Implementing an Educational Program for Primary Care Providers on Obesity Management and Bariatric Surgery

Abstract

Clear clinical practice guidelines (CPGs) for primary care providers (PCPs) are available that address the identification, evaluation, and treatment of obesity. The number of bariatric surgeries being performed is still low when compared to the number of obese Americans. This is despite guidelines, data on the efficacy and safety, and technical advances in bariatric surgery. The purpose of this project was to develop a reproducible educational program for PCPs based on CPGs for the identification, evaluation, and treatment of obesity in adults.

Sixty PCPs from an existing database were electronically sent an Internet survey. The PCPs were asked to identify a list of items of importance to be included in the program. Sixteen of 60 PCPs responded to the survey. The educational program was developed based on their recommendations and pilot tested in a hospital-owned primary care practice association. Sessions were scheduled with office practice managers in 10 offices. Twenty-one of 26 providers attended the program. Eighteen of the 21 providers returned the postprogram survey. Over 70% of the providers reported that the program would improve how they cared for their obese patients, increased their likelihood of adhering to the CPGs for diagnosis, evaluation, and treatment of obesity, increased their likelihood of referring their obese patients to a bariatric surgeon, and improved their opinion of bariatric surgery. Use of current CPGs, simple tools, and face-to-face meetings with PCPs may improve the care of obese patients and could be replicated at other practice locations.

Introduction

Many professional organizations and governmental agencies have position statements or guidelines regarding the assessment, diagnosis, and management of obesity. The U.S. Preventative Services Task Force (USPSTF) recommends that all adults be screened for obesity using body mass index (BMI) as the measurement. In addition, they recommend that clinicians offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults.¹ Counseling about diet, exercise, or both, in conjunction with behavioral interventions aimed at skill development, motivation, and support strategies, is recommended.¹ The American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Diabetes Association, and the American College of Preventive Medicine all have recommendations for measurement of height and weight or BMI.

In 1995, the National Heart, Lung, and Blood Institute's (NHLBI) Obesity Education Initiative in cooperation with the National Institute of Diabetes and Digestive and Kidney Disease (NIDDK) convened an expert panel to develop evidence-based guidelines for primary care management of obesity. Subsequently, in 1998, the NHLBI published clinical guidelines on the identification, evaluation, and treatment of overweight and obese adults.² The panel's recommendations were based on evidence that links obesity to increased mortality, and evidence that weight loss reduces the risk of developing obesity-related disease. The guidelines include an assessment and treatment guide and are currently being updated with a proposed publication date of fall 2011. In 2000, The Practical Guide to Interventions, Evaluation and Treatment of Overweight and Obesity in Adults was published to give practitioners a practical guide and tools to assist their patients.³

According to the NHLBI guidelines, assessment of the patient should include BMI, waist circumference, and analysis of risk factors. Adults with a BMI > 25 kg/m² are considered overweight and those with a BMI > 30 kg/m² are considered obese. Table 1 further shows the diagnostic classifications for weight based on BMI.² A waist circumference >40 inches in males and 35 inches in females is an independent risk factor for obesity-related complications in patients with a BMI of 25–34.9 kg/m². In addition, risk factors for potential obesity-related mortality and morbidity should be determined.

Table 1.

Classification of Obesity

1998 NIH Classification	BMI (kg/m ² )
Underweight	<18.5
Normal weight	18.5–24.9
Overweight	25.0–29.9
Obesity (Class 1)	30.0–34.9
Obesity (Class 2)	35.0–39.9
Extreme Obesity (Class 3)	>40.0

The treatment algorithm begins with diet therapy, behavioral therapy, and physical activity and includes consideration of pharmacotherapy and bariatric surgery.³ According to the practical guide, “if attempts to lose weight have failed, and the BMI is ≥40 kg/m², or 35 to 39.9 kg/m² with comorbidities or significant reduction in quality of life, surgical therapy should be considered”³ (p. 20).

Dietary, behavioral, and exercise interventions have limited data that validates long-term efficacy; high recidivism rates make frequent follow-up crucial in these patients.^2,4,5 There is an abundance of documentation about the lack of knowledge and the failure of primary care providers (PCPs) to identify and treat obesity.^6,7 Physicians identified obesity in 38% of their obese patients and only 36% of those patients were counseled on weight loss, according to data from the National Ambulatory Medical Care Survey.⁶ Galuska et al. found that 42% of obese adults recall receiving advice about diet from a healthcare provider.⁷ In the same study, patients who were told to lose weight were three times more likely to attempt to lose weight than those not told to lose weight. In a 2003 study about knowledge and attitudes of internal medicine residents on obesity, 60% did not know the BMI value that is diagnostic for obesity and 69% did not recognize that waist circumference is a measurement tool for obesity.⁸ Less than one-third of the residents in the study reported success in treating obesity, and nearly half incorrectly reported their own BMI. Crow et al. reported that of the three main components of the NHLBI guidelines, physicians offered weight-loss diets 31.2% of the time, behavioral modification 1.2% of the time, and exercise prescriptions 36.5% of the time.⁹ Almost 35% of physicians never offered weight-loss medications, and more than 40% never offered referral for gastric bypass. Andersen and Wadden found that providers are still remiss in recommending weight loss to their morbidly obese patients, but those who did recommend weight-loss surgery were more likely to have previously recommended other weight-loss interventions.¹⁰

Despite a six-fold increase in the use of bariatric surgery in the United States between 1990 and 2000, the percentage of extremely obese patients having surgery is still low.¹¹ It is estimated that 180,000 patients had bariatric surgery in 2006.¹² Accounting for only patients with a BMI of ≥40 kg/m², 180,000 means that fewer than 1.5% of the patients that qualified for bariatric surgery actually had surgery.²

Literature Review

A comprehensive review of the literature related to attitudes of patients and providers toward bariatric surgery and bariatric surgery safety, efficacy, insurance coverage, cost, and inequality was completed. Details of that review were published in 2009 and are summarized below.¹³ In addition, literature on educating providers on clinical practice guidelines (CPGs) was completed. The reviews are synthesized below.

Summary of patient and provider attitudes, safety, efficacy, insurance coverage, cost, and inequality in bariatric surgery

A synopsis of the literature on patient attitudes toward bariatric surgery reflects the paucity of research. Because of its qualitative, ethnographic design, Lynch et al.'s study of patient attitudes has limited generalizability.¹⁴ The findings showed that the participants felt that they had a lack of time and resources for weight loss, described a feeling of a lack of control regarding food, and identified with a large body image. They had fears and concerns about bariatric surgery and felt that it was too extreme. These data may prompt further research on the attitudes and barriers to bariatric surgery in other populations and prompt research on interventions for obesity.

Analysis and synthesis of the literature on provider attitudes about bariatric surgery is also limited due to the limited number of studies and the variability in the surveys (Table 2).^15–21 Four of the seven studies specifically looked at physician attitudes regarding bariatric surgery. The remaining three addressed attitudes toward obesity management and included a small subset of bariatric surgery. Seldom did researchers ask the same questions in the survey tools used. The literature shows mixed attitudes toward bariatric surgery. Table 3 describes some similarities among the surveys. Between 71% and 85% of providers have referred patients for bariatric surgery, but 45.5–53% of the referrals were patient initiated. Between 63% and 77% of providers/medical students would consider bariatric surgery themselves, and between 63% and 89% of providers/medical students would refer a family member for surgery. The numbers of providers who referred patients meeting the criteria for surgery were much broader. Inconsistency was found among the respondents of the surveys, and one study posed that this may be due to underlying ambivalence.¹⁵ In addition, there was a good deal of misinformation about bariatric surgery and a low percentage of providers had read or received education on bariatric surgery. The overall attitude of patients and providers toward bariatric surgery is inconsistent with research showing its efficacy and safety. Against the backdrop of the major obesity problem in the United States, many questions remain about provider attitudes toward bariatric surgery due to the limited data published. This supports the need to explore this area further and provide essential educational programs.

Table 2.

Comparison of Articles Surveying Provider Attitudes Regarding Bariatric Surgery

Authors	Date	Survey type/sampling methods	Sample size	Response rate	Respondents	Reliability or validity of the questionnaire	Sample size calculated/power
Avidor, Y., Still, C.D., Brunner, M., Buchwald, J.N., & Buchwald, H.	2007	Questionnaire, handed-in; all physicians in six specialty areas at their national meetings	NS	NS	478 (questionnaire 1) 484 (questionnaire 2)	Validated by independent testing agency	NS
Balduf, L., & Farrell, T.	2007	Cross-sectional questionnaire, mailed; random sample of family practitioners and internists from the North Caroline Health Professions Data System	611	47%	288	Content validity assessed by several experienced general surgeons	NS
Foster, G. Wadden, T., Makris, A., Davidson, D., Sanderson, R., Allison, D., & Kessler, A.	2003	Questionnaire, mailed;random sample of family physicians in two geographical areas from AMA	5000	13%	600	NS	NS
Perlman, S.E., Reinhold, R.B., Nadzam, G.S.	2007	Questionnaire, mailed; all family physicians in Connecticut	620	21%	129	NS	NS
Sansone, R.A., McDonald, S., Wiederman, M.W., & Ferreira, K.	2007	Cross-sectional questionnaire, mailed; all members of internal medicine, family medicine and obstetrics/gynecology medical staff of a mid-sized, mid-west, suburban, community hospital	246	40%	99	NS	NS
Schuster, R., Morton, J.M., Liu, G.Y., Alami, R.S., & Curet, M.J.	2006	Questionnaire, handed in; all medical students interviewing for surgical residency	61	93%	57	NS	NS
Thuan, J.-F., & Avignon, A.	2005	Cross-sectional questionnaire, mailed; all general practitioners in one French region	744	82%	607	NS	NS

NS (not specified).

Table 3.

Findings of Articles Surveying Provider Attitudes Toward Bariatric Surgery ^15–21

Author	Year	Would refer patients meeting criteria to a bariatric surgeon		Ever referred patients to a bariatric surgeon	If needed, would consider having bariatric surgery	Would refer a friend or family member for bariatric surgery
Avidor, Y. et al.	2007		71%	Patient driven: 45.5%Provider driven: 54.5%
Balduf, L. & Farrell, T.	2008		76%	Patient driven: 53%Provider driven: 47%
Foster, G. et al.	2003	23%
Perlman, S. et al.	2007		85%		63%	63%
Sansone, R. et al.	2007	84%
Schuster, R. et al.	2006				77%	89%
Thuan, J.-F. & Avignon, A.	2005

Multiple meta-analyses and systematic reviews have shown the safety and efficacy of bariatric surgery.^22–24 The death rate from bariatric surgery is declining, despite the increasing acuity and age of patients having bariatric surgery.^25,26 Bariatric surgery has been shown to decrease the relative risk of death when compared to control groups matched on age, sex, and BMI.^27–29

Bariatric surgery is a cost-effective weight-loss treatment with downstream savings as early as 2 years after the procedure.^30–34 Societal stigma and prejudice related to obesity are still present in healthcare, particularly in the arena of health insurance coverage, but coverage is increasing.^35–38 Obesity rates and weight misperception is more common among non-Hispanic blacks and Mexican Americans.³⁹ Flum et al. found that there is also a great deal of racial and financial disparity in bariatric surgery.³⁸ They found that while African-Americans, Hispanics, and the poor are more likely to be obese, they are less likely to have bariatric surgery. Ninety percent of patients who had bariatric surgery were white.⁴⁰ In addition to racial inequities, they found that the significant gender and age disparities offer an ethical and public health dilemma as well. A disproportionate amount of surgery was performed on the young, while older people account for a large percentage of the obese population.⁴¹ Eighty-four percent of bariatric surgeries were performed on women.^38–42 Following CPGs may help reduce these disparities.

Educating providers on clinical practice guidelines

There is increasing research on the implementation and adoption of CPGs for the management of obesity, yet studies still show that patients are not receiving the recommended care.⁴³ Reasons for providers' failure to follow CPGs are numerous. Research cites many reasons, including varying and conflicting CPGs and a lack of time for implementation.^44,45 Several methods have been tested to increase provider adherence to CPGs, but there has been varied success. These methods include interventions such as formulary restriction, computerized alerts, and academic detailing where peer clinicians use face-to-face social marketing and motivational interviewing techniques to change behavior.⁴⁶

As part of the Cochrane Collaboration, Bero et al. completed an overview of systematic reviews on interventions used to implement research findings.⁴⁷ Their conclusion divided interventions into three categories: consistently effective interventions, interventions of variable effectiveness, and interventions that have little or no effect. Research findings conducted over the past 10 years indicate that educational outreach visits (academic detailing), reminders (manual or computerized), and multifaceted interventions were found to be consistently effective. Peer audits with feedback, summaries of clinical performance, use of local opinion leaders, and local consensus processes have variable effectiveness. Interventions that were found to have little or no effect were distributed education materials and lectures. An overview published in 2001 also reported that educational outreach visits, reminders, and multifaceted interventions were most effective.⁴⁸

Another Cochrane Database Systematic Review was completed examining the effect of printed education materials (PEMs) on professional practice and health outcomes. The review found that when compared with no intervention, PEMs did have an effect on provider practice, but not on patient outcomes.⁴⁹

Academic detailing has also been well researched and basic principles have been described. Soumerai et al. list key steps such as (1) an assessment of the barriers to the change, (2) a tailored intervention, (3) identification of providers with low adherence, and (4) delivery of the intervention to those providers by a respected colleague.⁵⁰ Recent research supports the delivery of information by colleagues. In a study of 39 physicians, Hay et al. found that when making clinical decisions, the physicians preferred their own experience and the experience of their colleagues over evidence-based medicine literature.⁵¹

Avidor et al.'s study focused on referral patterns for bariatric surgery and asked 478 physicians what would need to happen in order to increase their referral rates.¹⁸ The physicians, who had an average of 11 years of postresidency practice, responded that educating patients, physicians, and nurses would be the most effective way to increase referrals to bariatric surgeons. Fifty-nine percent of the participants specifically wanted information about the postoperative care of bariatric patients. In addition, they ranked printed materials and CD-ROMs as the most desirable way to receive the education, continuing medical education (CME) as moderately desirable, and Web-based training as the least desirable. Balduf and Farrell found that physicians who had attended a CME program on bariatric surgery and had knowledge of the NHLBI treatment guidelines reported a statistically significant increase in referrals.¹⁹

While the Avidor et al. study described what providers believed would be most effective, there is actually limited research on which interventions are most effective in increasing adherence to obesity treatment guidelines. A Cochrane Database Systematic Review titled Improving health professionals' management and the organization of care for overweight and obese people found that there was insufficient research on to how to improve obesity management. They did find that reminder systems, brief training interventions, shared care, inpatient care, and dietitian-led treatments warranted additional research as possible interventions.⁵²

Synthesis of literature across all topics

Conventional weight-loss strategies have been ineffective for a majority of overweight or obese Americans. There is limited research on providers' attitudes and referrals to bariatric surgeons. The research that has been done has been completed on physicians. Physicians have been remiss in following CPGs on the evaluation, identification, and treatment of obesity. Specifically, their knowledge of and attitude toward bariatric surgery is suboptimal. Bariatric surgery is effective and safe as a treatment for morbid obesity. Yet despite record-high levels of obesity, bariatric surgery use is still low compared to the population who qualifies for this treatment. Of the patients who are seen by a bariatric surgeon for consultation, most are self-referred. There are numerous healthcare disparities among the population of patients seen by bariatric surgeons. Healthcare providers desire additional information on bariatric surgery and research shows that this will likely increase their referral of morbidly obese patients to bariatric surgeons. A multi-modal approach to provider education has been show to be the most effective.

Purpose

Research indicates that providers who are less familiar with obesity treatment guidelines are less likely to refer to bariatric surgeons.¹⁸ The purpose of this project was to develop and pilot test a reproducible educational program for PCPs to familiarize them with current CPGs for the identification, evaluation, and treatment of obesity, thereby increasing adherence to the obesity CPGs and referrals to the bariatric surgery center.

One local-hospital affiliated, bariatric surgery center was identified for this project. This center collects data about referrals from providers and departments throughout the healthcare system. Providers, for the purposes of this project, are considered physicians, nurse practitioners, and physicians' assistants. Monthly tracking reports indicate that referrals to this bariatric surgery center from the providers in a hospital-owned primary care practice association are low. Monthly referrals from hospital-employed providers range from zero to one, yet 30–60 patients attend information sessions about bariatric surgery each month. Furthermore, bariatric surgery center staff indicate that approximately 20% of the patients attending monthly information sessions are referred by a nonhospital-employed physician.

Methodology and Results

To meet the best practice recommendations for education in this population, a variety of resources were used over the course of 1 year to develop the program. A detailed review of the literature, mentorship from subject-matter experts, mentorship from organizational stakeholders, CPGs, and teaching and evaluation principles were used to guide the program development. The program consisted of verbal education, clinical reminder tools, and printed materials and was designed to be reproducible.

A list of potential items for the educational program was compiled into a survey. A convenience sample was recruited by e-mail from an existing database of PCPs with the goal of receiving responses from 10 PCPs. The minimum number of participants of 10 was selected to exceed the minimum recommended number of participants suggested to evaluate the survey for content validity evaluation.⁵³ The Internet survey was electronically sent to a total of 60 PCPs (18 physicians, 38 nurse practitioners, and 4 physicians' assistants). Five physicians, eight nurse practitioners, and three physicians' assistants responded. The providers were given 10 days to respond to the Internet survey and were asked to select which of the items would improve their ability to diagnose, evaluate, and treat obese patients. No identifiers were collected. The inclusion criterion for the program included items that the majority of the panel agreed upon, which is considered sufficient for establishing content validity.⁵⁴

Table 4 describes the responses from the PCP panel. Of the 11 items sent to the panel of PCPs, six items met the inclusion criteria of >50%. The items included in the program were:

Table 4.

Survey of Primary Care Providers of Which Items to Include in the Education Program

Item	% agreement (n = 16)
A copy of the obesity clinical practice guidelines	68.8
Laminated BMI charts	50
Handouts for you to give to your patients with their BMI on it	56.3
Handouts for you to give to your office staff on the importance of documenting BMI	18.8
Posters for your waiting room instructing patients to ask you about their BMI	18.8
Posters for your exam room instructing patients to discuss their BMI with you	18.8
Obesity presentation	43.8
Handouts for you to give your patients listing treatment options for obesity	81.3
Bariatric surgery referral process information	56.3
Bariatric surgery insurance reimbursement information	56.3
List of local bariatric surgeons	56.3

a copy of the NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults;

handouts to give to patients with their BMI on it;

handouts to give to patients listing treatment options for obesity;

bariatric surgery referral process information;

bariatric surgery insurance reimbursement information: and

a list of local bariatric surgeons.

Some of the items were already available and were, therefore, ordered through the National Institutes of Health. Other items were designed by the investigator, including handouts to give to patients with their BMI, information on the bariatric surgery referral process, bariatric surgery reimbursement information, and a list of local bariatric surgeons. Materials were developed at or below an eighth-grade reading level and were formatted in a minimum of 14-point font to accommodate those with decreased visual acuity.⁵⁵

Participants were recruited to attend the educational program. The investigator attended two practice manager meetings. Presentations about the upcoming project were presented at both meetings. During the first meeting, contact information was obtained from practice managers in the 15 hospital-owned primary care practices. There were 90 providers in total, 52 of which belonged to one practice of internal medicine attending physicians and residents. During the second meeting, contact information was verified. Practice managers were contacted to schedule the program in their office. Practice managers who scheduled sessions were asked to send an e-mail to all providers in their practices alerting them of the scheduled program. An advertisement listing the date and time of the scheduled program was also posted in the lunch room or lounge of each practice.

After repeated contacts, the program was pilot tested in 10 practices. Of the 26 providers in these practices, 21 providers attended the program. The educational programs were less than 30 min in length and were delivered individually to each provider in order to accommodate his/her patient schedule. Providers were given a paper copy and an electronic copy via compact disc of each item included in the program. In addition, paper and electronic copies were given to the practice managers. Each item and how to use it was reviewed with the providers. Providers were given an opportunity to ask questions. The providers who participated in the program were asked to complete a paper-and-pencil survey evaluating the program. The survey was adapted from previously validated program evaluation tools. Eighteen of 21 providers returned surveys.

Table 5 describes the responses from the program participants. For each survey question, more than 70% of the respondents answered affirmatively, indicating they believe the program would have a positive effect on their practice with obese patients. Of most significance was a positive response from 94.4% of respondents indicating that they believed the program would improve how they cared for their obese patients and that, because of the program, they were more likely to adhere to the CPGs for the diagnosis of obesity.

Table 5.

Survey of Program Participants

Item	% agreement (n = 18)
This program will improve how I care for my obese patients	94.4
This program improved my opinion of bariatric surgery	72.2
Because of this program, I am more likely to adhere to the clinical practice guidelines for the diagnosis of obesity	94.4
Because of this program, I am more likely to adhere to the clinical practice guidelines for the evaluation of obesity	88.9
Because of this program, I am more likely to adhere to the clinical practice guidelines for the treatment of obesity	88.9
Because of this program, I am more likely to refer appropriate patients to a bariatric surgeon	88.9

During the sessions, providers also spoke candidly about their struggles and successes in treating obese patients. Several reported having referred patients for bariatric surgery and one discussed dismay about a patient who died prior to receiving bariatric surgery. Another provider requested information for the office staff on the importance of measuring BMI and also requested BMI charts for the office, indicating that BMI was not routinely documented in their practice by medical assistants. In addition, providers had questions about upcoming revisions to the CPGs, research in pharmacotherapy, and bariatric surgery techniques.

Discussion

The literature suggests that providers have suboptimal knowledge about obesity and bariatric surgery and that they are interested in learning.^16–19,21 In addition, they felt that education would improve referral rates to bariatric surgeons. The project yielded several pieces of information and insight regarding the care of obese patients. Foremost, while obesity is currently believed to be the largest epidemic facing our nation, only 16 out of 60 PCPs responded to the call for panel participation. The investigator originally postulated that the panel would likely select most, if not all, of the items in the list as being helpful in improving their ability to diagnose, manage, and treat obesity, but this was not the case. Five of the 11 items were not selected. The panel consisted of experienced PCPs, but their prior level of knowledge regarding obesity diagnosis, treatment, and evaluation is unknown. Perhaps the low number of selected items is related to a lack of knowledge about what they need to know to treat their patients properly. Or, in converse, it could be related to a higher level of knowledge about the subject and their lack of need for additional information. In retrospect, having the providers substantiate why they did not select items would have been helpful. Future research might consider measuring the items that a bariatric specialist would select against those a PCP would select. In addition, future panels may benefit from having a visual of the items rather than only a list.

The low response rate from the practice managers is also a phenomenon to examine. It may be simply due to the overburdened workload in primary care offices and that they did not have time to arrange for the sessions. It is also possible that they believe that their providers do not have time or that their providers are not interested. It might also be due to the practice managers' own beliefs or negative attitudes toward obesity and bariatric surgery. The investigator elected to go through the practice managers to set up the sessions so that they could be provided on site at the practices for the convenience of the providers. In addition, the practice managers meet on a monthly basis and were easy to access. This may have added an unnecessary additional person to go through, ultimately limiting access to the providers. Soliciting providers in another way may have increased access. Future education efforts targeting PCPs should consider avoiding the added step of contacting practice managers, or should consider using a combined approach of contacting both the providers and the practice managers. Setting up sessions in the medical staff lounge or impromptu visits at lunchtime may increase the likelihood of providing the information. A large turnover in practice managers during this time may have also limited access to the providers.

The providers that did attend the sessions were active participants in the program. The providers were engaged and receptive to the information provided. A large majority of the participants felt the program would improve how they cared for their obese patients and believed that, because of the program, they were more likely to adhere to the CPGs for the diagnosis, evaluation, and treatment of obesity. Thirteen of 18 participants felt that the program improved their opinion of bariatric surgery. Whether the participants had a prior positive or negative opinion of bariatric surgery is unknown. In addition, the majority of the participants felt that, because of the program, they were more likely to refer their obese patients to a bariatric surgeon. Organizations seeking to improve quality of care may also consider mandatory physician training in this area.

Although the main aim of this project was to develop and deliver education to PCPs, a great deal of information was collected that will help form, improve, and deliver future education on this subject. While the education that was provided was only the written information that the panel requested, participants had several questions and requests for additional information. This may suggest that a tailored approach may be beneficial. Providers could be contacted ahead of time to discuss their specific needs. In addition, dealing directly with the providers may prove more fruitful that trying to coordinate education through their office staff.

While much of the research that has been completed has discussed the failure of PCPs to adequately diagnose, manage, and treat obesity, the needs of PCPs to complete this task is not well discussed. Based on the findings of this project, a brief reproducible program including copies of CPGs, handouts to give patients telling them their BMI, handouts to give patients on treatment options, information on the bariatric surgery referral process, bariatric surgery reimbursement, and a list of bariatric surgeons was developed. This program could easily be reproduced in other healthcare settings and would improve patient care in the obese population. Future research would be helpful to determine if, in fact, the program does improve the care of obese patients, increase the use of CPGs, and increase appropriate referrals to bariatric surgeons.

Footnotes

Acknowledgments

We would like thank Kate Reinhardt, MS, CRNP, Lisa Rowen, DNSc, RN, FAAN, and Bridgette Gourley, DNP, CRNP, for their support and mentorship during this project.

Disclosure Statement

No competing financial interests exist.

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