Problem: Rising prevalence of obesity and associated comorbidities; absence of standardized post-operative care guidelines for bariatric patients; lack of support structures to enable bariatric patients to adopt required post-operative lifestyle changes.
Solution highlights: A pilot aftercare programme offering a six-month nutritional counselling and weight monitoring service to qualifying bariatric patients was initiated by KKH, a major health insurer in Germany; thoughtful presentation of evidence and effective communication of observed problems by KKH staff was crucial for gaining the managerial support needed to start the initiative; capitalizing on existing infrastructure minimized the need for additional resource investments; active patient participation has been encouraged, with health education and counselling used to empower pilot participants to adopt healthy behaviours; continuation of the initiative will be determined based on a comprehensive analysis of collected data once the pilot reaches its target number of 100 participants.
Description of practice
Rising prevalence of obesity in Germany, increasing from 13% in 2000 to 25% in 2008, has strained the ability of services delivery to manage higher burdens of associated comorbidities, particularly type 2 diabetes and hypertension. Despite bariatric surgery being an available treatment option for obesity, high procedure costs limited the number of individuals offered this service in practice. Furthermore, the effectiveness of bariatric surgery was compromised by a lack of standardized post-operative care guidelines supporting necessary lifestyle changes, leaving patients unable to maintain weight loss over the long term.
After observing rising health care costs linked to obesity and associated comorbidities, employees at KKH – one of Germany’s largest statutory health insurers – designed a pilot project to assess the cost-effectiveness of a bariatric surgery care package designed to help patients achieve sustainable weight loss. Examination of evidence suggested that bariatric surgery could lead to significant health improvements for patients and, while costs of performing the surgery are initially high, leaders of the initiative felt it could prove cost-effective over the long term. Working with Hamburg University Hospital – carefully selected as the pilot site for the project based on their quality of care and experience delivering this type of surgery – KKH designed a new package of services combining bariatric surgery with a six-month nutrition counselling programme for patients with a body mass index of 45 or greater. The necessary infrastructure and specialist equipment for performing bariatric surgery was already available at the Hospital and the existing health coaching service offered by KKH to enrolees was easily extended to participating bariatric patients after minor adaptations. The pilot was launched in May 2012 and 59 patients have so far been enrolled. Following bariatric surgery, participating patients are given a telemetric scale and are required to weigh themselves weekly for six months; weight data is automatically transmitted to KKH. During this six-month period, patients receive a weekly health progress report, as well as monthly coaching and education sessions with a nutrition counsellor. After completion of the aftercare programme, patients are referred back to their general practitioner for any follow-up care. Patients are weighed for a final time one year post-surgery to assess long-term weight loss achieved.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
Despite initial resistance from senior management at KKH, persistent advocacy from lower-level employees succeeded in gaining approval for the pilot project. With senior management on board, a director for the project was hired to oversee activities. Hamburg University Hospital was selected as the pilot site based on their expertise and excellent performance record performing bariatric surgery. Surgeons and hospital management were both keen to participate in the initiative and assist in the planning process due to the financial incentives associated with performing bariatric surgery and a shared belief that the initiative would benefit patients.
As a pilot initiative, emphasis has been placed on data collection to enable evaluation. The initiative plans to collect data on 100 patients in an effort to achieve statistical significance in cost-benefit evaluations. Patient enrolment is ongoing but initial results are promising; “the weight loss is enormous and the comorbidities in terms of diabetes and hypertension are reduced”. Based on the results observed so far, initiative leaders are optimistic that the initiative will prove effective over the long term. If the final evaluation proves positive, initiative leaders hope to expand the service to other hospitals.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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- Markus Siedenburg
- KKH Health Insurance