Bariatric Surgery - Research Paper Example

Use of Bariatric Surgery to Resolve Symptoms of Type 2 Diabetes in Obese Patients (BMI>35Kg/m2) in Australia. Introduction Type 2 diabetes mellitus is always directly linked to obesity hence millions of people have been diagnosed with it. This condition makes various organ systems in the body to get damaged in one way or the other. Modern lifestyles contribute a lot to obesity which accounts for the increasing prevalence of T2DM (Whitlock et al., 2013). What worsens the condition is its existence with a number of other conditions, some of which are by far more fatal than obesity such as heart diseases, hypertension, stroke and some forms of cancer (Hernandez & Klyve, 2010). The biggest problem addressed in this paper is obesity evidenced by a Body Mass Index of more than 35Kg/m2. Type 2 diabetes is a comorbidity for obesity which almost always occurs whenever a patient’s BMI goes beyond 35Kg/m2 (Hernandez & Klyve, 2010). Obesity has of late been found to be like an epidemic that is slowly but frequently affecting the Australian population with cases doubling in the previous two decades according to Gloy et al., (2013). The cause of the problem can be largely attributed to poor eating habits, which is the leading cause of obesity worldwide (Whitlock et al., 2013). The purpose of this paper is to introduce and implement a strategic plan that will use effective bariatric surgery to reduce symptoms of T2DM in obese individuals in Australian public hospitals. Effective bariatric surgery would be accomplished if evidence based practice on bariatric surgery is displayed. Throughout its content, the paper analyses the various barriers towards implementing bariatric surgery in hospitals. Additionally, proposers of the implementation who are also its facilitators are also examined while a set of recommendations for the success of the implementation of the plan are discussed. Background and the area of practice Firstly, according to Padwal et al. (2010), bariatric surgery is the solution to the treatment of type 2 diabetes that occurs in conjunction with obesity when all other methods have failed to produce positive results. It has been evidenced that some individuals that undergo the procedure with high blood sugar levels recover within days to weeks after the surgery (Keidar, 2011). Buchwald et al. (2009) demonstrated the applicability of bariatric surgery in the treatment of Type 2 diabetes in a case whereby all other medication approaches had failed to produce results. Secondly, the area of study chosen for this study is in Australia whereby the members of the public have raised a lot of concern about the reasons as to why patients with obesity and diabetes type 2 have to spend the rest of their lives in healthcare centres in addition to facing unstoppable deaths either from the two conditions or from other conditions associated with obesity (Chopra et al., 2010). This particular study will therefore bring into practice a therapeutic procedure known as bariatric surgery into practice, whose outcomes are desirable with reduced times of stay in the hospital and also associated with little chances of hospital re-admission (Nguyen et al., 2004). Pharmacotherapy is also advisable, but it has its own risks of adverse effects hence should only be administered if the benefit is worth the risk (Wang et al., 2014). Obesity is as serious as any other chronic disease hence partnership between the patient with high motivation of recovering and committed health practitioners is essential. Such health professionals can include psychiatrist and psychologists, physiotherapists, dieticians and medical physicians among others. The efforts of these teams are capable of eventually and successfully producing a loss in weight of about 5% to 10% (Padwal et al., 2013). Australia has in the recent history developed a culture of consumption of fast foods which contributes to the poor eating habits attributed to be the cause of rising cases of obesity. Apart from the suggested approach towards treatment of obesity (bariatric surgery), obesity can be managed almost fully by engaging in exercise and managing the patient’s eating habits (Schweiger et al., 2010). Selection of the model The best model for use in this evidence based practice is Tyler Collaborative Model because this particular model faces few barriers as opposed to prior models whose barriers have impeded the development of EBP in nursing (Olade, 2004). According to Olade (2004), TCM is a model that embarks on utilizing electric methodologies to implement evidence based practice. It is sequential and considers all previously recognized procedures of handling the situation before making considerations of the evidence based practice. In the case of introducing bariatric surgery for resolution of type 2 diabetes, the model calls for identification of previous methods of handling obesity and type 2 diabetes such as diet therapy and exercise amongst other approaches before considering bariatric surgery. This model compares to Lewin’s theory of change in terms of all the major steps of achieving the evidence based practice while at the same time comparing to Havelock’s steps of planned change that aid in the development of EBP. Its advantage is that it is simple to apply and saves on time since it only involves three phases which are unfreezing, moving and refreezing (Shirey, 2010). The biggest disadvantage is that it requires that an effort is made to convince all stakeholders to buy the evidence based practice for it to be adopted (Shirey, 2010). The major phases involved in this model are unfreezing, moving and refreezing phase, all of which contain sub steps aimed at implementing the EBP (Olade, 2004). Tyler Collaborative Model (TCM) (Olade, 2004) Model Steps Phase 1: Unfreezing: involves facilitators and barriers to change. TCM expands on the facilitators while reducing barriers, and the unfreezing phase consists of three steps. Phase One: according to Lewin (1951), this phase of the TCM model is like a psycho-sociological view of the Evidence based change that incorporates facilitators and barriers that prevent adoption of the evidence based practice. In order for bariatric surgery to be adopted in Australia, the facilitators according to this model must be more energetic while the barriers must be minimized as much as possible. The six steps involved in TCM are therefore intended to minimize barriers towards adoption of bariatric surgery in Australia such as unavailability of Evidence based materials and lack of government funding towards bettering the medication sector. At the same time, the model aims at empowering the facilitators to see the benefit of adopting bariatric surgery in resolving symptoms of type 2 diabetes (Olade, 2004). Step 1: Building relationships including establishing multidisciplinary advisory panel to move to Step 2. This is the first step according to the model of change and it aims at coming up with new relational terms that will exist between the nursing leaders and the various institutions that provide healthcare in Australia. It is these stakeholders that will show commitment to ensure that the change is both adopted and implemented through overcoming all the barriers that pose a threat to its implementation. The nursing leader from the institution proposing adoption of bariatric surgery in resolving type 2 diabetes will for instance voluntarily move from one institution to another creating awareness of the benefits of the evidence based change. By so doing, the number of stakeholders supporting the change will greatly increase, increasing the chances of its adoption into medicine (Maljanian et al., 2002). Step 2: Diagnosing the problem—determine areas of care needing improvement through research evidence. During this stage, the nurse researcher who in this case is the developer of the evidence based practice will take the role of a consultant in explaining that prior approaches in resolving symptoms of type 2 diabetes including dietary approaches and exercise have failed to restore severe obesity to normal conditions. With provision of various evidence based materials for proving the nature of the situation, the nurse researcher will then explain why it is important to use bariatric surgery in dealing with symptoms of type 2 diabetes (Marland & Lyttle, 2003). Step 3: Acquiring resources—human and financial. This is the last stage of the unfreezing facing of TCM model and it is aimed at ensuring that resources are available to ensure untroubled adoption of the proposed change. In some cases for instance, the nursing consultant may not be initially part of the stakeholders, hence financially motivating him or her will make them a strong facilitator of the evidence based practice. Small medical facilities interested in the change may link up to raise finances to fund a single nursing consultant to implement step two above. Having all resources required for facilitation of the adoption of the change project will prepare the process adequately to enter the second phase of this model (Ciliska et al., 2001). Phase 2: Moving: This phase involves redefining the situation and striving to find new solutions. This phase calls upon the nursing consultants to consider new alternatives of dealing with resolving symptoms of type 2 diabetes. It is the step where finally the use of bariatric surgery will be mentioned and confirmed to be the best alternative for the management of type 2 diabetes resulting from severe obesity through both step four and step five of the TCM model. Step 5: Choosing the solution including a critical review of evidence-based reports. Develop a pilot project to introduce new EBP initiatives. The nursing researchers together with the nursing consultant during this stage will analyse evidence based materials to gain enough knowledge how bariatric surgery is performed, to which patients and also approximate the cost of the procedure (Evans & Pearson, 2001). After all these parameters are looked into critically and confirmed, the panel designs a pilot research that will serve to evaluate the effectiveness of bariatric surgery before it is implemented in the entire Australia. Having done this, the change project will be ready to undergo step five of the TCM model. Step 5: Gaining acceptance introduces the implementation of the pilot project including process and outcome evaluations to determine the differences in post implementation care. This is the step whereby the panel under the leadership of the nursing consultant priory selected to lead the panel apply the pilot research designed to find out the effectiveness of the bariatric procedure in resolving symptoms of type 2 diabetes. The pilot will be performed in a hospital unit that the nursing consultant will confirm, after which a thorough evaluation of the outcomes will be done. Once everything is done, the results will be reported back to the panel by use of a mechanism that will make all stakeholders feel that their efforts have been recognized and appreciated. Phase 3: Refreezing: It entails processes that ensure that the intended change is adopted, in this case, the use of bariatric surgery becomes a normal procedure in treatment of severe diabetes presenting with type 2 diabetes. The last phase in any planned change is that of making sure the desired change becomes an inherent part of the normal way of doing things in an organization. This phase involves only one step, which is stabilization (Olade, 2004). Step 6: It involves sustaining the proposed change, that is, use of bariatric surgery in resolving symptoms of diabetes type 2 caused by severe obesity. Here, the results of the change project will be analysed to ensure that the effects of performing bariatric surgery on a patient will be long term advantageous effects as opposed to short term and maybe lead to re-admission back into the hospital which would waste more time and increase the cost of treatment. The activities related to the bariatric surgery process will then be presented to the advisory committee for approval (Stevens, 2001). Approval of bariatric surgery as a method of resolving the symptoms of diabetes type 2 will imply incorporation of policies in healthcare organizations that guide its use in cases of severe obesity presenting with symptoms of diabetes in Australia. Barriers and Facilitators A great barrier that may hinder the adoption of use of bariatric surgery in resolving the symptoms of type 2 diabetes is lack of evidence based materials in the nursing field. This is a barrier that has affected adoption of such medical procedures not only in Australia but also in other places such as Hong Kong (Dargent, 2007). It would be quite difficult for progress to be made in terms of creating awareness of the existence of bariatric procedure and the outcomes related to adoption of such a procedure in medicine without the availability of materials that would serve as evidence that the procedure has been successful in other areas (Wallis, 2012). This barrier is totally interlinked with minimal access to research studies since the greatest facilitation of research and evidence based practice is achieved through going through available evidence based materials, lack of these materials will therefore by an equally essential hindrance to adoption of the procedure (Dargent, 2007). To solve this barrier, the Australian Department of Health in association with the Department of Education should be able to avail systematic reviews of such evidence based materials for the benefit of all key stakeholders towards adoption of the proposed change. Availing materials to serve as evidence of the practicality of applying bariatric surgery in treatment of obesity will act not only to achieve the eventual implementation of the project, but will also save time taken to finally implement the strategic change. Stakeholders and facilitators such as the government of Australia will therefore support the project by making an effort to ensure that such materials are availed in good time (Dargent, 2007). Moreover, lack of awareness and insufficient advocacy groups in Australia may serve as another great barrier hindering the adoption of bariatric surgery as an alternative method of managing symptoms of type 2 diabetes in obese patients. Such advocacy groups would actually serve to create awareness of the dangers associated with severe obesity including the fatal consequences of type 2 diabetes (Wallis, 2012). Furthermore, the advocacy groups would be the best group that would efficiently reach the obesity patients to the community level to enlighten them on the benefits of adopting evidence based practice in treatment of diseases such as type 2 diabetes which other initially available methods have been unable to successfully manage. Once such awareness is created, it would probably increase the urge of facilitators such as the government to invest in this expensive procedure partially from pressure from such patients. Creating voluntary advocacy groups would therefore be a core approach towards overcoming the barrier of lack of advocacy groups and people to create awareness on the benefits associated with adopting this new technique in medicine. However, creating such groups would not actually be as cheap as any voluntary service scheme would be because it would entail traveling and upkeep allowances for the advocacy groups. On normal occasions, it would be quite difficult to raise funds to support this program especially at its start (Wallis, 2012). However, convincing the government through the Department of Health to chip in and offer financial support for such a beneficial program to the citizens of Australia would finally solve the issue once and for all. The final outcome will then be achievement in adoption of the proposed change for resolving type 2 diabetes symptoms. Another barrier that may hinder adoption of this evidence based change is the cost of successfully performing the procedure which is quite high and would probably be unaffordable for some middle class patients. Lack of funding by desired facilitators such as the Department of Health in Australia and also the Department of Education acts as another potential barriers towards the adoption of the is procedure in management of severe obesity that presents with symptoms of type 2 diabetes (Dargent, 2007). This financial barrier will however be overcome through engaging the Department of Health to subsidize the cost of undergoing the procedure so that it becomes more affordable to a large number of patients that will require the services. Consultations with leaders of various relatively big healthcare facilities will help in making the advantages of adopting this change known to the government through the Department of Health with the hope that the cost of bariatric surgery would be factored in during annual budgetary arrangements (Wang et al., 2014). Since the move has more benefits and centres on reducing the prevalence of obesity and diabetes type 2 in the entire Australia, the government would be more than willing to provide funds to facilitate the change. Outcomes and Implementation Strategies Some strategies that best fit the implementation process of this proposed change include the use of mass media to make advertisements on the effectiveness bariatric surgery in management of type 2 diabetes (Marshall et al., 2006). This method is entirely relevant for the adoption of this proposed change since it is a sure method of letting all stakeholders learn the new approach to management of severe diabetes and can also provide a reason for facilitators to support the change financially. Research has documented that this strategy produces effectiveness of up to 100% in areas where it has been used to justify adoption of evidence based practice (Christel, 2000). Use of local opinion leaders to convince other stakeholders to adopt the change has not been very effective in the recent past. This strategy at one point in research however was able to produce an effectiveness of up to 81.3% since juniors are most of the time under obligation to do what their leaders propose (Duffy et al., 2006). Patient mediated strategies have been documented to produce an effectiveness of up to 64.3% and can in this case contribute to adoption of the change. This is because the risk associated with the outcomes of the bariatric procedure puts the healthcare providers under the obligation to seek the patients consent before initiating the procedure. Consequently, rejection of the procedure by patients would imply its lack of adoptability, hence necessitating seeking for support of the project by patients (Christel, 2000). A good example is the research performed by Babooram, Mullan & Sharpe (2011) which was able to confirm that application of bariatric surgery in the management of obesity with type 2 diabetes has more positive clinical outcomes than the negative one, hence guaranteeing its adoption for management of obesity. The research used a combination of mass media and opinion of leaders to push for its adoption and it was able to obtain greatly desirable outcomes, giving evidence of the success of bariatric surgery elsewhere. The research confirmed that out of 1886 obesity patients with type 2 diabetes as a comorbidity that underwent Roux-en-Y gastric bypass procedures in an institution, only 7 patients succumbed to death either as a result of the condition or effects of the surgery. This represented only 0.37% of the entire population that went through the surgery, hence the technique can comfortably be declared safe and a suitable option for management of the condition (Babooram, Mullan & Sharpe, 2011). According to the research also, there was evidence of decreased average time of stay in the hospital from the initial 6.7 days to 3.2 days, adding into the benefits of the procedure (Babooram, Mullan & Sharpe, 2011). There was also a significant decrease in the re-admission of the patients for the same condition or related conditions, decreasing from the initial 15.7% before the study to 8.1% after the study. Overall complication of the situation during management using other methods previously decreased from 18.6% to 4.8% after adoption of the bariatric procedure for obesity treatment (Babooram, Mullan & Sharpe, 2011). The reason as to why the strategy worked is because of its advantages of maximizing reduction of appetite through hormonal changes and the size of the stomach with subsequent reduction of amount of food that is made available for energy mobilization (Elgart et al., 2013). Since poor eating habits is the chief cause of increasing incidence of obesity with type 2 diabetes in Australia, adoption of this procedure would be the best therapeutic option for the disease conditions (Adams et al., 2012). All outcomes and process will be measured in order to determine the success of the approach. The clinical outcome of undergoing the surgery would be a great decrease in weight (maintained at 50%) which reduces the severity of diabetes type 2 and also decreases chances of suffering from other diabetes comorbidities such as heart diseases and hypertension (Hernandez & Klyve, 2010). As earlier highlighted, these outcomes occur as a result of reduced appetite stimulated by hormonal changes following the procedure (Hernandez & Klyve, 2010). The surgery also reduces the size of the stomach hence a small amount of food is contained in the stomach, cutting weight by far (Finks et al., 2011). The patients after the surgery will be expected to have behavioural changes such as low self-esteem hence will require more attention best given by care takers and relatives (Dalheim et al., 2012). Eating habits will also slowly change and patients will reduce rates of eating and will start eliminating junk food from their diets (Schweiger et al., 2010). Evaluation Both step five and six of the TCM model selected for this evidence based change clearly outline the need for evaluation of the outcomes of the initiated change (Narayan et al., 2012). It is advisable that praise in addition to commendations be offered as incentives that would motivate the developer. The overall outcome of the evaluation process as emphasized in step six should establish whether there was a general improvement in the quality of care provided by the new bariatric approach to treatment of obesity as well as the patient outcome (Adams et al., 2012). In order to evaluate the effects of adopting such a technique for management of obesity and type 2 diabetes, I will study the outcome and indicators of quality as outlined by (Hernandez & Klyve, 2010). Such indicators include caseload, the total amount of time spend in the hospital after the surgery, the rate of deaths caused by the disease and also those that occur as a consequence of undergoing the procedure (Chopra et al., 2010). Moreover, an observation of the number of readmission cases for similar conditions and study of the complication rates if they occur will aid in evaluating the success of the Evidence Based Practice (Hernandez & Klyve 2010). All the parameters to be included in the evaluation process will be indicated in terms of percentages and evaluated in comparison to other documented information concerning the same parameters (Adams et al., 2012). The entire evaluation process will take a period ranging from one year to two years in order to have a correct basis for comparison of old methods of managing diabetes and obesity with bariatric surgery as an option in Evidence Based Practice (Hernandez & Klyve, 2010). The Plan Introduction of the change will be done through an official forum that will be involving all stakeholders in a panel. The change will then be proposed and supported with evidence from literature reviews that show success of bariatric procedures in other countries and clinical settings. Leaders will take central role in expounding the change so as obtain maximum support (Hernandez & Klyve, 2010). When the change is finally adopted into the hospitals, it will be our duty to keep on monitoring the progress for a period of between one and two years. Such monitoring will be done by monitoring the indicators of quality including caseloads, length of time spend in the hospital following treatment and the number of deaths encountered during the bariatric procedure or as a result of the disease condition even after treatment (Babooram, Mullan & Sharpe, 2011). This will give a blueprint on whether the change should be fully adopted or abandoned. Conclusion Obesity occurs in comorbidity with other disease conditions, some of which are even more serious than obesity itself. Among the many comorbidities of obesity is diabetes which causes serious hyperglycaemia caused by inability of the cells to take in glucose from the blood, which may cause serious effects, the commonest of all being death. It has been shown through research that treatment of obesity acts as a cure to the comorbidities associated with obesity. Some of the approaches towards treatment of obesity have been based on diet management with exercise, approaches that have not been very successful especially in conditions of serious obesity with BMI exceeding 35Kg/m2. For this reason, evidence based research through this study has come up with another option of treating obesity hence type 2 diabetes by use of bariatric surgery with an advantage of reducing body weight by about 60% to 80% and most of the times maintaining it at 50%. 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Cost-effectiveness of bariatric surgical procedures for the treatment of severe obesity. The European Journal of Health Economics, 15(3), 253-263. doi:10.1007/s10198-013-0472-5 Whitlock, K. A., Gill, R. S., Switzers, N., Birch, D. W., & Karmali, S. (2013). Treatment of obesity and diabetes with bariatric surgery. Global Epidemic Obesity, 1(1), 1. Appendix A Olade, R. A. (2004). Strategic collaborative model for Evidence‐Based nursing practice. Worldviews on Evidence‐Based Nursing, 1(1), 60-68. doi:10.1111/j.1741-6787.2004.04003.x Read More