The Integrated Multidisciplinary Approach-Team in Bariatric

Surgery: An Overview

William Gourash, CRNP, MSN

The Integrated Multidisciplinary Approach-Team in Bariatric Surgery: An Overview

Presenter Name: William Gourash, CRNP, MSN

As previously disclosed, these are the companies with which I have a financial or other relationship(s):

Company Name(s) Nature of Relationship(s)

Infosurge Inc. Non-paid member of advisory board

Famous Multidisciplinary Team ….…

Multidisciplinary Approach (MDS) & Teams (MTDs) in Surgical Specialties

Considered “standard of care”

Cancer

Trauma

Transplant

Joint replacement

Reports of MDTs in Surgical Literature

“Multidisciplinary approach to esophageal and gastric cancer”

Quiros RM & Bui CLSurg Clin North Am. 2009

“Multidisciplinary teams achieve the

best results. This paper discusses the

surgical management of rectal

cancer ...”Glynne-Jones R, Mathur P, Elton C, & Train ML

Best Pract Res Clin Gastroenterol, 2007

“… evidence that influences current practices in the multidisciplinary treatment and shapes future directions in the treatment of resectable rectal cancer.” Diandra N Ayala, Suzanne M Russo and A William Blackstock Expert Review of Gastroenterology & Hepatology, 2009

“A multidisciplinary approach to breast cancer care is essential to the successful integration of available therapies.” Hulvat MC, Hansen NM & Jeruss JS Surg Clin North Am, 2009

Effectiveness of a multidisciplinary

team approach to hip fracture

management.

Khasraghi et al., J Surg Orthop Adv. 2005Multidisciplinary rehabilitation programs following joint replacement at the hip and know in chronic arthropathy.“… assess the evidence for effectiveness of multidisciplinary rehabilitation on activity and participation in adults following hip or know joint replacement for chronic arthropathy.” Khan F, Gonzalez S, Hale T, & Turner-Stokes L.Cochrane Database Syst Rev. 2008

Interdisciplinary approach to the rehabilitation of open-heart surgical patients“… Interdisciplinary team reduces fragmentation of care, improves patients outcomes, and enhances patient, family, staff and physician satisfactions.” Carbone LM, Rehabil Nurse, 1999

Multidisciplinary Approach & Team in The Care Of Bariatric Surgical Patient

First advocated in bariatric surgery in the late 1970’s at the “Iowa meetings” by Dr Edward Mason

“Anti-obesity surgery is ‘behavioral surgery’, outcome is independent of the technical performance of the operation.” …

Kral, JG Selection of patients for anti-obesity surgery International Journal of Obesity (2001) 25, S107-112

The NIH in the 1991 Consensus Statement advocated the use of the “multidisciplinary approach” and the "multidisciplinary team” to optimize patient care.

and

“Optimal care o the bariatric surgical

patient requires a multi-disciplinary

team to address the medical

complications, nutritional management,

and psychological and behavioral

implications of obesity.”

Kaplan, LM

Gastroenterol Clin North Am. 2005 Mar;34(1): 105-25

Recommendations for MDTs & MDAs

“Preoperative assessment and selection should be performed by a multidisciplinary team to obtain optimal results”Yurcisin BM, Gaddor MM & DeMaria EJ, 2009Clin Chest Med. 2009 sep;30(3):539-53, ix

This study emphasizes that obesity surgery requires a significant experience of the surgical team and a multidisciplinary approach to improve

behavioral changes.Chevallier et al.Ann Surg. 2007 Dec;246(6):1034-9.

“With this increased popularity, comes a responsibility for health-care professionals to guard against patients' perception of surgical treatment as a panacea. To counter this possibility, three recommendations are presented as components of a treatment paradigm by a multidisciplinary team of health professionals, which incorporate surgical and non-surgical treatment components, increase patient responsibility, promote lifelong health behavior change and effect permanent weight loss.

Bond et al. Obes Surg. 2004 Jun-Jul;14(6):849-56.

The best results are available to the well-informed patients under the care of a dedicated multidisciplinary team that includes professional from a wide range of health-related disciplines (medicine, nursing, health

promotion, psychology, exercise physiology and dietetic sciences.

Saltzman, E, 2005 Obesity Research, 13(5) 2005,234-243

“Follow-up in the bariatric clinic should

be a multidisciplinary effort, and

patients should have easy access to the

nurse practitioner and surgeon as well as

to the dietician and support-group staff.

In addition, as exercise physiologist and

psychotherapist familiar with the

problem experienced by bariatric surgery

patients should be available.”

DiRocco, JD, Halverson, JD, Planer, J., Walser, M.

& Cunningham, PR.,

“Bariatric surgery patients undergo many dramatic lifestyle changes, and comprehensive presurgical screening conducted by a multidisciplinary team is important to prepare patients for the numerous changes necessary for successful outcome.”

Elder, KA and Wolfe, BM, 2007, Gastroenterology, 132:2253-2271

“Bariatric care should be delivered within credentialed multidisciplinary systems.”Clinical application of laparoscopic bariatric surgery: an evidence-based review.

Farrell, TM et al., 2009, Surgical Endoscopy, 23:930-949

“Candidates for bariatric procedures

should be selected carefully after

evaluation by an interdisciplinary

team with access to medical, surgical,

psychiatric, and nutritional expertise.”

Kuruba, R, Koche, LS & Murr MM, The Medical

Clinics of North America, 2007, 91: 339-351.

Rosenthal & Jones 2008

Is there Evidence? for Efficacy & Positive Outcomes?

Betsy Lehman Center for Patient Safety and Medical Error Reduction:

Expert Panel on Weight Loss Surgery (12-12-2007)

Evidence for MDTs in Bariatric SurgeryCATEGORY A Evidence obtained from at least one well-conducted randomized clinical

trial of a systematic review of all relevant RCTs

CATEGORY B Evidence from well-conducted prospective cohort studies, registry or meta-analysis of cohort studies, or population-based case-control studies

CATEGORY C Evidence obtained from uncontrolled or poorly controlled clinical trials, or retrospective case-control analyses, cross-sectional studies, case series or case reports

CATEGORY D Evidence consisting of opinion from expert panels or the clinical experience of acknowledged authorities

 Adapted from criteria used by the U.S. Preventive Services Task Force (USPSTF) and the American Diabetes Association

Definitions: Multidisciplinary Approach (MDA)

& Multidisciplinary Team (MDT)

“Involves drawing appropriately from multiple disciplines to redefine problems outside of normal boundaries and reach solutions based on a new understanding of complex situations.” Wikipedia 2009

“A group of health care workers of different disciplines, each providing different services to the patient”

Mosby's Medical Dictionary 8th edition. © 2009, Elsevier

“… is composed of members from different healthcare professions with specialized skills and expertise. The members coordinate and communicate with each other to provide quality patient care.

Journal of HealthCare Quality 2004

“The use of multidisciplinary teams to evaluate bariatric surgery patients: Results from a national survey

in the U.S.A.”

Santry, H.P., Chin, M.H., Cagney, K.A., Alverdy, J.C., & Lauderdale, D.S. Obesity Surgery, 16 (2006), 59-66.

• NIH Consensus Statement recommended candidates “should be selected carefully after evaluation by a multidisciplinary team with access to medical, surgical, psychiatric, and nutritional expertise.”

• Others recommended – Teams that included different groupings of the following:

surgeon, PCP/internist/OMP, behavioral health professionals, dietician, exercise specialist, nurses, & NP/PA

• Variety of team compositions and execution models & practices

“The use of multidisciplinary teams to evaluate bariatric surgery patients: Results from a national survey

in the U.S.A.”

Santry, H.P., Chin, M.H., Cagney, K.A., Alverdy, J.C., & Lauderdale, D.S. Obesity Surgery, 16 (2006), 59-66.

• Hypothesis: “great variability in types of MDTs used by bariatric surgeons”

• National survey of practicing bariatric surgeons

• September-December 2004

• 813/1312 responses (62%)

Results:

• 95% reported using a MDT

• Only 53% had general physician, nutritionist and mental health specialist on their team (?NIH recommended team)

• Only 47 % mandated primary care, nutrition and mental health evaluations preoperatively

• Practice type, size, location and membership in ASMBS did not influence these reported parameters

• Practicing Bariatric Surgery for > 8 years reduced the odds of reported MT use and requirement for evaluations

Conclusions:

“Inconsistent and unpredictable patterns of multidisciplinary approaches/methods were found”

“Variety of team composition and

execution models practiced…”

Explore Multidisciplinary Team & Member Characteristics in Bariatric Surgery

• Disciplines Represented• Team Location• Member Characteristics

– Core & Non-Core– Dedicated and Non-Dedicated

• Team Function• Team Decision Making• Utilization throughout the Bariatric Surgical Process

– Preoperative, Perioperative and Post Operative

• Team Member Roles– “Overlap” or Specialist/Generalist

Disciplines Represented

Patient

Surgeon

Behavioral Health Professional

Dietician

NP/PA

Exercise Professional

Medical Specialist

Internist PCP OMP

Nurse

Patient

Psychologist

PCP/IM/O

MP

Member Location: Intramural or Extramural

Member Characteristics

Core and Non-core

Patient

=Integral member of team sees selected patients

=Integral member of team who sees every patient

Member Characteristics

Dedicated and Non-dedicated

Patient

Member(s) of a discipline share responsibilities to other teams

Team Function (continuum)

independent consulted members with no structured interaction

collaborative members with scheduled patient centered interaction

Leader

Team Decision Making (continuum)

individual decision

Leader/

Primary

Clinician

Specialist

Specialist

SpecialistSpecialist

Specialist

Team Decision Making (continuum)

Surgeon

Dietician

BEH Health Professional Nurse

PCP/IM/OMP

group consensus

MDTs throughout the Bariatric Surgical Process: Preoperative:

Goals:• Candidate selection• Preparation for surgery:

– Further risk assessment & Promote medical stability– Foster psychological coping & function– Foster nutritional knowledge & appropriate eating

behaviors– Address knowledge gaps

• Preparation for after surgery:– Knowledge of complications– Anticipatory guidance

• Nutritional• Behavioral• psychological

MDTs throughout the Bariatric Surgical Process: Preoperative: 

Patient

Surgeon

Dietician

Behavioral Health Professional

Nurse

PCP

IM

OMP

Medical

Subspecialists

Exercise Professional

PA/NP

Anesthesiologist

MDTs throughout the Bariatric Surgical Process: Perioperative:

Goals:• Complete safely and precisely a complex surgical

procedure on a potentially medically complex individual in an at times anatomically “hostile” environment.

• Anticipate and prevent potential medical and surgical complications

MDTs throughout the Bariatric Surgical Process:Peri-operative:

Patient

Surgeon

RN

OR/PACU

Staff RN

Medical

SubspecialistsSurgeons

Assistants

Anesthesia

PCP

IM

OMP

MDTs throughout the Bariatric Surgical Process: Postoperative

• Team more variable and roles less well defined

• Lack of consensus in essential elements at different time points

• multiple visits over an open-ended time frame

• ? multiple team members to see patient within each visit

• Challenges: for scheduling, communication & coordination between disciplines, cost, patient convenience, patient adherence

MDTs throughout the Bariatric Surgical Process:POST-OPERATIVE

Patient

Surgeon

Dietician

Behavioral Health

Nurse

PCP

IM

OMP

Medical

Subspecialists

Exercise Professional

PA/NP

“Role Overlap”

Summary: MA and MDT’s in the Care of Bariatric Surgical Patient

• Use is rational & moving toward being a “standard of care”• No empiric evidence supporting the establishment & use

– (Category D evidence - Expert and Consensus Opinion)

• Today - use is variable and ill-defined (but less than had been)

• NIH (1991) recommended utilization of MDA and MDT– “Should have access to medical, surgical, psychiatric and nutritional expertise”

• Definition requires delineation of team and member roles, characteristics & processes throughout the bariatric surgical process– Disciplines represented /Team membership – Team Location– Member characteristics (dedicate/non-dedicated, core, non-core)– Team function (independent – collaborative)– Team Decision Making (Central – consensus)– Team member roles

Summary: MA and MDT’s in the Care of Bariatric Surgical Patient

• Utilization of MDT throughout the Bariatric Surgical Process differs– Currently most effectively utilized in preoperative &

perioperative

• Post Operative application somewhat more challenging – Multiple visits over a long period of time utilizing

multiple disciplines present unique problems– Challenges: communication, cost, scheduling and

patient convenience– Often disciplines utilize “role overlap” and single

professionals perform aspects of multiple roles with selected consultation

Conclusion:– We need to better define and document the

characteristics and implementation of the MDA & MTs in Bariatric Surgery.

» In our practices, in research, …

– Further evidence is needed to substantiate the efficacy (outcomes and cost/benefit) so we can arrive at some consensus as to “optimal team(s)”

» Best practices, Evidence-Based Practice recommendations, Standards of Care, …

– In the long-term what we are reaching toward is an “integrated’ multidisciplinary team …. where separate disciplines are combined and coordinated in such a way as to provide care for our patients as “one harmonious, interrelated whole”.

Today … Steps … to these Goals

First exploring Consensus and Controversy within the function and roles performed by the individual disciplines– Preoperative evaluation– Postoperative follow- up care

Second, exploring how the MDC is perceived, characterized and practiced in different parts of the world

Invite you to be active and add your perception and practice of MDC to the mix in the panel discussion.

Thank you!

William Gourash, CRNP, MSN