operations in Grampian hospitals following bariatric surgery,
over a four year period from September 2006. During this period 122 patients had 147 bariatric surgery
procedures. Therefore, over the four year period from September 2006 to August 2010, 11% of patients
who received bariatric surgery in Grampian Hospitals, also had follow-up plastic surgery in Grampian
Hospitals.
Prescribing Data
An annual increase of 9.6% over four financial years (2006 – 2009) has been observed in prescriptions
(defined daily doses) of drugs used in the treatment of obesity in Primary Care in the NoS.
Summary of demand and capacity findings
Applying NICE estimates to the NoS population gives an estimated demand for 132 procedures per year (but
this would not meet all needs for surgery). Across the NoS, the current planned surgical capacity is 80
procedures per year, which is less than the NICE benchmark for the population.
Applying the NICE template and assumptions around surgery and current planned surgical procedure rates
to North of Scotland data estimates the increase in the number of people eligible, willing and therefore,
potentially waiting for surgery. The current planned 80 procedures will not match estimates of the growth in
the numbers of new cases each year, if surgery was offered to all those meeting NICE criteria (net annual
increase of 231) or SIGN 115, 2010 (net annual increase of 216).
The predicted demand for surgery can be reduced by applying more stringent criteria but would not meet
the NICE or SIGN 115, 2010 guidance. For example applying the narrowest age and BMI ranges - adults
aged 20-44 years with BMI 35-39kg/m2 and comorbidity – gives a predicted annual increase in demand that
is less than the current planned activity of 80 procedures. This would allow the "backlog" of cases that
already meet the criteria and are expected to be willing for surgery to be addressed gradually (but not within
the current 18 week referral time).
10
Conclusions
Published research evidence and guidelines have been reviewed and used to show the rising prevalence of
obesity in the adult population in the NoS. The NICE template has been used to project the demand for
effective interventions, such as bariatric surgery. The management of those who are severely obese will
continue to rise and will not be managed within current capacity / funding parameters.
NoSWMG will need to consider the evidence presented in planning future services. NoSPHN recommend
that planning should be achieved within the context of an overall weight management pathway, that levels
1-3 of the care pathway should be prioritised for development (disinvesting in bariatric surgery and investing
in weight management further upstream) and that a plan should be developed to ensure good data capture
in all service development, work to understand properly patients needs (through wider work with
stakeholders in addition to the current survey of those who have had surgery), and a plan to review the
process on a regular basis. In particular Boards should be asked to consider how they will deal with unmet
need within any option analysis (unmet needs in considering NICE criteria and also wider unmet needs for
weight management out with the NICE criteria).
NoSPHN Weight Management Sub Group Members
Roseanne Urquhart NHSH and Chair of NoSPG Weight Management Group
Fiona Clarke NoSPHN representative on NoSPG Weight Management Group, NHSH
Corri Black, CPHM, NHS G
Jillian Evans Head of Health Intelligence, NHSG
Nicola Beech, Health Intelligence Sector Lead, NHSG
Pip Farman NoSPHN Coordinator
11
DRAFT v12.07.10
Appendix 1
North of Scotland Public Health Network (NoSPHN)
Proposal for Work (and Health Intelligence Support if required)
(If you are requesting patient identifiable data please complete and sign the Confidentiality Statement on
page 2)
Version: 2
Date: 12.07.10
Prepared by: Pip Farman
1.
Project Title NoSPHN - North of Scotland Weight Management Group (WMG) - Bariatric
Surgery/Obesity Management Review Programme
2.
Aim of Project
To gather appropriate information and evidence to inform the work of the NoS Weight Management
(NoSWM) Sub Group and their development of a regional strategy / delivery plan.
3.
NoSPHN Project Objectives
•
•
•
•
•
•
4.
How will success of project be measured?
(Do any of these issues require
management?)
•
•
•
4.
To summarise the key documentation (and any recent documentation) with regard to the nature
of the needs of patients with severe/complex obesity and the evidence for (effectiveness and cost
effectiveness) of associated interventions and service models for meeting these needs by surgical
and other services (eg community based services)
To detail the epidemiology (current and future) of severe / complex obesity needs (in the context
of wider healthy weight / obesity needs from a population perspective)
To analyse the demand and capacity of current bariatric / obesity services in the NoS, including
an analysis of ‘legacy’ patients
To give an indication of (or quantify) the severe/ complex obesity management needs for North
of Scotland Board populations
To effectively engage with the NoS Weight Management Group in the delivery of the NoSPHN
work
To work where appropriate with ScotPHN / national working group to maximise input to the
NoSWM group.
Engagement with Members of the NoS
Weight Management Sub Group
Delivery of work/information to the proposed
time scales (nb the timelines are changing)
Evidencing that the work done has informed
the development of a Regional strategy
delivery plan.
Proposed management
•
•
•
Need to review opportunities for and capacity
of staff to engage with Group and willingness
of Group to engage
Regular updates / meeting with Chair of
NoSWMG working group
Regular updates / meeting with Chair of NoS
working group and review of work at the end
of project.
Detailed specification of support required (please be as detailed as possible) – time /
costs
Work elements and staffing required:
A. Review of key literature:
•
Four elements: Review evidence of patient needs / understanding of preferences, evidence of
effectiveness, evidence of cost effectiveness, evidence of service models, inequalities / equality
and diversity issues
12
•
•
•
Brief Summary of evidence to be produced
Work to be shared with the NoS WMG asking them to identify if there is anything critical that they
think is missing.
Respond to NoS WM questions on an ad- hoc basis.
B. Epidemiology
•
From literature/ health surveys etc identify expected numbers of people (current and future) with
severe / complex obesity needs (in the context of wider healthy weight / obesity needs)
•
To assess local data on actual numbers currently recorded (or identify where the gaps in current
local knowledge and data are)
Time
10 days CPHM time (across 3 months)
5 days Information scientist
5 days Reviewer (Janine no longer available due to time lapse from first meeting)
C. Demand / capacity review
Analysis of legacy patients – approx 1 week
Current demand & activity trends – approx 2 weeks
Assessment of future demand – approx 1 week
(Conducted over a 3 month period)
D. Key questions
NoS WMG to identify key questions on an ad-hoc basis for NoSPHN to seek answers to.
E. Liaison / information exchange with national organsiations / working groups
Engage with ScotPHN / the national working group to share developments / reduce duplication of
effort.
5.
On what basis has the request for this piece of work been made, eg NOSPG Workplan,
connection to Local Health Plan, Change and Innovation Plan, etc
NoS Bariatrics working Group lead approached NoSPHN for support.
6.
Timescales:
Work required for final report to be submitted to NoSPG by the 8th
September (this deadline is being reviewed). Work however needs
to be fed into regional discussions over the period).
7.
Project Lead/Requestor:
NoSPG - Roseanne Urquhart (Chair of NoS WM Group
NoSPHN Lead - tbc
Job Title:
Sector/Dept:
E mail address:
Telephone Number:
Work Leads (if identified):
Project Team (if required):
Roseanne Urquhart NHSH and Chair of NoSPG Weight Management
Sub Group
Fiona Clarke NoSPHN representative on NoSPG Bariatrics Surgery /
Obesity Management Sub Group, NHSH
Corri Black, CPHM, NHS Grampian
Jillian Evans Head of Health Intelligence, NHSG
Nicola Beech, Health Intelligence Sector Lead, NHSG
13
Pip Farman NoSPHN Coordinator
8.
Reporting mechanisms
(with milestones /
timescales if known):
Roseanne to advise on NoS WMG meeting dates and final deadlines
(February 2011).
Work required of NoSPHN
Boards / others:
Eg work with current services to determine current service provision
/ use (Jillian can you feedback re conversations with Louise
Ballantyne).
Louise Ballantyne will support all Boards in developing current and
future state 4 tiered ICP
9.
Risks: (the project will
need to define how these
will be managed)
•
•
•
•
10.
Required to deliver to tight time scales: need to prioritise
recruitment to lead for work and associated support(s).
Need to secure the time resource from existing public health
staff
Need to ensure ‘buy in’ and engagement with the process from
NOS WMG members.
Meetings will need to be scheduled to achieve this within
timescales.
Further information e.g.
budget available
11.
Please identify how
patient and public
engagement aspects of
the work of will be
addressed (if appropriate)
12. Please identify how
Equality and Diversity
requirements / the needs
of disadvantaged groups
will be addressed / met
HI Use only:
This will not be progressed by NoSPHN but the NoS WM Group
Review of literature will seek to understand evidence of specific
needs.
No of Days Required
Specific skills required
Opportunity costs
External Commissioning
14
North of Scotland Weight Management Group (WMG)
North of Scotland Public Health Network (NoSPHN)
Final Version 12
09.02.11
Key questions to support work
1.
2.
3.
4.
Questions from Weight Management Group
(WMG) for NoSPHN
Summary of key evidence / SIGN guidelines / new
evidence requested
Evidence comparing gastric banding and bypass
Do we understand the needs of patients - any
evidence of what patients want / expectations?
What are the post-operative risks for:
BMI between 35 and 50 }
breakdown
by age and diabetes
BMI between 35 and 40 }
Male sex
Age > 45
Hypertension
Previous DVT
Any evidence that risk is higher in these groups?
Action
Completed
Information
summary
(attached)
CB
1
CB
CB
2
3
CB
Not able to
answer in
terms of
evidence
available
4
CB
Not
answerable
-
-
-
7
5.
Do we know how many patients who have surgery
abroad require non-surgical support from the NHS
for post-surgery problems e.g. bands too tight,
malabsorption, psychological problems etc?
6.
Duplicate question - removed.
7.
Is there any clinical criteria available for
undertaking gastric by-pass or gastric banding?
CB
8.
Is there any evidence around the number of times
a gastric band requires to be adjusted in the first
12 months, and thereafter, to optimise its
effectiveness?
CB
9.
Plastic Surgery
Do we know how many patients who undergo
bariatric surgery then present for plastic surgery?
CB /
NB
No evidence
found (other
than
Grampian
NICE
costing data)
9
10. There is a suggestion that plastic surgery should
only be performed on patients with a BMI of 27 or
less and a stable weight – is there any evidence
to support this?
CB
10/11/12
11. What are the current plastic surgery criteria in
relation to plastic surgery following bariatric
surgery?
CB
10/11/12
NB
11
-
12. How many bariatric patients in the NoS would
meet a criteria of BMI of 27 or less if the criteria
for bariatric surgery was set at an upper limit of:
15
BMI of 40?
BMI of 50?
(see no. 4 above)
Clarification to question (08.11.10) - If operate on
the people with the BMI criteria we have agreed to
model numbers on – how many will reach a BMI
of <27 after surgery and thus be eligible for plastic
surgery? Proposed method - take the number
operated on now with plastic surgery, as a
proportion of the total who had bariatric surgery
during the time period and apply (apply Grampian
and/or ISD data).
NB
12
Patient
survey by
LB
-
-
CB
14
15. Estimating backlog for surgery – AGREED NO
LONGER REQUIRED
16. Estimating current demand using NICE template
and comparing to Scottish statistics / local
information
17. Estimating projected demand using NICE
template
NB
-
-
NB
16
NB
17
18. Impacts of flying re gastric bands
CB
18
19. Who can provide CBT?
JE
19
20. Who can do band adjustments?
JE
20
Not
possible to
determine
-
-
CB
25
13. What treatment options would very obese patients
prefer if they had a choice?
Is there any evidence to suggest that people
would opt for surgery if there were successful
alternatives easily available eg diet with
appropriate psychological support, medication etc.
14. Epidemiology information / queries
Suggestions / questions for WMG from
NoSPHN
21. In mapping the pathways need to understand
what are the bottle necks in pathways/ or will be
and impacts (map numbers against these) – this
will guide where to focus action eg:
• Number of patients waiting for surgery and
whether they meet the criteria (legacy
patients)?
• Dietetics?
• Plastic surgery?
22. Understanding required of inequalities / equality
and diversity issues in relation to access to
Bariatric surgery
16
Key Question 1: Traffic Light Summary of SIGN evidence base: Bariatric Surgery
RECOMMENDATION
EVIDENCE SUMMARY
Bariatric surgery should be included as part of an overall
clinical pathway for adult weight management.
Clinical consensus on best practice
and trial evidence for place care
Bariatric surgery should be part of a programme of care that is
delivered by a multidisciplinary team. There should be close
communication between health professionals.
Trials included multidisciplinary
teams
Specialist psychological/psychiatric opinion should be sought
as to which patients require assessment.
Very limited evidence. No trials
Bariatric surgery should be considered on an individual case
basis in patients who fulfil the following criteria:
•
BMI ≥35 kg/m2
•
Presence of one or more severe comorbidities which
are expected to improve significantly with weight
reduction.
>25 trials of surgery vs. standard
treatment or different types of
surgery; consistent benefit
Good trial evidence
Very limited trial evidence of benefit
in the moderately obese with
comorbidities but evidence
extrapolated from improvements in
severely obese
AND
evidence of completion of a structured weight management
programme involving diet, physical activity, psychological and
drug interventions, not resulting in significant and sustained
improvement in the comorbidities.
Binge-eating disorder, dysfunctional eating behaviour, past
history of intervention for substance misuse, psychological
dysfunction or depression should not be considered absolute
contraindications for surgery.
Dietary counselling should be provided before and after
surgery. A standard dose of a multivitamin and micronutrient
supplement could be considered post malabsorptive bariatric
procedures.
Healthcare professionals should undertake the following in all
patients post bariatric surgery:
• simple clinical assessments of micronutrient status
• Simple blood tests.
Only patients with abnormalities should be considered for
formal biochemical measurements of micronutrient status.
Calcium and vitamin D supplements should be considered for
all patients undergoing bariatric surgery. Baseline calcium and
vitamin D should be measured.
Patients should be supported to increase their physical activity
in a sustainable manner post surgery.
Policies on the criteria for receiving plastic surgery post
bariatric surgery should be developed. These should be based
on both BMI and consideration of long term benefit balanced
against risks for the individual patient. Patients should be
made aware of these policies as part of their informed consent
for bariatric surgery.
Plastic surgery should be delayed until weight loss post
bariatric surgery has reached a plateau.
No evidence
Several studies support
recommendation
No evidence
No evidence
Very limited evidence. No trials
Limited evidence. No trials
Very limited evidence around
complications
No evidence
17
Key question 1: Traffic Light Summary of evidence for Intragastric Balloon
RECOMMENDATION
EVIDENCE SUMMARY
9 trials, ~400 patients mainly women
Balloon versus diet
Evidence that there is NOT greater
weightless in Balloon group at 12 or
24wks; higher minor side effects in
balloon group
Balloon plus diet vs. diet or balloon alone
Some trail evidence that combination
is not better than either treatment
alone
Balloon plus surgery vs. surgery alone
No trial data (tbc)
Source: Cochrane review Fernandes MAP, Atallah ÁN, Soares B, Saconato H, Guimarães SM, Matos D, Carneiro
Monteiro LR, Richter B. Intragastric balloon for obesity. Cochrane Database of Systematic Reviews 2007, Issue 1.
18
Key question 2: Traffic Light Summary of Gastric Bypass (GBP) vs. Gastric
Banding (GB)
In context (Douketis 2005)
OUTCOME
EVIDENCE SUMMARY
CURRENT GUIDANCE
SIGN
Surgeon experience is an important factor in determining
good outcomes.
NICE clinical guideline CG43 on obesity recommends
that the choice of surgical intervention should be made
jointly by the person requiring surgery and the clinician,
and taking into account:
• the degree of obesity
• comorbidities
• the best available evidence on effectiveness and
long-term effects of the procedure
• the facilities and equipment available
• the experience of the surgeon who would perform
the operation.
NICE
Studies:
1 RCT in HTA report 2010
1 meta-analysis (RCT and case series)
Long term weight loss (>3yr)
Excess weight loss
achieve BMI<30
Operative issues
Theatre time
Hospital stay
Complications:
Deaths
Reoperation required
Early
Late
Angrisani 2007 ( Lap Gastric bypass vs Lap gastric
banding) – n=51 participants
Garb 2009 (Lap GBP vs. L GB) – n=7383 participants
but poor quality studies.
Greater in GBP group (% wt loss @>3yr: ~65% vs.
49%).
Greater in GBP group : 62.5% vs. 11.5%)*
*
Longer for GBP: 220min vs. 60min
Longer for GBP: 4dy vs. 2 dy
†
None reported in this study
Similar in both: 12.5% vs. 15.2%
Low for both
†
Low for both
*from Angrisani 2007 only. Operative data supported by reports from studies of surgery versus other
comparators.
† Complications data likely to be inaccurate. Studies of surgery versus other comparators suggest that
reoperation rate are variable. One study (SOS 2007) reported that 31% of GB and 17% of GBP
surgeries required reoperation (not RCT so other differences in the patient characteristics may explain
this difference). Perioperative complications were reported in ~13% of patients.
Dietary/lifestyle therapy
Pharmacologic therapy
Surgical therapy
provides < 5 kg weight loss after 2-4yr
provides 5-10 kg weight loss after 1-2yr
provides 25-75 kg weight loss after 2-4yr
NOTE: surgical interventions recommended only in the context of lifestyle, nutritional and psychological
support both before and after surgery. None of the guidelines or reviews feel that there is sufficient evidence
one way or the other to say which is the better procedure and patient choice plus surgeon experience are
important factors in the decision process
19
Key question 3: Traffic Light Summary of evidence around understanding patient
needs:
RECOMMENDATION
Choice
Informing choice
EVIDENCE SUMMARY
Advice, treatment and care should take into account
people’s needs and preferences. People should have the
opportunity to make informed decisions about their care and
treatment, in partnership with their health professionals.
Good communication between health professionals and
patients is essential. It should be supported by evidencebased written information tailored to the patient’s needs.
Advice, treatment and care, and the information patients are
given about it, should be non-discriminatory and culturally
appropriate. It should also be accessible to people with
additional needs such as physical, sensory or learning
disabilities, and to people who do not speak or read English.
Source: NICE Clinical Guideline No.43 Obesity guidance on the prevention, identification, assessment and
management of overweight and obesity in adults and children. 2006
20
Key question 4: Traffic Light Summary of Adverse events and complications of
surgery: high risk groups
Data has not been presented for subgroups of patients so it is not possible to comment on
who might be at greatest risk.
OUTCOME
EVIDENCE SUMMARY (n=number of studies)
Peri-op mortality (<30dy)
0-1.5% (n>10)
Major intra-operative
~2% (n=1)
Major early post operative
~2-4% (n=1)
Major Late complications
~5-8% (n=1)
Re-operation
Follow up studies (not trials): average re-operation rate
GB 6.5% (range 0.5% to 24%) (n = 16)
Lap GBP 1.8% (range 0.03% to 9.8%) (n = 4)
open GBP 5% (2.8% to 12%)(n = 3)
Other complications
Revision rates
Trials: Reoperation rates were higher in the LAGB group
compared with the LGBP group (26.2% vs 10.7%
overall) (trials = 1)
Thromboembolic complications low in all trials (0-0.4%)
(n>10)
Revision rates varied across operations, and studies.
From the observational studies
2.3% of laparoscopic adjustable bands were removed
0.06% of the LGBPs were reversed
Illustrative frequency of complications
Key Question 7: Clinical Criteria for Gastric bypass or gastric banding?
Higher hospital and surgeon volume (10 or more procedures per year) is associated with
lower rates of mortality and complications (n=3 studies)
21
Key Questions 10, 11, 12: Traffic Light Summary of evidence for Plastic Surgery
after bariatric surgery:
Who chooses plastic surgery?
Does age matter?
Does Gender matter?
Marital status
Income (USA)
Other factors increasing likelihood
of choosing plastic surgery
What are the complications
following plastic surgery
Post-operative complications
following plastic surgery are
high
EVIDENCE SUMMARY (n=number of studies)
Mean age ranged from 42-47 (n=3)
Age was not a factor in patients choosing plastic surgery
Note study age range limited
Females were two times more likely to choose plastic surgery
than men (n=5)
Divorced women were more likely to choose plastic surgery (n=1)
Patients who could afford the costs of plastic surgery after a
gastric bypass were twice as likely to have a multiple or
subsequent plastic surgery (n=1)
Open bariatric surgical procedure
Recent bariatric surgery (as time passes less likely to want further
surgery)
Lower post bariatric surgical BMI
EVIDENCE SUMMARY (n=number of studies)
20-50% (n=7)
Type of complications
•
Infections
Seroma
Hematoma
Skin dehiscence
Skin breakdown/
necrosis
• Blood transfusions
• Re- exploration
• Deep vein thrombosis /
Pulmonary embolism
• Healing disturbances
Who is at greatest risk of
complications?
• Higher pre-plastic
surgery BMI
•
•
•
•
•
•
Larger changes in body
mass index after
bariatric surgery
Smoking
factors not associated with
complications following
plastic surgery
12-25% (n=4)
14-16% (n=3)
6- 13% (n=3)
32% (n=2)
9-11% (n=2)
6- 15% (n=2)
11% (n=1)
2% (n=1)
11% (n=1)
2
patients with BMI greater than 25kg/m are at nearly three
times at risk of post operative complications ( n=1)
Patients with BMI of 30 or greater had greatest risk of
getting complications (n=2)
( n=3)
Smokers are more likely to get complications than non
smokers
50-150% greater risk ( n=3)
Sex, age
22
“Best Practice Recommendations” for plastic surgery following bariatric surgery
Recommendations
Pre-operative issues
• Patients should be at a stable weight for several months and ideally at their lowest
weight (may take several months/years after surgery).
• Standard prophylaxis measures to prevent deep vein thrombosis before operation and
after surgery
• Infection prophylaxis before plastic surgery
• Cease smoking when applicable
• Encourage patients considering plastic surgery to start iron supplementation. They
prefer a baseline haemoglobin of 12. Severely anaemic patients are referred to a
haematologist.
• Medical problems and psychosocial issues to be assessed before surgery, with
appropriate specialist consultation as necessary.
• Consultation with patients regarding issues such as postoperative scarring and the
common incidence of wound healing problems is essential
Surgical choice
• Avoid performing body lifts on individuals with a body mass index of greater than 35
• Avoid performing body lifts on postbariatric patients older than 55 years.
Abdominoplasty or an abdominoplasty to be followed in 6 months by a thigh and buttock
lift for those who are over 55
• Recommend combining abdominoplasty and mastopexy
Care Model
• Surgeon experience, operative setting, and a patient's medical status to be considered
when planning how much surgery should be performed in the same operative setting
• Team approach combining comprehensive patient evaluation, outcomes research, and
surgical training to be the optimal approach for treating the massive weight loss patient
Reference
1. Arthurs ZM, Cuadrado D, Sohn V, Wolcott K, Lesperance K, Carter P, et al. Post-bariatric panniculectomy:
pre-panniculectomy body mass index impacts the complication profile. Am J Surg 2007;193(5):567-70.
2. Gravante G, Araco A, Sorge R, Araco F, Delogu D, Cervelli V. Wound infections in post-bariatric patients
undergoing body contouring abdominoplasty: the role of smoking. Obes Surg 2007;17(10):1325-31.
3. Greco JA, 3rd, Castaldo ET, Nanney LB, Wendel JJ, Summitt JB, Kelly KJ, et al. The effect of weight loss
surgery and body mass index on wound complications after abdominal contouring operations. Ann Plast
Surg 2008;61(3):235-42.
4. Nemerofsky RB, Oliak DA, Capella JF. Body lift: an account of 200 consecutive cases in the massive
weight loss patient. Plast Reconstr Surg 2006;117(2):414-30
5. Taylor J, Shermak M. Body contouring following massive weight loss. Obes Surg 2004;14:1080 –5.
6. Sanger C, David LR. Impact of significant weight loss on outcome of body- contouring surgery. Ann Plast
Surg 2006;56:9 –13
7. Vastine VL, Morgan RF, Williams GS, et al. Wound complications of abdominoplasty in obese patients.
Ann Plast Surg 1999;42:34 –9.
8. Gusenoff JA, Messing S, O’Malley W, Langstein HN. Patterns of plastic surgical use after gastric
bypass:who can afford it and who will return for more. 2008a; Cosmetic ;122(3):951-58
9. Gusenoff JA, Messing S, O’Malley W, Langstein HN. Temporal and Demographic Factors Influencing the
Desire for Plastic Surgery after Gastric Bypass Surgery. Cosmetic 2008b;121( 6):2120-26
10. Gusenoff JA , Rubin JP. Plastic Surgery after Weight Loss: Current Concepts in Massive Weight Loss
Surgery. Aesthet Surg J. 2008; 28 (4):452-5.
23
Key question 11: NHSScotland: Exclusion of Exceptional Aesthetic Procedures from the 18
Week Referral to Treatment Standard and Existing Waiting CEL 30 (2009) 2nd July 2009
Appendix 2
Physical Assessment Criteria for General Practitioners
Aesthetic surgery is not routinely offered by the NHS and can only be provided on an
exceptional case basis in line with these guidelines.
The following procedures should only be referred after a clinical assessment when there is a
symptomatic or functional requirement for surgery. All cases will be judged against agreed criteria
on an individual basis. Referral for consideration does not necessarily mean that surgery will be
offered and this should be communicated to the patient.
Procedures:
not available on NHS for
aesthetic reasons
Body contouring:
Abdominoplasty/Apronectomy,
Liposuction, thigh/arm lift,
excision of redundant skin/fat
Exceptional Physical Criteria
•
•
•
•
Severe, intractable intertrigo beneath the skin fold and
massive weight loss (BMI≤27).
Significant weight loss following treatment for morbid
obesity resulting in functional problems (BMI<27).
Lipodystrophy
Adjunct to reconstructive procedures
24
Key question 9 and 12: Plastic Surgery following Bariatric Surgery in NHS Grampian
14 patients have had 19 plastic surgery operations following bariatric surgery, over a four year period from
September 2006. During this period 122 patients had 147 bariatric surgery procedures.
Therefore over the four year period from September 2006 to August 2010, 11% of patients who received
bariatric surgery in Grampian Hospitals, also had follow-up plastic surgery in Grampian Hospitals.
The codes used to identify bariatric surgery were those specified by the NICE Commissioning and
Benchmarking tool, (see tables 1 and 2, below) and the codes used to identify plastic surgery follow-up
treatment were identified by ISD and listed in table 3.
Table 1: Primary Diagnosis of Obesity
Obesity due to excess calories
Description
ICD10 Code
E660
Extreme obesity with alveolar hypoventilation
E662
Other obesity
E668
Obesity, unspecified
E669
Table 2: Bariatric Surgery Main Procedure
Description
OPCS-4
Code
Total gastrectomy and excision of surrounding tissue
G27.1
Total gastrectomy and anastomosis of oesophagus to duodenum
G27.2
Total gastrectomy and interposition of jejunum
G27.3
Total gastrectomy and anastomosis of oesophagus to transposed jejunum
G27.4
Total gastrectomy and anastomosis of oesophagus to jejunum nec
G27.5
Other specified total excision of stomach
G27.8
Unspecified total excision of stomach
G27.9
Partial gastrectomy and anastomosis of stomach to duodenum
G28.1
Partial gastrectomy and anastomosis of stomach to transposed jejunum
G28.2
Partial gastrectomy and anastomosis of stomach jejunum nec
G28.3
Sleeve gastrectomy and duodenal switch
G28.4
Sleeve gastrectomy nec
G28.5
Other specific partial excision of stomach
G28.8
Unspecified partial excision of stomach
G28.9
Gastroplasty nec
G30.1
Partitioning of stomach nec
G30.2
Partitioning Of Stomach Using Band
G30.3
Partitioning Of Stomach Using Staples
G30.4
Other specified plastic operations on stomach
G30.8
Unspecified plastic operations on stomach
G30.9
Bypass of stomach by anastomosis of oesophagus to duodenum
G31.1
Bypass of stomach by anastomosis of stomach to duodenum
G31.2
Closure of connection of stomach and duodenum
G31.5
25
Attention to connection of stomach and duodenum
G31.6
Other specified connection of stomach to duodenum
G31.8
Unspecified connection of stomach to duodenum
G31.9
Bypass of stomach by anastomosis of stomach to transposed jejunum
G32.1
Conversion to anastomosis of stomach to transposed jejunum
G32.3
Closure of connection of stomach to transposed jejunum
G32.4
Other specified connection of stomach to transposed jejunum
G32.8
Unspecified connection of stomach to transposed jejunum
G32.9
Bypass of stomach by anastomosis of stomach to jejunum nec
G33.1
Conversion of anastomosis of stomach to jejunum nec
G33.3
Closure of connection of stomach to jejunum nec
G33.5
Other specified other connection of stomach to jejunum
G33.8
Unspecified other connection of stomach to jejunum
G33.9
Other specified other open operations on stomach
G38.8
Insertion of gastric bubble
G48.1
Duodenal switch
G71.6
Table3: Plastic Surgery following Bariatric Surgery
Description
Facelift and tightening of platysma
Facelift NEC
Submental lipectomy
Other specified plastic excision of skin of head or
neck
Unspecified plastic excision of skin of head or
neck
Abdominoplasty
Abdominolipectomy
Other specified plastic excision of skin of
abdominal wall
Unspecified plastic excision of skin of abdominal
wall
Buttock lift
Thigh lift
Excision of redundant skin or fat of arm
Other specified plastic excision of skin of other site
Unspecified plastic excision of skin of other site
Other specified other excision of skin
Unspecified other excision of skin
OPCS-4 Code
S01.1
S01.2
S01.3
S01.8
S01.9
S02.1
S02.2
S02.8
S02.9
S03.1
S03.2
S03.3
S03.8
S03.9
S04.8
S04.9
26
Key Question 14: Traffic Light Summary: Epidemiology of Obesity in Scotland
ADULTS
2
Obesity (BMI>30kg/m ) has been increasing in all age groups over the last 15yrs. No evidence of reaching a
plateau.
Prevalence of obesity in Scotland, by gender, 1995-2008
CHILDREN
Some evidence that a plateau has been reached. Still much higher than UK average.
Prevalence of obesity in children aged 2-15yrs, Scotland, 1995-2008
27
Geographical variation
In 2003, North of Scotland has been similar to all Scotland in terms of obesity. New data awaited.
Deprivation
Levels of obesity rise with deprivation.
Prevalence of obesity in Scotland, by gender and deprivation, 2008
Women
Men
Note Scale
Predictions for 2030
By 2030, 40% of adults will be obese. The greatest increases are predicted to be in those with a
2
BMI>40kg/m
28
Key questions 16 & 17 (demand) Obesity Prevalence (6/10/20)
Population statistics by age and sex obtained from General Register Office for Scotland, mid year 2009 estimates. NICE costing template used to convert population
2
figures into prevalence of people aged 20 or over with BMI of 40 kg/m or more based on English prevalence estimates.
2
Total estimated population with BMI between 35 and 39.9 kg/m with at least one of the following co-morbidities: cardiomyopathy, coronary heart disease, hypertension,
ischaemic attack, obstructive sleep apnoea, osteoarthritis, pulmonary hypertension, stroke and type 2 diabetes, obtained from NICE assumptions. Estimate is 0.8% of the
total population.
Table A: Estimated Prevalence
Total All Persons All Ages
Total estimated BMI >=40 for persons >=20 years
Percentage of total population
Total estimated BMI between 35 and 40 with comorbidities (0.8% of total population)
Scotland
5,194,000
69,497
1.34%
Grampian
544,980
7,197
1.32%
Highland
310,530
4,235
1.36%
Tayside
399,550
5,352
1.34%
Orkney,
Shetland,
Western
Isles
68,350
917
1.34%
41,552
4,360
2,484
3,196
547
North of
Scotland
1,323,410
17,700
1.34%
10,587
Comparison of obesity prevalence estimates between Scotland and England made on Scottish Public Health Observatory, from the Scottish Health Survey (2008): Topic
Report UK Comparisons published 2010.
2
Obesity prevalence (BMI greater than 30 kg/m ) in men in Scotland (26.0%) did not differ significantly to that of England (24.1%)
Obesity prevalence in women in Scotland (27.5%) compares to 24.9% in England: the difference is only marginally significant.
2
Morbid obesity (BMI greater than 40 kg/m ) for men aged 16 years and over is 1.4% in Scotland compared with 1.1% in England.
Morbid obesity for women aged 16 years and over is 3.4% in Scotland compared with 2.8% in England. No comment found on significance.
1
2
3
4
http://www.gro-scotland.gov.uk/statistics/population.html
http://guidance.nice.org.uk/CG43/CostingTemplate/xls/English
http://www.nice.org.uk/usingguidance/commissioningguides/bariatric/assumptions.jsp
http://scotland.gov.uk/publications/2010/08/31093025/17
29
Applying factors for eligibility and willingness
3
Factors for eligibility and willingness taken from NICE assumptions based on expert clinic opinion, as follows:
Around 60% of the combined group would be considered eligible for bariatric surgery (mid point of the estimates provided by the topic-specific advisory group, i.e. 50% to
70%). 40% of those eligible would take up surgery if it was offered (mid point of the estimates provided by the topic-specific advisory group, i.e. 30% to 50%).
Although the factors quoted above were quoted as applying to the combined criteria group (see Table B below), they have been applied to all three sets of criteria.
Table B: Eligibility and Willingness
Criteria
Eligible and willing for surgery
BMI >=40 and >=20 years
Eligible and willing for surgery
BMI between 35 and 40 with
co-morbidities
Combined
factor
15%
24%
35%
Position
min
mid-point
max
Scotland
10,425
16,679
24,324
Grampian
1,080
1,727
2,519
Highland
635
1,016
1,482
Tayside
803
1,284
1,873
Orkney,
Shetland,
Western
Isles
138
220
321
15%
24%
35%
min
mid-point
max
6,233
9,972
14,543
654
1,046
1,526
373
596
869
479
767
1,119
82
131
191
1,588
2,541
3,706
15%
24%
min
mid-point
16,657
26,652
1,733
2,774
1,008
1,613
1,282
2,052
220
351
4,243
6,789
35%
max
38,867
4,045
2,352
2,992
512
9,900
North of
Scotland
2,655
4,248
6,195
Combined Group:
Eligible and willing for surgery
BMI >=40 and >=20 years or
between 35 and 40 with comorbidities
Thus the estimated numbers of people eligible and willing to have surgery ranges from a minimum of 2,655 to a maximum of 9,900 for North of Scotland. This equates to
0.2% and 0.75% of the total population respectively.
1
2
3
4
http://www.gro-scotland.gov.uk/statistics/population.html
http://guidance.nice.org.uk/CG43/CostingTemplate/xls/English
http://www.nice.org.uk/usingguidance/commissioningguides/bariatric/assumptions.jsp
http://scotland.gov.uk/publications/2010/08/31093025/17
30
Treatment Scenarios
3
Using the minimum and maximum figures from the Table B above, the scenarios set out by the NICE Topic-Specific Advisory Group, based on expert clinical opinion , the
resulting annual cases are given in Table C below.
Table C: Treatment Scenarios
2
3
4
Grampian
Highland
Tayside
min
167
17
10
13
2
42
max
622
65
38
48
8
158
not
applicable
519
54
31
40
7
132
min
521
54
32
40
7
133
max
1943
202
118
150
26
495
Treatment scenario
Position
1.6% of eligible and willing people could
be treated each year given appropriate
investment in services
A population benchmark of 0.01% per
year in 5 years' time
Annual growth rate of eligible population
is 5%
1
Scotland
Orkney,
Shetland,
Western
Isles
North of
Scotland
http://www.gro-scotland.gov.uk/statistics/population.html
http://guidance.nice.org.uk/CG43/CostingTemplate/xls/English
http://www.nice.org.uk/usingguidance/commissioningguides/bariatric/assumptions.jsp
http://scotland.gov.uk/publications/2010/08/31093025/17
31
Prevalence and Surgery Summary Table
Annual
benchmark for Annual increase in Elligible
New Demand minus Status
NoS based on and Willing people in NoS New Demand minus Annual Quo planned capacity of 80
0.01% of
patients (assumes one
Eligibility and Willingness
Benchmark (i.e. annual
based on 5% of prevalence
population (3)
procedure per patient) (6)
for NoS(2)
shortfall) (5)
(i.e. new demand) (4)
Prevalence(1)
Row Cohort
Original assumptions made
by NICE in addition to
Extension to original NICE assumptions
those listed in footnote
in addition to those listed in footnote
Scotland
Grampian Highland
Tayside
Orkney,
Shetland,
Western
Isles
North of
Scotland
min
average
max
min
average
max
min
average
max
min
average
max
2856
4570
6665
132
143
229
333
10
96
201
63
149
253
2655
4248
6195
132
133
212
310
0
80
177
53
132
230
5194000
544980
310530
399550
68350
1323410
BMI >40 for all ages
74873
7752
4540
5765
986
19043
2
BMI >40 as percentage of total population
1.44%
1.42%
1.46%
1.44%
1.44%
1.44%
3
BMI >40 and age >20 years
69497
7197
4235
5352
917
17700
4
BMI >40 and age >20 years as percentage of
total population
1.34%
1.32%
1.36%
1.34%
1.34%
1.34%
5
Male, BMI >40 and age between 20 and 44
years
4357
458
224
333
47
1063
159
255
372
132
8
13
19
-124
-120
-114
-72
-67
-61
6
Female, BMI >40 and age between 20 and 44
years
21934
2243
1113
1569
245
5170
776
1241
1810
132
39
62
90
-94
-70
-42
-41
-18
10
7
BMI >40 and age between 20 and 44 years
26291
2701
1337
1902
292
6233
935
1496
2182
132
47
75
109
-86
-58
-23
-33
-5
29
0
Mid year 2009 population estimate
1
8
9
BMI >50 for all ages
Prevalence is 7% of
population with BMI > 40
BMI between 40 and 50 and age >20 years
BMI between 40 and 50 and age between 20
10 and 44 years
11 BMI between 35 and 40 with co-morbidities
5241
543
318
404
69
1333
200
320
467
132
10
16
23
-122
-116
-109
-70
-64
-57
Prevalence is 7% of population in this
age group with BMI > 40
64632
6693
3938
4977
853
16461
2469
3951
5761
132
123
198
288
-9
65
156
43
118
208
Prevalence is 7% of population in this
age group with BMI > 40
24451
2512
1244
1769
272
5797
870
1391
2029
132
43
70
101
-89
-63
-31
-37
-10
21
Prevalence is 0.8% of total
population
41552
4360
2484
3196
547
10587
1588
2541
3706
132
79
127
185
-53
-5
53
-1
47
105
BMI between 35 and 40 with co-morbidities and
12 age > 20
Prevalence is 0.8% of total population of
this age
32140
3379
1937
2487
422
8225
1234
1974
2879
132
62
99
144
-71
-34
12
-18
19
64
BMI between 35 and 40 with co-morbidities and
13 age between 20 and 44
Prevalence is 0.8% of total population of
this age
13997
1477
712
1006
156
3351
503
804
1173
132
25
40
59
-107
-92
-74
-55
-40
-21
BMI between 35 and 50 with co-morbidities and
14 age >20
BMI distribution is uniform between 35
and 50 for ages >20
96419
10136
5811
7461
1267
24675
3701
5922
8636
132
185
296
432
53
164
299
105
216
352
BMI between 35 and 50 with co-morbidities and
15 age between 20 and 44
BMI distribution is uniform between 35
and 50 for ages 20 to 44
41990
4430
2137
3019
467
10053
1508
2413
3519
132
75
121
176
-57
-12
44
-5
41
96
Original assumptions and factors
Original NICE factors for eligible and willingness applied to the cohorts in rows 3 and 11 combined
Original NICE assumptions of a 5% increase in annual demand applied to the cohorts in rows 3 and 11 combined
Assumptions for all rows:
NICE assumptions and prevalence in BMI ranges by sex and age group hold for the Scottish population
Eligibility and willingness factors (15%, 24% and 35% for minimum, average and maximum values respectively) can be applied to all cohorts individually, and new annual demand in the future
The prediction of 5% for future increases in annual demand can be applied to all cohorts individually
Possible further assumptions:
For rows 11 to 15, the estimates for people with diabetes may be approximately similar to but less than those with co-morbidities
Explanation of column headings
1. Estimated current prevalence of this cohort
2. Estimated number of people who are appropriate cases for surgery in this NoS cohort currently
3. What NICE have said is reasonable to do annually given appropriate investment for the next five years
4. How much will the pool of people in column 2 increase by (ie how many we need to operate on to maintain the same numbers waiting for surgery)
5. How much the numbers in column 4 exceed the annual benchmark
6. How much the numbers in column 4 exceed the status quo of 80 patients
32
Drugs used in the treatment of obesity and trends
This is an ISD Scotland National Statistics Release
IR2010-02878
Years ending 31st March 2005/05-2009/10
Prescribed in Scotland - "Foreign" prescribers omitted - Scotland and by NHS Board
Title:
Period:
Range:
Data:
No. prescribed items, gross ingredient cost and number of defined daily doses (DDDs)
Notes:
1
2
3
4
5
6
7
8
Data is based on British National Formulary section 4.5
Data is based on British National Formulary (BNF) September 2010
Data are given for all prescription form types
Data excludes prescription prescribed in England
Gross ingredient cost excludes broken bulk
Data shown is based on prescriptions dispensed by community pharmacists, appliance suppliers and dispensing doctors only
The World Health Organisation produces Defined Daily Doses for medicines based upon the assumed average maintenance
dose per day for a drug used in its main indication in adults. More information can be found at www.whocc.no
Data given refer to prescriptions dispensed in the community, but do not take into account medicines dispensed by hospitals or hospital based clinics
33
North of Scotland Prescribing Trend
Sum of No of defined daily doses
Approved drug name
ORLISTAT
RIMONABANT
SIBUTRAMINE
Grand Total
Financial year
2005
444438
259578
704016
2006
509943
27949
298400
836292
2007
538110
65384
310083
913577
2008
547323
32243
354254
933821
2009
690516
320946
1011461
2006
14.7
n/a
15.0
18.8
2007
5.5
133.9
3.9
9.2
2008
1.7
-50.7
14.2
2.2
2009
26.2
n/a
-9.4
8.3
Grand Total
2730330
125576
1543262
4399168
Annual Percentage Increase on Previous Year
Approved drug name
ORLISTAT
RIMONABANT
SIBUTRAMINE
Grand Total
Financial year
2005
n/a
n/a
n/a
n/a
Average Annual Percentage Increase over Four Years
Approved drug name
ORLISTAT
RIMONABANT
SIBUTRAMINE
Grand Total
12.0
41.6
5.9
9.6
34
Prescribing Summary by Health Board
Sum of No of defined daily doses
Health Board
Grampian
Highland
Orkney
Shetland
Tayside
Western Isles
Grand Total
Financial year beginning April
2005
2006
327238
385787
180704
223040
7132
7783
12526
14590
156081
175465
20335
29627
704016
836292
2007
426661
247233
8511
11758
185576
33838
913577
2008
452545
233346
9715
15387
194036
28793
933821
2009 Grand Total
481111
2073341
251612
1135936
14042
47183
14905
69166
222225
933382
27566
140159
1011461
4399168
Defined daily doses
Prescriptions of Obsesity Drugs by Health Board
1200000
Western Isles
Tayside
Shetland
Orkney
Highland
Grampian
1000000
800000
600000
400000
200000
0
2005
2006
2007
2008
2009
Financial Year beginning April
35
Key Question 18: Flying and gastric bands
Three potential problems with flying
1. Setting off the security systems – not a major problem but some surgeons issue a card that the
patient can carry to say they have a gastric band.
2. Expansion (tightening) when flying – changes in pressure have the potential to cause band
tightening. Along with dehydration that thickens gastric secretions with the potential result of
vomiting. The problem has been reported but appears to settle after a few hours after landing.
Recommendations for long haul flights include: don’t fly just after increasing the band pressure;
adjust the band down prior to flight; avoid alcohol and stay well hydrated.
3. Perhaps biggest (and overlooked) problem – health insurance to cover band related health problems
while abroad.
This is a quick and dirty review of internet based discussions about bands – not evidence based or
unbiased. Nothing in guideline evidence about flying or other restrictions post banding/surgery.
Key questions 19 and 20: CBT and Gastric Band adjustments
QUESTIONS ON BARIATRIC SURGERY ASKED FROM CHAIN (on-line mutual support network)
1) Does any hospital have experiences of using professionals other than psychologists (e.g. trained
dieticians) to provide cognitive behavioural therapy (CBT) in the care and treatment of morbidly obese
people? If so, what were the competencies, skills and training/qualifications that were necessary to
develop?
2) Does any hospital have experiences of using clinicians other than doctors to do gastric band adjustments
for bariatric surgery patients (e.g. dieticians; specialist nurses)? If so, what skill sets/qualifications were
required and how many procedures were needed to maintain skills and competencies.
RESPONSES
Positive answers to question 1
1.
We run a morbid obesity programme that is also the bariatric surgery pathway within a community
setting. Our weight loss mentors have all been trained in the use of specific CBT tools and questioning styles
and our self management workers who lead on morbid obesity/bariatric have been trained to certificate level
in CBT. The programme has been very successful in terms of both weight loss and increasing client
confidence in managing their own weight without the need for surgery. Do phone if you want to discuss.
Robert Langford
Service Manager Nutrition and Obesity - Adults
Telford and Wrekin Community Health Services
Ground Floor
Wrekin Housing Trust Building
Colliers Way
Old Park
Telford TF3 4AW
Office: 01952 217466; Mobile: 07969 296068
2.
The dietitians in the weight management teams here at Aintree Hospital use a behavioural approach
with patients which includes some CBT techniques if appropriate - but is not a full CBT programme. The
training is the level 1, 2 and 3 behavioural change skills courses that Dympna Pearson runs (her email is
[email protected]) . In the Aintree LOSS service which I manage we also have trained
psychotherapists who provide CBT as one option (also CAT, group work, psycho-education as appropriate).
Hope this helps
Michaela James
Principal Dietitian & Operational Manager for Aintree LOSS
Eskdale
University Hospital Aintree
36
Lower Lane
Liverpool, L9 7AL
Tel 0151 529 5938; Blackberry 07896 186 719
3.
Your CHAIN query with regard to provision of CBT for Obese clients has been referred to Dr. Nazih
Eldin, Head of Health Promotion, Health Service Executive Dublin North Eastern Area and to myself. In
response to your question above, yes, our Department are undertaking a research project to pilot the
effectiveness of utilising a CBT Model for morbidly obese clients in the primary care setting. The research
programme is in its 2nd year and is being conducted in conjunction with the School of Psychology, University
College Dublin. The aim of this study is two-fold (i) to establish a psychological profile of obese patients
attending a primary care service for weight reduction and (ii) to evaluate a cognitive behavioural approach to
the treatment of obesity in line with that devised by Cooper & Fairburn (2001).
Clinical Psychologists in the main were recruited and trained in this specific intervention model. In the longer
term, it is anticipated that this panel of trained experts will in turn devise and deliver an adapted training
programme to allied health professionals in the provision of CBT for morbidly obese clients across the health
service. Professor Zaffra Cooper provided the training to a panel of appropriate trained staff recruited
specifically to provide sessions for the purpose of this study.
Further details of our research project are as follows:
The initial study (STUDY 1) to establish a profile of obese patients involved data being collected at the
recruitment stage recording BMI, waist circumference, medical history, food intake, exercise profile,
readiness for change, eating disorder, body dissatisfaction, self-concept, depression, anxiety and quality of
life. This information will form the quantitative profile. In addition focus group interviews were utilised to
explore the issue of obesity for the client group.
Study 2 is a randomised control trial to test benefits of a Cognitive Behavioural Therapy (CBT) approach to
the treatment of obesity. To ensure a sufficient sample size to determine statistically the efficacy of the
treatment, a sample of >200 were initially recruited into the study. Previous research on attrition suggested
that at all stages of an intervention attrition occurs. To ensure that at the end of the study phase the sample
size is approximately 100 an initial recruitment of 200 will be required. Inclusion criteria: BMI > 35, referred
Patients were asked to consent to participate in the study with the knowledge that wouldl be randomly
assigned to treatment as usual or treatment as usual + cognitive behavioural therapy. This phase of
randomisation ensures that group equivalence is established before the treatment phase begins. Each
participant was assessed pre treatment, at the end of phase 1, end of phase 2 and then at six months follow
up. Thus yielding 4 stages of testing. The dependent variables that will be studied using this mixed model
design include: on BMI, food intake, exercise profile, readiness for change, eating disorder, body
dissatisfaction, self-concept, depression, anxiety and quality of life.
The study is currently aimed at those clients attending GP surgeries and receiving dietetic support but not
achieving and maintaining weight loss and with a BMI >35.
I would be happy to discuss this project further with you on completion of our study but if you have any other
questions in the interim, you can contact me on this email or telephone contacts below.
Emer Smyth, Cardiovascular Strategy Facilitator
A/Senior Executive Officer
Department of Health Promotion; (046) 9076463; 087 2585080
4.
A collegue told me about your CHAIN targeted query: provision of CBT for obese patients and
bariatric surgery. UCD is currently running a research programme on CBT for obese clients in primary care
(BMI >35). However, the CBT treatment is provided by clinical psychologists and specialised CBT therapists.
We are considering extending the provision to trained nurses and dieticians but so far we unfortunately do
not have experience of this. Please let me know if you still want to know more about our programme.
Have you been involved in work that provides CBT for obesity? If so, can you tell me if the CBT treatment
worked in the long run?
37
Aurelia Ciblis
UCD School of Psychology
Newman Building
University College Dublin
Belfield, Dublin 4, Ireland
Tel: +353-894144270; Fax: +353-1-7161181
5.
Lynne Chivers forwarded me the recent email and thought that I would be the most appropriate
person to respond as the Bariatric Nurse Specialist for weight loss surgery.
Our specialist bariatric dietician has done a post grad diploma in CBT. However this does not enable her to
manage her own case load but she is able to use her CBT skills in consultations. To manage a caseload
officially people need to be BABCP accredited and this would require a full masters program or can be done
at diploma level.
Cara Barnes
Bariatric Nurse Specialist
Calderdale and Huddersfield NHS Foundation Trust
01422 222086
6.
Yes, RIO are big supporters (as are the NOF) of all talking therapies (CBT, NLP, EFT, life coaching,
hypnotherapy, hypnobanding etc). Our therapists at RIO practice them all, but find NLP/EFT more
successful than CBT. They are available to discuss if required.
Dr Matthew S Capehorn
Clinical Director, National Obesity Forum (NOF)
Clinical Manager, Rotherham Institute for Obesity (RIO)
Clifton Medical Centre, The Health Village, Doncaster Gate, Rotherham, S651DA
Work 08444773622; Mobile 07786931007
Positive answers to question 2
1.
I am the nurse lead for NHS Lothian Bariatric Surgical Service, the service is nurse/AHP run. As the
nurse lead I undertake band filling and have created a protocol surrounding this, with competancies and
evidence.
I have attached band filling protocol. Local training could be undertaken by a surgeon who is happy to
monitor and assess competencies, we were lucky to go to Prague and Hexham to undertake this role with a
designated team. Some of the band companies, Allergan and Ethicon run these courses in specialist
centres.
With regards to weight management, Graham Simpson is the service lead for NHS Lothian Weight
Management Service, he should be able to give you pathway information regarding movement from Tier 3 to
Tier 4, I have attached pathway regarding acceptance from Tier 4 to Tier 5 bariatric surgery.
I have included Graham in this e-mail and this will enable you to contact him independantly.
If you require any further information, please let me know.
Mhairri Duxbury, Bariatric Nurse Specialist
NHS Lothian Bariatric Surgical Service
Royal Infirmary of Edinburgh
Little France Crescent, Edinburgh, EH16 4SA
Phone: 0131 536 1000 ext 21615; Mobile: 07776341859; [email protected]
2.
Lynne Chivers forwarded me the recent email and thought that I would be the most appropriate
person to respond as the Bariatric Nurse Specialist for weight loss surgery.
All of our gastric bands are adjusted by the radiologists under xray control. However, I am aware that Derby
have nurses who adjust gastric bands and actually run training courses for this. I’m sure that if you contact
them they’ll be able to give you the criteria and competencies required.
Hope this helps. If I can be of any further assistance please don’t hesitate to contact me.
38
Cara Barnes
Bariatric Nurse Specialist
Calderdale and Huddersfield NHS Foundation Trust
01422 222086
3.
Gastric band adjustments are easy, and this is a prime example of a procedure that is more
appropriate for primary care (as per the Australian model) where we are equiped to provide additional time,
counselling and more frequency of adjustments etc, if needed. I was trained in Australia to do this and it is
easy, and rarely required radiology or USS to identify the port. If this role is to be devolved from the surgeon
(which I approve of) it should not be to other members of an expensive secondary care team, who already
struggle to meet demand.
Happy to discuss either point in more detail.
matt
Dr Matthew S Capehorn
Clinical Director, National Obesity Forum (NOF)
Clinical Manager, Rotherham Institute for Obesity (RIO)
Clifton Medical Centre, The Health Village, Doncaster Gate, Rotherham, S651DA
Work 08444773622; Mobile 07786931007
4.
My colleague a bariatric nurse specialist and I have experience of band filling. In addition although
not CBT trained I have undertaken a series of behaviour change courses which uses a lot of CBT techniques
which I use with the Bariatric patients
Happy to discuss this with you, telephone number below
Christine Ward, Metabolic Research / Bariatric Dietitian
OPD 4
Edinburgh Royal Infirmary
51 Little France Crescent
Edinburgh
EH16 4AS
0131 242 1615
Do not do either, but are interested in knowing more
No, but interested
1.
Not in Fife.
Annette Lobo
Consultant Midwife
Forth Park Hospital
Kirkcaldy
KY2 5RA t: 01592 643355 x2851
2.
Hi Jill
I cant help with your query re CBT and banding adjustments in morbidly obese patients but would be
interested in your findings.
Marie Todd,
Lymphoedema CNS
Glasgow
3.
We are designing a community-based obesity service at the moment and are looking into providing a
CBT therapist as part of it. So, I’d be very interested in the answer to your first question. Would you mind
sharing it with me, when you get it, or even with the wider group?
Dr Sandra Husbands
Consultant in Public Health Medicine
NHS Harrow
39
59-65 Lowlands Road
Harrow-on-the-Hill
Middlesex HA1 3AW
Tel. 020 8966 1055; Mobile 07903 252652
Offers of advice
1.
In response to your email from chain see below
FYI: my background, health psychologist specialising in weight management, conduct private practice with
bariatric clients. However am public health lead for healthy weight in Knowsley and programme and
commission healthy weight services so hopefully I can offer you some input.
Lisa
Dr. Lisa Newson, BSc (hons), MSc, D.Health Psyc. C.Psychol
Public Health Programme Manager- Healthy Weight
NHS Knowsley/Council
Public Health
Tel: 0151 285 6010
Fax: 0151 285 6018
www.knowsley.nhs.uk
www.knowsley.gov.uk
40
Key Question 25: Traffic Light Summary of inequality issues
Issue
Impact
Higher levels of obesity
Socio-economic
Ethnicity
Other groups
Poorer diet
Lower physical activity outside of work
Poor access to sport facilities
Obesity higher in:
In men - in black Caribbean
In women - black Caribbean, black African and Pakistani
Cardiovascular risk for South Asian men and women
much higher than general population in UK – any
modification of risk factors likely to have significant health
benefits.
Obesity higher among those with learning disabilities
Obesity higher among those with serious mental health
problems
Source: NICE Clinical Guideline No.43 Obesity guidance on the prevention, identification, assessment and
management of overweight and obesity in adults and children. 2006
41
Obesity Management Service - Patient Involvement Report, Dec 2010
(NHS Grampian Better Care Without Delay Team)
1. How long have you had problems with your weight?
- Every Patient has had weight problems for at least 20 years.
2. How many times have you been to see your GP for help with your weight?
Number of times patients visited their GPs about their weight
before being referred
40%
30%
20%
10%
0%
Never
Up to 5
5 to 10
10 to 15
15 to 20
40-50
3. What led to you being referred to the Nutrition Clinic?
Referral Decision
80%
70%
60%
50%
40%
30%
20%
10%
0%
GP suggested referral
Patient suggested referral
Other Specialist suggested
referrral
Health Professional support offered to Patients before referral
60%
50%
40%
30%
20%
10%
0%
Had health professional support before referral
Had no health professional support before referral
42
4. On a scale of 1 to 5 (five being the highest mark), how would you rate the quality
of any information given or sent to you before your first appointment?
Information sent to patients before first Nutrition Clinic Appointment
50%
40%
30%
20%
10%
0%
5
4
3
2
1
Received none
5. What sort of support was offered to you at your first appointment?
Experience of first clinic appointment
40%
35%
30%
25%
20%
15%
10%
5%
0%
no appointment
offered
supportive and
informative
supportive
informative
poor support
offered
43
6. How long did you wait between being referred to clinic by your GP and receiving
surgery?
Time take n from re fe rral to surge ry
25%
20%
15%
10%
5%
0%
3 months
6-12
months
12-18
montths
18-24
months
3 years
4 years
5 years
11 years
15 years
7. Did you have a letter from the obesity or surgical services at NHS Grampian
confirming that you were on a waiting list for surgery?
Letter received by Patient confirming they were on a Waiting
List
60%
50%
40%
30%
20%
10%
0%
Yes
No
8. How long were you on the waiting list for surgery?
Time waited from decision to surgery
60%
50%
40%
30%
20%
10%
0%
2 weeks
3-12 weeks
6-12 months
18-24 months
3-4 years
44
9. Were you told when to expect being at the top of the waiting list?
Patients told how long they would wait
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Yes
No
10. What sort of support was offered to you while the waiting list?
Support offered whilst on Waiting List
80%
70%
60%
50%
40%
30%
20%
10%
0%
Dietician
appointments - 1
person told after 18
months there was no
point attending before
surgery and 1 person
told if they didn't
attend would not get
surgery
None
Dietician support over Given dietician phone
Rarely offered
phone
number
dietician apps - thinks
they were forgotton
45
Kept better
inf ormed
Shorter w aiting
times
Better
communication
betw een boards
0%
P la s tic s u r g e r y
D ia b e tic /N u tr itio n a d v ic e
c o n tin u ity
N e w s le tte r w ith tip s
a n d r e c ip e s
T a lk s g iv e n b y p e o p le
w ho hav e had s urgery
c ook ery
c la s s e s /d e m o n s tr a tio n s
S upport G roup
P s y c h o lo g ic a l s u p p o r t
b e fo r e s u r g e r y
P s y c h o lo g ic a l s u p p o r t
a fte r s u r g e r y
B e h a v io u r a l/C o g n itiv e
T herapy
S u p p o r t w ith
e x c e r is e /a c tiv itie s
P s y c h o lo g ic a l
T h e r a p y /c o u n c e llin g
T h e % o f P a t ie n t s t h a t m a d e t h e
s u g g e s t io n
11. Other than gastric surgery, what other things do you think the obesity service
should offer?
Suggestions for Nutrition Clinic
35%
30%
25%
20%
15%
10%
5%
12. Could anything be done differently about the referral process and waiting
times/lists?
% of Patients that suggested the top 4 areas for improvement
to the referral/waiting processes
30%
25%
20%
15%
10%
5%
0%
Better admin
processes
46
13. What did you think the risks of surgery might be?
How pr e pare d did Patie nts fe e l be fore s ur ge r y
9 0%
8 0%
70%
6 0%
50%
4 0%
3 0%
2 0%
10%
0%
Fully aware o f risks
Did n't want t o know
Didn't know as called 10
d ays b ef ore surg ery
14. How well prepared did you feel before your surgery?
How prepared patients felt before surgery
80%
70%
60%
50%
40%
30%
20%
10%
0%
Well prepared
Quite prepared
Not so prepared
Excited
15. How well prepared did you feel at the time of surgery?
How felt at time of surgery
Positive but
scared
Still quite
anxious
Very anxious
and
upset/emotional
Wasn't
prepared,
terrified, never
saw Mr Bruce
before surgery
Not prepared
Well prepared
70%
60%
50%
40%
30%
20%
10%
0%
47
16. Where you asked to lose weight prior to surgery (pre-op weight loss)?
- All Patients answered yes.
16.1. How did you achieve this?
How weight was lost pre-surgery
60%
50%
40%
30%
20%
10%
0%
PSMF
On own
Gastric Balloon
low carb diet
17. On a scale of 1 to 5 (five being the highest mark), how would you rate the quality
of any information given to you regarding your surgery?
Quality of information about surgery
60%
No. of Patients
50%
40%
30%
20%
10%
0%
Very good
Good
OK
Poor
Very Poor
48
18. How did you find the surgical staff?
Experience of Surgical Staff
Nurses not
knowledgeable
enough
Nurses busy
Helpful and
supportive
Good/Ok
Very good/very
nice
Brilliant/Fantastic/
Excellent
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
19. On a scale of 1 to 5 (five being the highest mark), how would you rate the verbal
explanations about your surgery given by your surgeon, doctor or Dietician?
Verbal explanation of surgery
80%
70%
60%
50%
40%
30%
20%
10%
0%
5
4
3
2
1
20. Were you a patient from NHS Highland, Orkney, Shetland or Western Isles?
Patients by NHS Board
80%
70%
60%
50%
40%
30%
20%
10%
0%
NHS Grampian
NHS Highland
NHS Lothian
NHS Forth Valley
49
21. If so, did coming to Aberdeen cause any practical difficulties for you?
Did coming to Aberdeen cause you problems
80%
70%
60%
50%
40%
30%
20%
10%
0%
Not applicable
No issues
caused by
distance
Yes Band
maintanance
issues due to
distance
I had to be
driven to all
apps by my
daughter
Was not told Long journeys
by any Board
that I could
claim
expenses
22. What would have made this easier for you?
What would make living outwith Aberdeen easier?
80%
70%
60%
50%
40%
30%
20%
10%
0%
Not applicable
Nothing
Nurse trained in Surgery available Wife being able to
band maintenance closer to home
claim for
in Inverness
expenses too
50
23. Which procedure/s did you have?
Procedure performed
40%
35%
30%
25%
20%
15%
10%
5%
0%
Gastric Bipass Gastric Band
Gastric
Balloon
followed by
Bipass
Gastric Band
followed by
Bipass
Gastric Sleeve
Sleevectomy
24. How did you find the quality of your post operative surgical support?
% of Patients that made these comments
25%
20%
15%
10%
5%
0%
Good
Very good
No local support
Unsympathetic Clear soup aw ful Too long until 1st
nurses
follow up app
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25. How much weight have you lost since your surgery?
Weight lost since surgery
30%
25%
20%
15%
10%
5%
0%
1-2 stone
3-4 stone
5-6 stone
8-9 stone
10-11 stone
12-13 stone
14-15 stone
16-17 stone
Average weight loss per patient by procedure
Weight loss in Stones
16
14
12
10
8
6
4
2
0
Band (8 Pts)
Bipass (7 Pts)
Balloon then
bipass (4 Pts)
Sleeve (1 Pt)
Sleevectomy
(1Pt)
26. Was it more/less/the same as you expected to lose?
Was it more, the same or less weight loss than expected?
70%
60%
50%
40%
30%
20%
10%
0%
More
The same
Less
52
27. Do you think it would have been possible to have lost this weight without
surgery?
Could you have lost the weight you did without surgery
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Yes
No
28. Has your surgery made losing weight any easier compared to the time before
your surgery? If so, why was this?
Is it easier to lose weight now after surgery
80%
70%
60%
50%
40%
30%
20%
10%
0%
yes
slightly
not sure
no
29. Overall, did your experience match your expectations – was the surgery
better/worse/about the same as you would have expected it?
Overall experience of surgery
60%
50%
40%
30%
20%
10%
0%
exceeded expectations
same as expected
worse than expected
29.1. Why was that?
- The patients who had good weight loss felt their experience exceeded their
expectation and the patients who had a smaller weight loss felt it was worse than
they expected.
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30. Would you recommend surgery to someone else?
Would you recommend this surgery?
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Yes but person must be well informed
It's up to the individual
31. Could anything have been done differently?
Main Suggestions for improvement
More contact and better informed through the whole journey
reduced waiting times for clinic appointments and surgery
More information earlier about effects of surgery
Nurses more aware on the Wards
GPs made more aware
Better access to support groups
Quicker band adjustments after surgery
Easier access to get band fills - difficult to request through
dietician sometimes
Psychological support after surgery
32. Given that we can only perform a limited number of surgical procedures, how
would you suggest we decide who gets gastric surgery?
% of patients that suggested the top 5 priorities that were mentioned
100%
80%
60%
40%
20%
0%
Health
problems/medical
benefits from
surgery
Commitment and
proactivity
Tried everything and Only people w ho
failed
are Psychologically
suitable
High BMI
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