Transcript General Surgery Workshop:

General Surgery Workshop:
Bariatric Surgery
Current evidence and guidance
Rob Davies and Rob Cook
Introduction
 This slide set aims to give a brief overview of the evidence and
guidance surrounding bariatric surgery to inform the resolution of a
high value clinical pathway
 Word doc “Evidence summary: bariatric surgery” provides more
information for reference
 Rapid evidence review conducted August 2011:
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NHS Evidence/NICE
Cochrane database of systematic reviews
NHS Map of Medicine
PubMed (using filters)
Clinical Knowledge Summaries (CKS)
Department of Health
 Recent, UK guidance, systematic reviews and pathways prioritised
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Background
 Bariatric surgery for obesity in adults is usually only considered
when all other treatments have failed
 Bariatric surgery for young people may only be considered in
exceptional circumstances
 Adults who are currently eligible must have a BMI>40, or greater
than 35 with related co-morbidities such as type II diabetes
 It has often been suggested that people with a lower BMI may
benefit from surgery (PCTs can set their own BMI thresholds)
 A number of different techniques are carried out through either
open or laparoscopic surgery
 Unclear which procedures are most effective in reducing weight
and which have the least complications
 Conservative treatment can include drugs, changes in diet and
exercise regimes
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Current guidance and evidence
 Key evidence NHS Map of Medicine Clinical Pathways
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Adults (published 2011, latest study incorporated 2010)
Assessment and diagnosis pathway
Non-specialist management pathway
Specialist management pathway
Surgery for obese adults pathway
 Literature search date March 2007 [sic]
 Based on 6 high-quality guidelines and 2 critically appraised metaanalyses and systematic reviews.
 Practice-based knowledge added by Royal College of Physicians
representatives
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Current guidance and evidence
 Key evidence NHS Map of Medicine Clinical Pathways
 Children (published 2011, latest study incorporated 2010)
• Initial assessment in primary care pathway
• Management in secondary care pathway
 Literature search date March 2010
 Based on 4 high-quality guidelines and 2 critically appraised metaanalyses and systematic reviews
 Practice-based knowledge added by clinician experience
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Current evidence and guidance
 Cochrane systematic reviews:
• *Colquitt (2009). Surgery for obesity.
 NICE Guidelines:
• *Bariatric surgical service commissioning guideline (2007)
• *CG43 Obesity: guidance on the prevention, identification,
assessment and management of overweight and obesity in adults
and children (2006)
 NHS Clinical Knowledge Summaries (CKS):
• *NHS Clinical Knowledge Summaries. Obesity Management (2007)
* Incorporated into the current map of medicine clinical pathway
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Current evidence and guidance
 PubMed search for systematic reviews:
• To supplement existing clinical pathway information
• 11 relevant studies retrieved (briefly described in Appendix C of
the accompanying word document)
• Of potential interest for discussion:
• Chang 2011. Cost-effectiveness of bariatric surgery: should it be
universally available?
• Runkel 2011. Evidence based German guidelines for surgery for
obesity.
• Pontiroli 2011. Long-term Prevention of Mortality in Morbid Obesity
Through Bariatric Surgery
• Fried 2010. Metabolic surgery for the treatment of type 2 diabetes
in patients with BMI <35 kg/m2: an integrative review of early
studies.
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NICE 2006 referral to secondary care
 Bariatric surgery is recommended as a treatment option for people
with obesity if all of the following criteria are fulfilled:
• they have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40
kg/m2 and other significant disease that could be improved if they lost
weight
• all appropriate non-surgical measures have been tried but have failed
to achieve or maintain adequate, clinically beneficial weight loss for
at least 6 months
• the person has been receiving or will receive intensive management in
a specialist obesity service
• the person is generally fit for anaesthesia and surgery
• the person commits to the need for long-term follow-up.
 Also recommended as a first-line option (instead of lifestyle
interventions or drug treatment) for adults with a BMI of more than
50 kg/m2 in whom surgical intervention is considered appropriate.
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Economic evaluation
 Chang 2011 reported that surgery (mixed types) is, in general, cost
effective over non-surgical alternatives in BMI range 35-49.9kg/m2
and cost saving when BMI>50kg/m2 with comorbidities
• BMI 35-40kg/m2 + comorbidities:
• Incremental cost effectiveness ratio (ICER) of $2,413 per qualityadjusted life year (QALY) gained (surgery vs. non surgery)
• BMI 35-40kg/m2 – comorbidities: ICER rises to $3,872 per QALY
• BMI 40<50kg/m2 + comorbidities $1,853 per QALY
• BMI 40<50kg/m2 - comorbidities $3,770 per QALY
• BMI >50kg/m2 + comorbidities = cost saving
• BMI >50kg/m2 - comorbidities $1,904 per QALY
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Economic evaluation...
 Chang 2011
 Extended model to BMI 30-35kg/m2 and predicted:
• With comorbidities $2,926 per QALY
• Without comorbidities $4,222 per QALY
 Much smaller ICERs than previous studies:
• More robust estimation of effectiveness and cost in Chang 2011
• Previous studies didn’t separate out comorbidities
• Different sensitivities to underlying assumption changes
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Metabolic surgery
 Runkel 2011 German Evidence Based Guidance on bariatric surgery
has recommended considering those with a BMI<35 with type II
diabetes for surgery
• Precondition: failed 6-12 month conservative program/futility
 Dixon 2011 reviewed the evidence to produce a statement for the
International Diabetes Federation:
• Surgery considered in patients with BMI 30-35kg/m2 when diabetes
cannot be adequately controlled by other means
• BMI action points to be reduced by 2.5kg/m2 in Asian and some
other ethnic groups
 Fried 2010 reported an average BMI change from 29.4 to 24.2kg/m2
in overweight individuals (moving them to healthy weight)
 85% were off their diabetes medications at a range of follow-ups
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NHS Map of Medicine interactive
clinical pathways (Adults)
• Assessment and diagnosis pathway
• Non-specialist management pathway
• Specialist management pathway
• Surgery for obese adults pathway
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NHS Map of Medicine interactive
clinical pathways (Children)
• Initial assessment in primary care pathway
• Management in secondary care pathway
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Session 1: Describe a high value primary
care pathway
1. What does a high value care pathway look like from a patient’s
perspective?
 describe your evidence base
 examples of this is within the UK
2. Are there other models of care we should consider? e.g. GPSI/
community services?
 describe your evidence base
 examples of this is within the UK
3. Is there significant variation in care pathways across the UK?
 describe why
 what research questions would need to be asked
4. Measures
 what measures can we use to follow patients along your care pathway
 suggest outcomes measures that describe the quality of care given
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Session 2: Describe primary to secondary
care referral criteria
1. What are high value referral criteria from a health community
perspective?
 what are the thresholds for referral
 describe your evidence base
 examples of this is within the UK
2. Are there other models of care we should consider e.g. direct
access to secondary care/ nurse led clinics?
 describe your evidence base
 examples of this is in the UK
3. Is there significant variation in referral patterns across the UK?
 describe why
 what research questions would need to be asked
4. Measures
 what measures can we use to evaluate referral patterns
 can you suggest outcomes measures that describe their effectiveness
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Session 3: Describe a high value
secondary care pathway
1. What does a high value care pathway look like from a patient’s
perspective?
 What are the thresholds for intervention
 describe your evidence base
 examples of this is within the UK
2. Are there other models of care we should consider e.g. shift care
into community/ centralisation of complex services?
 describe your evidence base
 examples of this is within the UK
3. Is there significant variation in care pathways across the UK?
 describe why
 what research questions would need to be asked
4. Measures
 what measures can we use to follow patients along your care pathway
 suggest outcomes measures that describe the quality of care given
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References
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