Upload
maximo-seeger
View
216
Download
0
Tags:
Embed Size (px)
Citation preview
Making difficult decisions - Obesity
TreatmentEddie CoyleJane Bray
Sara DaviesDavid Cline
Jennifer ArmstrongHeather Knox
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
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.
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
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
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
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
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
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)
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
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
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
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
Obesity Options: criteria and estimated demand
Option 1
Option 2
Option 3
43,182
Minimiserisk?
16,740
625
PrioritiseT2DM?
No
Yes
Yes
No
BMI 35-39 = 375BMI 40-50 = 250
“Framework without criteria”
“Framework with topped criteria”
“Framework plus Type 2 DM”
- BMI >35
- Age ≥18
- At least one co-morbidity
- Age 18-44 years
- BMI 35-50 BMI
- At least one co-morbidity.
- Recent (< 5 years) onset of Type 2 diabetes mellitus, in addition to Option 2 age/BMI criteria
Table 1 : Estimated impact of models
(bariatric surgery only)
Impacts for Scotland on adult population
Current practice
Procedures in 2009/10
Option 1Framework
without criteria
Option 2Framework with topped
criteria
Option 3Criteria-
T2DM
Option 3BModified
criteria for Option 3 – BMI 35-39
Number of patients
197 43,182 16,740 625 375
Rate /100,000 4.6 1,000 388 14.5 9
Cost range (band & bypass)
£1-2.2 million
£215-492 million
£83-191 million
£3-7 million £1.9-4.2 million
SummaryPrimary 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
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
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
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
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
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