OUTLINE

Objective of case studies is for students to work on a case study and explore this topic in depth using literature reviews, internet searches, document reviews, interviews, etc and develop a recommendation based on evidence. The first case study will be for using the PROACTIVe method for rational decision making on a particular case. Each case study will be 25 percent of the course grade.

 

The maximum total length of the case study paper is 6 page single-spaced. A minimum of 12pt characters must be used with one inch or 2.54 cm borders. If exists, references, and appendices are not counted within the page limit. Five percent deduction will be applied for each half a page over the page limit.

 

Should include appendices and a decision tree

 

CHARACTERISTIC	% OF TOTAL
Clear definition of the problem under review (Definition of problem, identification of additional dimensions of the problem, people involved and redefining the problem)	20
Setting the objective (clear objective which provides clues as to from whose perspective)	10
Developing/Identifying Alternatives and consequences and Assessing the Merits and Trade-offs of the Alternatives.	30
Use of the research evidence in the paper	20
Formulation of recommendations	10
Writing (clear, concise, correct, correct references, )	10

 

Eats out because of ease

Cannot manage obesity on own – has successfully lost weight but no motivation to maintain loss, “doing best to go” to gym, although does not have energy or time to go exercise.

Wants a recommended treatment before visiting a clinician.

 

CASE

Ms. Chatham is a 29-year-old woman. She is a friend of your friend. She heard that you are in Health Information Science and likely to know more about medicine than she does and she also heard that you take a medical decision making course which she believes helpful for her to decide. Her main concern is that she wants to lose weight.

 

She wants you to help her to assess how she can lose weight, whether there are medications that she can take to aid in weight loss or whether she should consider bariatric surgery. She is relatively healthy, except for a history of childhood asthma. She says that she has been told indirectly and repeatedly, by her friends and family, that she is “overweight.” She has tried several popular diets without success; each time, she has lost 4.5 to 6.8 kg (10 to 15 lb) but has been unable to maintain the weight loss for more than a few months.

 

She does not have a history of coronary artery disease or diabetes. She has a regular menstrual cycle. She does not take any medications or nonprescription supplements. She does not smoke but does drink alcohol, occasionally as many as 4 or 5 drinks in a week, when she is out with friends. She tells you that she “watches what she puts in her mouth” and reads the nutritional labels on food packaging. However, she enjoys eating out and orders take-out meals 8 to 12 times a week.

 

She works as a computer programmer and spends most of her day sitting in an office. She belongs to a fitness club and tries to go there about once a week but notes that her attendance is inconsistent.

 

On physical examination, her vital signs are unremarkable except for a blood-pressure measurement of 144/81 mm Hg. She is 1.7 m (5 ft 7 in.) tall and weighs 110 kg (244 lb), and her body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) is 38. Her waist circumference is 116 cm (37 in.). There is no peripheral edema. The rest of the examination is unremarkable.

 

Which of the following treatment options would you recommend for her?

• Maximize lifestyle modification and non-pharmacologic and surgical therapies
• Start lifestyle modification and therapy with an approved drug.
• Consider bariatric surgery for weight loss and maintaining weight

 

 

 

 

 

 

 

Use of PROACTIVe Method for Decision Making in Treatment of Obesity

 

Abstract

Summary of Case Study

Introduction

A 29 year old female expresses a desire to lose weight. She has tried several trendy diets, although she has been unable to maintain the weight loss in these instances. Her lifestyle is sedentary, she exercises occasionally – approximately 60 minutes of moderate activity once per week. She drinks 4 – 5 alcoholic beverages per week, and consumes take out meals 8 – 12 times per week. A recent physical examination shows signs of potential Stage 1 Hypertension due to a blood-pressure measurement of 144/81 mm Hg (MAYO CLINIC). The patient has not received an official diagnosis or undergone treatment for hypertension. Based on the patient’s Body-Mass Index (BMI) of 38, she falls in the Obese Class 2 classification (Hruby, 2015). The patient’s weight circumference of 37in puts her at very high risk of developing obesity related conditions, such as Type 2 diabetes, hypertension, cardiovascular disease, psychiatric & psychological disorders, osteoarthritis, and several types of cancer (Vettor R., Conci S. 2017). The patient has expressed a desire to lose weight and is seeking treatment options to determine the best weight loss strategy for her.

 

The patient struggles significantly in her daily life because of her obesity. She feels anxious about her weight, experiences depressive episodes, and has extremely low self confidence. The excess weight drastically impacts her quality of life. While she is motivated to lose the weight, each time she tries, she reverts back to old habits once she has lost 10-15 pounds. Often, she finds herself comparing herself to others that are more thin and embody societies “ideal” standards of beauty. She feels disgusting, states that often she is low energy which is why she does not work out regularly. Her experience at her fitness center has not been pleasant as she feels that everybody is watching her and making fun of her. When she does workouts with friends, she compares herself to them and feels bad about herself. Dating is a challenge for her as she feels she is not good enough, feels unattractive, and does not enjoy being intimate due to her low confidence.

 

Ms Chatham has been told indirectly by many loved ones that she should lose weight. Her family and friends want to see her healthy. Those around her are concerned about her wellbeing and want her to take immediate action. She has an excellent support system that will assist her on her journey, although she is embarrassed to accept the help from them. Those in her life have noticed she has distanced herself from them, and when she is around, she does not seem like her normal self. There are concerns about her mental health because of her weight. Her family is concerned about her developing conditions related to her obesity. These diseases have significant consequences. Ultimately they want her to be healthy and happy.

 

Her lifelong family doctor has noticed high blood pressure and a BMI and waist circumference that indicate obesity. Her doctor is concerned about her and is willing to help her lose the weight to prevent further complications and improve her quality of life. Her doctor has suggested 3 possible treatments for her: drastic lifestyle modification, therapy with an approved drug alongside starting lifestyle modification, and bariatric surgery for weight loss & maintaining weight. All possible treatments have various complications and impacts that will affect the patient, her family, and possibly the healthcare system; these will be further discussed.

Objective

The fundamental objective is to recommend the treatment path that will result in weight loss and enable long term weight management to prevent the patient from gaining the weight back. Ms Chatham would like a suggested treatment path prior to seeking help so she is informed when she goes to a consultation with a specialist. Obesity has many potential consequences that impact medical, economic, psychological, ethical, and social dimensions of an individual’s life, which will be further explored when discussing treatment options. It is important to suggest a treatment path that will mitigate the possible consequences of obesity and improve the patients quality of life in a sustainable way.

 

(ADD MORE? CITE?)

https://www.cdc.gov/obesity/adult/causes.html

Treatment Options

Developing/Identifying Alternatives and consequences and Assessing the Merits and Trade-offs of the Alternatives.

 

https://obesitycanada.ca/wp-content/uploads/2019/04/OC-Report-Card-2019-Eng-F-web.pdf

 

Maximize Lifestyle Modification

(Daniel) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3313649/

 

Therapy with an Approved Drug

(Jasmine) https://www-sciencedirect-com.ezproxy.library.uvic.ca/science/article/pii/S0002934316301978?via%3Dihub

Bariatric Surgery

(Leah)

Bariatric surgery reverses the pathophysiological effects that obesity has, it can result in substantial sustained weight loss and improvement/remission of related diseases (Blackstone, 2016). It is considered the most effective treatment for extreme obesity, although there are barriers to the utilization of this treatment (Funk et al, 2016). Primary care providers have identified that there are concerns about the long term benefits of bariatric surgery, and risks patient safety when undergoing surgery (Funk et al, 2016).  There is standardized criteria that a patient must meet in order to be selected for bariatric surgery. The treatment can be offered to individuals with a BMI of at least 40kg/m², or 35kg/m² with associated serious comorbid conditions such as diabetes or hypertension, where behaviour intervention is inadequate to achieve goals (Kothari S.N., Kim J.J, 2017). A list of potential benefits, risks, and complications that arise from undergoing this type of surgery can be found in APPENDIX ? (Oskrochi, 2015). Access to the surgery is a significant barrier to this treatment. To receive surgery, the patient must have a referral, attend a consultation, and then receive the surgery. In British Columbia, 0.002% of adults with Class 2 or 3 Obesity have this treatment available to them. The average wait times in BC between referral and a consultation is up to 2 years, and the wait between the consultation and the surgery is up to 1 year (Obesity Report Card, 2019).

 

Alternatives: Consider all relevant alternatives

• Do I know all the reasonable alternatives? Consider wait-and-see, intervention, and obtaining information.
• Can I expand the number of options? List all possible options – brainstorm first, decide later.

 

Consequences and chances: Model the consequences and estimate the chances

• Which diseases could the patient possibly have?
• What events may occur overtime?
• What are the chances?

 

Trade-offs: Identify and estimate the value of trade-offs

• How do benefits and harms compare for each possible outcome?
• What are the values and value trade-offs?
• How do patients value consequences?
• What are the monetary costs?

 

Integrate: Integrate the evidence and values

• Can I qualitatively integrate the evidence and values or do I need a quantitative estimate of expected value?
• If there are uncertainties, what is the overall expected value of each alternative?

 

Value: Optimize expected value

• How do I optimize the decision?
• Are the outcomes desirable or undesirable?
• Do I need to choose the option with the maximum or minimum expected value?
• Can I combine the desirable and undesirable outcomes into one multi-attribute outcome?
• Are there any intangible factors that we have omitted?

 

INSERT TREE DIAGRAM

Evaluation

Explore and evaluate: Explore the assumptions and evaluate uncertainty

• What if I have a different patient consult me?
• Can I generalize the results to other patients?
• What if the population for which I am choosing a public health program is somewhat different?
• What if the estimates in my model are not quite accurate?
• Would plausible changes in any variable change the recommended action?
• What if my modeling assumptions are inaccurate?

 

Recommendation

Explain recommended treatment and provide evidence for why.

Conclusion

Conclude

References

MAYO CLINIC https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/diagnosis-treatment/drc-20373417

 

Hruby A, Hu FB. The Epidemiology of Obesity: A Big Picture. Pharmacoeconomics. 2015;33(7):673‐689. doi:10.1007/s40273-014-0243-x https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4859313/

 

CDC https://www.cdc.gov/healthyweight/assessing/index.html

 

Obesity Canada-Obésité Canada. Report Card on Access to Obesity Treatment for Adults in Canada 2019. Edmonton, AB: 2019, April.

 

Vettor R., Conci S. 2017) Obesity Pathogenesis. In: Sbraccia P., Finer N. (eds) Obesity. Endocrinology. Springer, Cham).

 

Blackstone R.P. (2016) Bariatric Surgery. In: Obesity. Springer, Cham

 

Luke M. Funk et al, Primary care physician decision making regarding severe obesity treatment and bariatric surgery: a qualitative study, Surgery for Obesity and Related Diseases, Volume 12, Issue 4, 2016, Pages 893-901, https://doi.org/10.1016/j.soard.2015.11.028.

 

Kothari S.N., Kim J.J. (2017) The Surgical Management of Obesity. In: Blackstone R. (eds) Bariatric Surgery Complications. Springer, Cham

 

Oskrochi Y, Majeed A, Easton G. Bariatric surgery BMJ 2015; 351 :h3802

 

Appendices

Appendix X: Bariatric Surgery potential benefits, risks, and complications

Possible Benefits
Weight loss	Average 25% loss of body weight depending on procedure
Comorbidities may improve	Not inevitable, but can help with diabetes Type 2, sleep apnea, and hypertension control
Lower mortality	29-40% lower risk of death from any cause
Better quality of life	Improvement in physical functioning
Possible short term postoperative risks
Perioperative mortality	Low, although depends on type of operation and patient related factors
Complications	4-25%
Reoperation	22-26%
Possible long term postoperative complications
Nutritional deficiencies	Iron, Vitamin B12, folic acid, and Vitamin D deficiencies retire lifelong monitoring and replacement if needed
Food restriction	Patients may be unable to eat the same amounts/types of food as they were before surgery
Failure	Gastric banding failure rates are 30-50% and revision surgery is not routinely offered
Risk of future problems	Dumping syndrome, hypoglycemia events, and lower alcohol tolerances
Excess skin	Present as a result of weight loss, removal is often not covered

Adapted from Oskrochi Y et al, 2015.