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Making difficult decisions - Obesity Treatment

Making difficult decisions - Obesity Treatment. Eddie Coyle Jane Bray Sara Davies David Cline Jennifer Armstrong Heather Knox. Background.

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Making difficult decisions - Obesity Treatment

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  1. Making difficult decisions - Obesity Treatment Eddie Coyle Jane Bray Sara Davies David Cline Jennifer Armstrong Heather Knox

  2. Background • National Planning Forum (NPF) requested by Scottish Government’s Route Map to establish a subgroup to provide advice on how NHS Scotland should respond to growing demand for bariatric surgery, including need for weight management. • OTS set up June ’10 • Membership: clinicians, public health, SG, planners, QIS, primary care, patient reps, ethicist

  3. Obesity Treatment Subgroup ( NPF OTS) Remit: • Inform prioritisation of planning provision of treatment for severe and complex obesity in adults Working methods: • Evidence gathering from experts; review of research evidence including cost effectiveness; development of range of options for NPF and board Chief Executives to consider.

  4. Obesity Facts • Scotland has second highest prevalence of obesity in the world at 27% (1.1 million people) • 8.4% population BMI ≥ 35 (347,000) • 2.4% population BMI ≥ 40 (103,000) • Epidemic expected to peak at 40% (2030) • Severe obesity prevalence is increasing at 5% per year • 50% of all obese people have significant health problems - co-morbidities

  5. Obesity Pathway‘route map’ • Tier 1 Population-wide health improvement work • Tier 2 Primary care e.g. Counterweight • Tier 3 Specialist Weight Management • Management of severe and complex patients • Gatekeeper for surgery • Tier 4 Specialised surgical service • Ante and post surgery • Actual operations

  6. Evidence Base: Tier 3 specialist weight management • Weight management is clinically effective compared to no treatment (5kg, 2-4 yrs) • Cost effectiveness evidence is limited, but suggests cost effectiveness • Small weight loss of <5kg can reduce co-morbidities such as diabetes

  7. Evidence base: Tier 4 Bariatric surgery • Bariatric surgery is highly clinically effective and cost effective for achieving wt loss (25-75 kg, 2-4 yrs) • 75% of initial wt loss sustained at 10 years • Cost effectiveness is greatest for BMI>40 or BMI 35-40+comorbidity • £1,400 per QALY at 20yrs for BMI 30-40 and diabetes

  8. Needs Assessment: Tier 3 Weight Management • Variable provision across Scotland • Estimated population need 200-550/100,000 • Essential both for • treating obesity not managed in primary care • and to provide support mechanism to manage demand for surgery

  9. Comparative numbers (rates) of bariatric surgery • Sweden: 4,879 (52.7/100,000) • England: 6,520 (10.6/100,000) • Scotland: 197 (4.6/100,000)

  10. NPF/OTS: Evidence Summary Outcomes: • Strongest evidence for bariatric surgery - £1400 - £4000 per QALY at 20 years (T2DM and BMI 30-40; or BMI>40) • Evidence of clinical effectiveness for Tier 3 but little on cost effectiveness

  11. NPF/OTS: Pre Surgery Principles • Build on existing services • Tier 2 – in all NHS Boards • Tier 3 – consider different models (could be shared provision across boards; use of existing staff would reduce costs) • Referral to Bariatric assessment from T3 • Success weight loss is criteria

  12. NPF/OTS: Bariatric surgery • ‘Ante’ and ‘post’ Bariatric with the surgical service • Clear pre and post assessment and management protocols • Concentrate in centres with at least 2 surgeons with minimum of 20 cases each per year with networking • Audit: equity, access, outcomes • Revisit by April 2013

  13. Tier 4 Bariatric surgery - models • Seminar required – NPF/OTS - to get buy in to evidence and agree models, due to varied opinions of planners, clinicians and particular concerns re-financial impact. The 3 models are : 1. “Framework without criteria” 2. “Framework with topped criteria” 3. “Framework plus Type 2 Diabetes” • 3B = Modified with tighter criteria All models can be flexed to address case by case

  14. Option 1 43,182 “Framework without criteria” No Minimise risk? Yes Option 2 16,740 No Prioritise T2DM? Yes Option 3 625 BMI 35-39 = 375 BMI 40-50 = 250 Obesity Options: criteria and estimated demand - BMI >35 - Age ≥18 - At least one co-morbidity “Framework with topped criteria” - Age 18-44 years - BMI 35-50 BMI - At least one co-morbidity. “Framework plus Type 2 DM” - Recent (< 5 years) onset of Type 2 diabetes mellitus, in addition to Option 2 age/BMI criteria

  15. Table 1 : Estimated impact of models (bariatric surgery only)

  16. Summary Primary care and specialist weight management services • Primary care services in all health board areas • Tier 3: As local as possible but cross Board provision should be explored • Use existing staff and consider role of technology Surgery • pre and post surgery weight management services should be co-located with surgery in centres with at least 40 cases per year and 2 surgeons • Criteria with case by case flexibility

  17. Outcome: NPF/OTS • Planning principles agreed • Preferred option – option 3B i.e. smallest numbers (important to emphasise that this recommendation includes increase in rate to minimum 9/100,000 in all boards) • Regional approach to planning Tiers 3 and 4 services agreed

  18. Next Steps • Communication of NPF agreement to all boards: aim is to keep clinicians, planners, CEs bought in to this national agreement and ensure changes are made • Implementation arrangements to be made by boards • Monitoring and feedback to NPF 2013

  19. Health and equity impact assessment Current Access • Access to surgery very varied between health boards • Men - approx 25% of wt mgmt and surgery • Other groups e.g. ethnic minority, carers, mental health problems - access unknown • Bariatric surgery requirements for attendance may exclude many e.g. carers, remote/rural, those with mental health problems, lower socioeconomic groups

  20. Health and equity impact assessment cont. Recommendations • Communication strategy – to reduce stigma and discrimination around obesity • Equity of access to services required across Scotland including rural/remote • Careful patient selection to reduce adverse outcomes • Family involvement recommended in order to provide appropriate support

  21. Health and equity impact assessment cont. Recommendations cont • Alternative services needed for those unable to comply with behavioural change and follow up required for surgery • Men – single sex groups, internet groups may be beneficial. • Staff training needs assessment required to determine staff training needs • Additional research required on needs of men, ethnic minorities, antenatal women, those with learning disabilities

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