Group Visits and Technology for Weight Loss Maintenance Literature Review

Care for Bariatric Surgery Patients

Comorbidities exist from obesity related health conditions, such a hypertension, type 2 diabetes mellitus, cardiovascular disease, etc. Racial and cultural factors also play a part in lifestyle habits and belief systems. With incidences of bariatric surgery on the rise, there is a need for effective strategies to engage post bariatric surgery patients in follow-up care to support healthy weight loss and maintenance and reduce risk of obesity related health conditions. Several studies have examined how group visits, shared medical appointments, and technology could be used in efforts to engage patients in self-management, skills building, and education.

Shared medical appointments (SMA) after bariatric surgery was studied with a two-fold purpose: 1) to design a patient-validated SMA satisfaction survey and 2) to determine satisfaction as a means of follow-up after surgery (Seager, 2012). This study was chosen as an examination of the SMA as an intervention strategy to engage post bariatric patients in follow-up care and how feedback can help in designing SMAs. The study found that SMAs demonstrated high levels of patient satisfaction.

Patients were invited to a SMA by a letter that detailed the session and reasons for each aspect. The appointments were centered on education concerning eating behavior, dietary modifications, and adjusting medications where appropriate. Time was given to address individual questions. Indications of discomfort in sharing experiences suggests careful selection of patients to SMAs. Other suggestions included clear reasons for the SMA and further research in whether SMAs improve outcomes compared to clinical visits.

Another study on SMAs examined the usefulness of exchanging personal experience as a support system (Kirsh, 2007). This was a quasi-experimental study utilizing diabetic and cardiovascular professionals in a team approach. The purpose was to improve outcome measures for diabetics by focusing on cardiovascular risk. This study was appropriate for review because type 2 diabetes mellitus and cardiovascular disease are both obesity related comorbidities.

The method utilized the chronic care model and measured cardiovascular variables. It was designed on clinical information, decision support, and self-management. This study found that SMAs were useful for sharing knowledge. A team approach with emphasis on self-management benefits patients in receiving care from various professionals in different ways and can offer successful lifestyle management strategies. There was indication that small group numbers are insufficient for resource utilization.

A pilot study designed as a SMA targeting metabolic syndrome prevention in ethnically diverse groups found that group visits provide a forum for health providers to use for delivery of extensive patient education and self-management instruction (Greer, 2011). Where metabolic syndrome is increasingly related to obesity and sedentary lifestyles, this study focuses on individual modification of lifestyle behaviors. The method used was SMAs once per week, for 90-120 minutes, over a ten-week period. It measured BMI and weight control knowledge.

This study is important in addressing cultural variables where culture determines lifestyle and beliefs. Barriers to improved outcomes can include lack of family support, lack of resources, health literacy, and complexities of comorbidities. This is especially important in how patients perceive their conditions, but leaves questions concerning support systems for the long-term.

A longitudinal study to address challenges demonstrated and evaluated potential of outreach interventions to enhance engagement and retention in care of disadvantaged populations found that participants who had nine or more visits within the first three months had significantly reduced the risk of gaps in care (Bradford, 2007). The study used a framework of shared goals and common data reporting expectations and focused on persons who had negative experiences with care. A cultural adaptation methodology required by the Centers for Disease Control and Prevention (CDC) used a mixed method to define and measure equitable access to care.

This study is important to intervention strategies because disadvantaged persons have a harder time in accessing care. Negative experience, stigma, health belief, as well as unmet needs can create barriers.This study provided lessons learned in providing resources to remove barriers, coaching, skills building, and education facilitates utilization of care, additional resources and systematic changes are necessary for equitable access, and designing and implementation to comply with research standards to support rigorous evaluation and analysis.

A study performed to test the effectiveness of a web-based self-management program with coaching on improving self-management behavior found that educational and behavioral support as well as self-management programs were effective and improved behavioral and health related outcomes (van Vugt, 2013). This was a randomized controlled trial with an intervention group with access to a web portal and additional coaching as well as a control group with just access to the web portal. An interactive care platform was used with personal information and education modules on risks related to specific behaviors and physical aspects on a HAPA model.

This study was based on type 2 diabetes and measured body mass index (BMI), cardiac, and lifestyle habits. This shows that a web-based portal with additional coaching could become an effective strategy to engage post bariatric patients in a self-management program. Patients who do not feel comfortable with sharing experiences in SMAs could utilize the web portal for encouragement in self-management without embarrassment. Although, the study was unclear as to what extent patients were motivated to use the technology.

A pilot study on the effects of smartphone technology to reduce alcohol behavior in HIV patients found treatment retention was excellent and showed significantly improved patient engagement and satisfaction with HealthCallS application (Hasin, 2014). The method used was input from patients and professionals to create engaging, user-friendly application that implemented script and video into android technology to create a virtual counselor with patient response. It used measurements of participation with reactions to specific aspects.

This study used self-monitoring and personalized feedback. The advantages included the use of visuals and graphics, video with greetings, questions, reinforcement, and suggestions, and ease of accessibility and connectivity. Smartphone technology applications can be explored to provide support intervention to bariatric surgery patients who have active lifestyles and may not have access to providers at given times for suggestions and reinforcement. The disadvantage indicated was a high drop-out rate at the end of 60 days, although the majority of users at 60 days indicated increased motivation and confidence.

Themes identified are SMAs, technology, and intervention evaluation. Where (Seager, 2012) analyzed patient satisfaction with SMAs, (Greer, 2011) analyzed for education and self-management instruction delivery, and (Kirsh, 2007) analyzed for shared experiences. Although, they all emphasized self-management, education, and skills building as well as including feedback opportunity through discussions. While patient satisfaction was measured by (Seager, 2012) and (Greer, 2011), knowledge attainment by (Greer, 2011), comfort sharing by (Seager, 2012), only cardio variables were measured by (Kirsh, 2007). This is useful for research design in determining appropriate variables to measure.

Although (van Vugt, 2013) and (Hasin, 2014) both used technology, (Hasin, 2014) focused on self-monitoring and personalized feedback where (van Vugt, 2013) focused on education and patient engagement by comparing personal information to general practitioner advice to trigger health improvement thinking. The coaching that (van Vugt, 2013) used shows more promise in motivating patients than the drop-out rate from (Hasin, 2014). Even though (Hasin, 2014) measured motivation where (van Vugt, 2013) measured BMI and cardiovascular variables consistent with the SMA studies. This is useful in determining concepts that are beneficial to bariatric patients.

Where (Bradford, 2007) analyzed barrier reduction, coaching, and systematic changes for intervention evaluation, (Seager, 2012) analyzed for survey design, which would also be a form of intervention evaluation through patient feedback. And, where (Seager, 2012) focused on bariatric surgery patients, (Bradford, 2007) focused more on cultural and socioeconomic variables to evaluate engagement and retention. Both studies are useful to determine how to motivate and retain patients.....