Seattle—A video-based decision aid helped severely obese people to make more informed choices about bariatric surgery and reach more certainty about them, according to a trial involving 152 Group Health patients, e-published in Obesity in advance of print. This randomized controlled trial is the first to test shared decision making for weight-loss surgery.
Researchers randomly assigned half the patients to receive an educational booklet on bariatric surgery and half to watch the video-based decision aid. After three months, those who watched the video felt less conflicted about their decision. They also knew more about pros, cons, and likely outcomes.
“We think a video like this one can play a key role as people talk with their primary care doctors or specialists, consider pros and cons, and decide whether or not to have bariatric surgery,” said David E. Arterburn, MD, MPH, an associate investigator at Group Health Research Institute. “This is important because U.S. bariatric procedures have increased 20-fold since 1996—from 9,400 to more than 220,000.”
The Food and Drug Administration recently approved lowering the weight cutoff for gastric-banding surgery. For a 5 foot 9 inch person, the cutoff is now 203 pounds—a body mass index (BMI) of 30—if they have at least one obesity-related health condition, such as type 2 diabetes, and have “failed” weight loss with diet and exercise. “That’s about one in four U.S. adults,” he added. But insurers (including Medicare and Group Health) set their own criteria for coverage of bariatric surgery, which do not necessarily align with FDA approval.
The patients in this trial averaged 50 years old with a BMI of 47. For a 5 foot 9 inch person, that means a weight of 308 pounds. In previous trials, patients who used decision aids were less likely to opt for various types of elective surgery, Dr. Arterburn said. But in this trial, that trend was not statistically significant.
Bariatric surgery can help severely obese people keep off enough weight to improve their obesity-linked diseases, such as type 2 diabetes, and even live longer, he added. But the long-term outcomes are still unknown; and surgery carries risks, including complications and even death.
“When an intervention has many pros and cons—as bariatric surgery does—each individual patient’s preferences should play an even larger role than usual,” Dr. Arterburn said. That’s why Dartmouth Atlas Project experts call this kind of care “preference-sensitive.” These experts, who track Medicare spending nationwide, have found that too often this kind of care reflects the practice patterns of the doctors in their area. Instead, he said, preference-sensitive care, including bariatric surgery, should reflect the preferences of individual patients.
For that to happen, it helps for patients to go through a process of “shared decision making” with their doctors, said Dr. Arterburn. In shared decision making, each doctor shares with their patient all relevant information on the possible risks and benefits of detection and treatment options for a health condition. Each patient considers what might make them prefer or tolerate one treatment, side effect, or outcome more or less than others. Then, in conversations with their doctors, patients clarify their preferences, weigh their options, and make the choice that’s right for them, he explained.
Prior studies have shown that informed patients who participate actively in their care decisions tend to choose less invasive options than their physicians would make alone, Dr. Arterburn added. When patients are more informed and active, they also tend to make more conservative choices—and to be more satisfied with their outcomes regardless of whether they choose the intervention or not.
The nonprofit Foundation for Informed Medical Decision Making funded the trial. The Foundation arranges with a for-profit company, Health Dialog, to coproduce and market aids for shared decision making to health care organizations. The Foundation developed the shared decision making video on bariatric surgery that this trial used: “Weight Loss Surgery: Is It Right for You?” But the Foundation had no involvement with this trial, data, or article.
Dr. Arterburn’s coauthors were Emily Westbrook, T. Andrew Bogart, MS, and Steven N. Bock, MD, of Group Health; Karen R. Sepucha, PhD, of Massachusetts General Hospital and Harvard Medical School; and William G. Weppner, MD, MPH, of the University of Washington.
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