Although there have been significant advances in managing obesity, approaches vary greatly among primary care physicians. Jacob Nudel, MD, and colleagues developed a study to determine the clinical management obstacles contributing to weight loss surgery (WLS) underuse. Obesity published the study results.
Dr. Nudel spoke with Physician’s Weekly (PW) regarding the findings and their applicability to practice.
PW: Why did you feel this topic needed exploration?
Dr. Nudel: WLS is the most effective, durable treatment for obesity, and its underutilization has been a lively topic in the medical literature for many years. The research to date has focused on identifying barriers to WLS utilization (primary care physician [PCP] perceptions of safety, patient wariness, and quality of life). We wanted to propose a model for how people get from their PCP to the operating room for weight loss surgery, that is, to break that process down into discrete steps. Then, use that model to quantify and explain attrition from subspecialty obesity care.
We feel we have developed a generalizable and flexible approach to understanding clinical management problems. Namely, to develop multi-state models for clinical management processes, fit the models to real clinical data, and observe the probabilistic behavior of the models to explain observed phenomena and predict counterfactual changes. In our study, for example, we showed how replacing PCPs with the highest-referring PCP would yield increased surgical volume over time. However, one could marshal our methods to scrutinize the utilization of various important clinical processes.
What are the most important findings from your study?
The most important thing for physicians to recognize is that physicians behave differently from one another, and their differences in behavior are quantifiable using electronic medical records (EMR) data. The medical literature typically focuses on differences between patients and institutions (ie, high vs low volume, geography, etc.). We intuitively know that physicians behave differently from one another, but it is rarely proven in the literature.
Additionally, we are in a new era of highly effective obesity medications. It is imperative that physicians talk to their patients about obesity, make shared decisions about treatment, and get patients to the right provider to offer treatment. Our study suggests patient outcomes may depend in part on the doctors they see. We do not want to be prescriptive about what physicians do, but they should recognize that they are part of an ecological system for allocating healthcare. Some PCPs, for example, may be comfortable treating obesity. That is fine—as is being uncomfortable with offering the latest advances in obesity care. Either way, we want physicians to consider their comfort and capabilities thoughtfully and then treat or refer accordingly.
How can physicians incorporate these findings into practice?
Physicians should be aware that patients who are struggling with excess weight are at high risk for treatment attrition no matter where they are in the weight management pathway. The risks of attrition vary across the steps in the pathway, but attrition is always high. Early in the pathway, physicians should pay particular attention to men, older patients, and those who are overweight but not severely obese. When they make referrals, physicians should be attuned to social barriers that might prevent their patients from converting referrals to visits.
What would you like future research to focus on?
There are several future directions for this research. First, we want to adjust our model to incorporate the use of glucagon-like peptide 1 and other highly effective obesity medications. Second, we would like to extend this approach to other clinical management problems and develop software to help other researchers apply our methods to problems that vex and interest them.
