WA MORBID OBESITY MODEL OF CARE

1. WA MORBID OBESITY MODEL OF CARE THE BIGGER PICTURE Presented by: Professor Jeff Hamdorf Ms Karina Moore Health Networks Branch

2. Outline What is the bigger picture? • Let’s look at morbid obesity • Synergistic therapeutic approaches • Impact on Chronic Disease Using the bigger picture model to manage better. • WA health networks and network processes • Model of care development • WA morbid obesity model of care highlights

3. Global Prevalence of Obesity

4. Projected Prevalence of Obesity by 2025

5. Estimating historical changes in physical activity levels Australian settlers 150 years ago were 2.3 times more active than today’s office workers, with energy expenditures equivalent to walking 8 - 16 Km more each day Egger GJ et al. Med J Aust 2001

6. DIET versus EXERCISE (Great Britain)

7. What’s so morbid about Obesity? Ischaemic stroke Depression Coronary heart disease Respiratory disease Congestive heart failure Gallbladder disease Type 2 diabetes Dyslipidaemia Cancer (breast, endometrial, colon, prostate) Hormonal abnormalities and pregnancy complications Osteoarthritis Hyperuricemia and gout

8. 2.5 2.0 MortalityRatio + drugs ± CBT 1.5 Diet/Lifestyle 1.0 VeryLow VeryHigh Moderate Low Moderate High 0 20 25 30 35 40 BMI Obesity and Mortality Risk + Surgery Gray DS. Med Clin North Am. 1989;73(1):1–13.

9. Treatment Team • Surgeon • Physician • Dietitian • Psychiatrist/psychologist • Exercise physiologist • Outpatient Nurse

10. Physician • Endocrinologist or primary care physician • Supervise investigations • Optimise reversible co-morbidities • Role in follow up

11. Role of the Dietitian • Initial assessment • Portion sizes, choices, “smart shopping” • Supervise lifestyle modification • Post op follow up

12. Psychologist Problem-solving skills Coping strategies Goal setting Monitoring Skills Social skills

13. Surgeon • Team leader • Co-ordinate preparation • Select surgery to suit patient • Supervise stringent follow up

14. NIH Consensus Conference 1991 • Surgery is the only approach that provides consistent, permanent weight loss for morbidly obese patients • Surgery indicated in patients with: • BMI of 40 or over • BMI of 35-40 with significant co-morbidity • documented dietary attempts ineffective

15. 40 - 60 mL pouch Restriction + satiety Adjustable Gastric Band • Minimal access (100%) • Low morbidity • Negligible mortality • Adjustable • Readily reversible

17. LAGB vs RYGB EWL O’Brien, Dixon Brown ANZJS 2004

18. Collated Outcomes LAGB • 7 - 10 x safer than bypass surgery • Perioperative complication rate 1- 2 % • Mortality negligible (0.3%) • Late morbidity (2 -3%) • Issues Late prolapse/slippage Erosion Port sepsis

19. Co-Morbidity Control • Type 2 diabetes • Remission at 1 yr in 64%, improved 26% • Hypertension • 60% normotensive off meds, 33% improved • Better control of asthma, GORD, lipids, OSA • Significant improvement in QOL measures

20. A Healthy Future for West Australians • 2004 - Health Reform Committee examined WA service delivery • A Healthy Future for Western Australians (2004) • 86 recommendations to guide health reform • Recommendation 23 • Health Networks to support integrated models of care

21. What are Health Networks? • A group of interested people and organisations including health professionals, patients, non-government organisations, carers, consumers and others, coming together to talk, think, plan and develop health policy and services across the State

22. Why Health Networks? An excellent means of forging new relationships with a much wider range of people and organisations to: • Plan better policy • Ensure better coordination and integration of services • Increase participation, partnerships, communication and accountability across WA Health • Clinician-led and clinician engaged

23. What Can Health Networks Offer? • Increased focus upon patient/patient journey • Engagement of stakeholders • Facilitation of communication • Breaking down of silos • Coordinated pressure on bureaucracy • Commitment to a vision

24. Who Is Involved? Director General State Health Executive Forum Executive Director Health Policy and Clinical Reform Health Network Lead SHEF sub-committee Health Network Leads Forum Health Network Exec Advisory Group Non-government organisation, private sector, research group, academic, indigenous health, community/consumer/carer, commonwealth sector & state sector representatives Health Networks Branch Working & reference groups

25. What Networks Do? PERFORMANCE Performance indicators across the system are driven by the Health Networks POLICY Health Networks lead and facilitate the development of evidence based policy PLANNING Strategic and operational planning for health and health service delivery is informed by Health Network advice Working together to create a healthy WA PROTOCOL Health Networks provide opportunities to develop systems and work practices that improve clinical expertise and encourage best use of both physical and intellectual resources PEOPLE Health Networks provide stakeholders with opportunities for leadership. Opportunities to improve clinical workforce support, teaching and training are identified and advised upon PRIORITIES Health Networks align with the DOH (WA) Strategic Intent, focusing on the promotion of health and wellbeing

26. 16 Networks so far… • Infections and Immunology • Injury and Trauma • Mental Health • Musculoskeletal Health • Renal Diseases • Respiratory Medicine • Neurosciences & the Senses • Women’s & Newborns • Acute Care • Aged Care • Cancer & Palliative Care • Cardiovascular Health • Child & Youth Services • Digestive Health • Endocrine • Falls Prevention

27. Network Processes • Tools for collaboration and engagement • Workshops & forums • Model of Care Development • Policies and Guidelines • Endorsement – best evidence, clinical expert and government and consumer/carer

28. Vision The right care for the right person at the right time in the right place with the right team. Model of Care defines: Health care services required to satisfy all consumer needs in the appropriate setting. Principles, guidelines and criteria for health care services. Integration of health care services in a seamless manner along the entire care continuum (evidence based pathways). Focus Enablers Health Networks (GPs, Consumers, etc) Prevention & Promotion Initiatives (eg ABHI) Early Detection & Intervention Frameworks (eg National Service Improvement) Integration & Continuity of Care Strategies (eg Ambulatory Care) Self Management Care Continuum Severe Fragility & Environmental Condition Advanced Conditions Advanced Conditions Healthy Healthy High Risk High Risk Early Symptoms Early Symptoms

29. Think tank to Workshop • Think Tank on Obesity- February 2007 • Aim: To establish a shared vision for a coordinated approach on obesity • Morbid Obesity Workshop - November 2007 • Aim: to foster interest in the development of a shared vision for morbid obesity management in WA.

30. Expert Reference Groups – Feb 08 • Comprehensive primary care strategies for the management of morbid obesity • The role of General Practice in the care of the morbidly obese • Surgical interventions for treatment of morbid obesity • Health care services, equipment and facility issues/initiatives

31. Model of Care Recommendations • Develop and support a multidisciplinary team approach • Integrated Health promotion and prevention strategies • Promote morbid obesity as a chronic disease • Surgery should be appropriately credentialled • Implement surgical guidelines • Develop a statewide database with national capability • Promote management in a dignified manner • Develop transport guidelines

32. From policy to patient Policy Development Model of Care Health Networks Health Care Services Required Guidelines and Criteria Integrated Pathways Translation to Refinement of Clinical Service Framework Planning – Strategic Development of Proof of Concept physical context Service Model AHS in consultation with Health Networks Workforce Infrastructure Information & Communications Technology Equipment and Resources WA Health Translation to local setting Planning – Operational Deployment Local Implementation Model AHS Eg Multipurpose Health Care Facilities Telehealth Community Health Care Practitioners Metropolitan Rural Community

33. Morbid Obesity – the bigger picture Thank you Contact Prof Jeff Hamdorf or Ms Karina Moore via: Department of Health (WA) Health Network Branch PO Box 8172 Perth WA 6849 (08) 94892800 Email: healthpolicy@health.wa.gov.au Link to the web version of the Morbid Obesity Model of Care: www.healthnetworks.health.wa.gov.au - ‘Models of Care’

34. Gastric banding technique