Dear Colleagues - PDF document

Dear Colleagues, F ormer Surgeon General Richard Carmona, MD has called obesity “the fast - est-growing, most threatening disease in America today”. It is no surprise that many physicians feel overwhelmed and frustrated by the daunting task of ad - dressing weight issues with their patients given the physical, emotional, social, and environmental factors associated with obesity and weight management. Providers hear a variety of messages about the prevention, treatment and management of obesity from health plans, medical specialty associations and the news that make it kpetgcukpiny dkf�eunv vo dgvgtokpg vhg dguv rncp of cevkop vo vckg ykvh rcvkgpvu0 In an effort to address these issues and to improve patient care and outcomes, the California Medical Association (CMA) Foundation and California Association of Health Plans (CAHP) convened expert panels of physicians and other health - care providers to study and discuss published materials and best practices to help clinicians determine the best way to prevent, assess and treat overweight and obesity in their practice. Thg gxrgtv rcpgn dkvkdgd kpvo vhtgg yotk itouru vhcv kdgpvk�gd rtcevkecn kpfot - mation and approaches for healthcare providers. The result is a set of toolkits that address the prevention and effective management of overweight children and adolescents, overweight and obese adults, and pre/post bariatric surgery patients. The toolkits include: • Effgevkvg eoooupkecvkop vgehpksugu Please join the efforts of the CMA Foundation and CAHP to reverse obesity trends by utilizing the resources developed by healthcare providers for health - care providers. The toolkits and additional resources are available on the CMA Foundation and CAHP websites and through participating health plans. For more information visit: http://www.calmedfoundation.org/projects/obesityProjec

t.aspx. Sincerely, Dexter Louie, MD Odgukvy Toonkkv Exrgtv Rcpgn Co/Chckt Associate Medical Director Chinese Community Health Plan Carol A. Lee, Esq. California Medical Association Foundation Helen Jones, MD Odgukvy Toonkkv Exrgtv Rcpgn Co/Chckt Internal Medicine Fresno Madera Medical Society Christopher Ohman California Association of Health Plans CMA Foundation & CAHP • Pre/Post-Bariatric Surgery Provider Toolkit • Revised April 2008 i CMA Foundation & CAHP • Pre/Post-Bariatric Surgery Provider Toolkit • Revised April 2008 ii Acknowledgements T he California Medical Association Foundation and California Association of Health Plans would like to thank the following individuals for their dedication to this project. Their support, time, and expertise were critical to the development of this document. Chris Bekins, MS, RD Health Information Specialist, Prevention and Planning County of Sonoma Health Services Nathalie Bergeron, PhD Associate Professor Touro University, College of Pharmacy Gaye Breyman CA Academy of Physician Assistants Javier Carrillo, MPH Area Health Promotion Specialist, Gtgcvgt Bcy Ctgc California Diabetes Program Art Chen, MD Medical Director Alameda Health Alliance David Der, MD Chinese American Physicians' Society Lakshmi Dhanvanthari, MD, FAAP Staff VP, Medical Director - Edward Dietz, MD Medical Director, Glendale HealthCare Facilitation Center CIGNA Health Care of California Jason Eberhart-Phillips, MD, MPH Scott Gee, MD Medical Director, Prevention and Health Information Kaiser Permanente Northern California Lawrence Hammer, MD Professor of Pediatrics Stanford University School of Medicine William Henning, DO Medical Director John Hernried, MD, FACP Obesity Treatment Center Medical Group Donald Hufford, MD Medical Director Western Health Advantage Kathy Shadle James, DNSc, NP Associate Professor of Nursing Univ

ersity of San Diego, Hahn School of Nursing Helen Jones, MD Family Practice Fresno-Madera Medical Society Patrick Kearns, MD Director, Chronic Care Management Program Santa Clara Valley Medical Center Dexter Louie, MD, JD, MPA Chinese Community Health Plan CMC Houpdcvkop Boctd Mgodgt Kelly Lee, PharmD, BCPP Assistant Professor of Clinical Pharmacy University of California, San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences Samrina Marshall, MD, MPH Regional Medical Director, State Health Programs Health Net, Inc. Suzanne Michaud, MPH CenCal Health Shobha Naimpally, MD, MPH, FAAP Medical Director, Community Health Plan Los Angeles County Department of Health Services Jennifer Nuovo, MD Senior Medical Director, State Health Programs Health Net, Inc. David Ormerod, MD Regional Medical Director Maggie Parks, MD Pediatrician Ventura County Medical Center Donald Rebhun, MD Regional Medical Director HealthCare Partners Medical Group Peggy Rowberg, DNP, APN Past President CA Association of Nurse Practitioners Linda Rudolph, MD, MPH Milton Sakamoto, MD Senior Medical Director, West Region Aetna US Healthcare, Inc. Harvinder Sareen, PhD, MPH Director, Health Care Quality and Ippovcvkopu, Svcvg Sropuotgd Buukpguu Timothy Schwab, MD SCAN Health Plan Mel Sterling, MD, FACP Internal Medicine California Medical Association Sherry Stolberg, MGPGP, PA-C Director, Primary Care Associate Programs CA Academy of Physician Assistants Jennifer Trapp, MD Staff Physician, Department of Family Medicine Sharp Rees-Stealy Medical Group Donald Waldrep, MD Sutter Roseville Medical Center Joseph Wanski, MD Medical Director LA Care Health Plan Seleda Williams, MD, MPH California Department of Health Care Services Bruce Wolfe, MD Professor of Surgery Oregon Health and Science University Nancy Wongvipat Health Net, Inc. Sophia Yen, MD, MPH Clinical Instructor,

Division of Adolescent Medicine Lucille Packard Children's Hospital at Stanford University Medical Center Toolkit Purpose I n 2006, The California Medical Association (CMA) Foundation and the California Association of Health Plans (CAHP) collaborated with commercial and Medi- Cal managed care health plans, practicing physicians and other health provider organizations to complete a provider toolkit addressing the prevention, early iden - vk�ecvkop, ygkihv ocpcigogpv gduecvkop cpd rtg/rouv dctkcvtke uutigty ectg of overweight and obese individuals. This collaboration brought together leaders from health plans, academic medical centers, physician practices and other providers of health care to share their daily experiences of working to address the growing obesity epidemic in their practice and community. Through the collaborative efforts and interest of the expert panel individual tool - kits have been developed addressing the weight management of Adult Patients, Cdonguegpv/Rgdkcvtke cpd Rtg/Rouv Bctkcvtke Sutigty Rcvkgpvu0 Thg Rtg/Rouv Bct - iatric Surgery toolkit is a stand alone document intended to supplement summary information provided in the Adult and Pediatric/Adolescent Obesity Provider Tool - kit. Thg odlgev of vhg Rtg/Rouv Bctkcvtke Sutigty voonkkv ku vo uurrny rtovkdgtu ykvh pertinent information to discuss with patients when considering bariatric surgery as a treatment option. This document contains information about medical, behav - ioral, psychological and lifestyle changes necessary for long term post operative weight loss success. CMA Foundation & CAHP • Pre/Post-Bariatric Surgery Provider Toolkit • Revised April 2008 iii Disclaimer T his toolkit is intended for physicians and healthcare professionals to con - sider in managing the care of their patients before and after bariatric sur - gery. While the toolkit describes recom

mended courses of intervention, it is not intended as a substitute for the advice of a physician or other knowledge - able healthcare professional. This toolkit represents best clinical practice at the time of publication, but practice standards may change as more knowledge is Sutikecn rtoegdutg rkevutgu eoutvguy of Evhkeop Epdo/Sutigty, Ipe0 Corytkihv Evhkeop Epdo/Sutigty, Ipe0 Cnn Tkihvu Tgugtvgd0 TaCle od Contents Letter from the Obesity Toolkit Expert Panel Disclaimer Toolkit Purpose Collaborators Bariatric Surgery Overview Common Surgical Procedure Types Evaluation of the Bariatric Surgery Patient Special Populations Medicare and Medi-Cal Surgical Treatment Criteria Post-Operative Patient Care Surgical Complications Repeat Procedures Living with Bariatric Surgery Appendix A: BMI Calculation Method and Table • Cdunvu Body Mcuu Ipdgx (BMI) Tcdngu Appendix B: Bariatric Surgical Procedures Advantages & Disadvantages Table Appendix C: Bariatric Surgery Resources • Ipfotocvkopcn Wgd Lkpku Appendix D: References CMA Foundation & CAHP • Pre/Post-Bariatric Surgery Provider Toolkit • Revised April 2008 Bariatric Surgery Mvervieu ariatric surgery helps obese individuals achieve long term weight loss by limiting the volume of food intake, reducing appetite, slowing digestion and tgduekpi vhg cduotrvkop of ecnotkgu/puvtkgpvu ftoo food0 Bctkcvtke uutigty ku a tool, not a cure, and will not resolve morbid obesity without active participation by the patient. Individual weight loss depends on a complementary commitment to lifestyle alterations, healthy eating habits, and daily physical activity. Categories of Bariatric Surgery: 1. Restrictive: Reduces the amount of food the stomach can hold without interfering with normal digestion of food and essential nutrien

ts. 2. Malabsorptive: The digestive tract is shortened to limit the absorption of calories and nutrients from food. 3. Combination: Restricts the amount of food the stomach can hold and reduces absorption of calories through surgical alteration of the digestive tract. Approaches to Surgery: Laparoscopic: A series of small incisions allow insertion of a small video camera and surgical instruments into the abdomen to conduct the surgery. • Tgduegd tkuk of youpd kpfgevkopu cpd incisional hernias - tivity Open: Involves providing the surgeon open abdomen access through a long incision. In some patients conversion from laparoscopic to open surgery may be necessary due to any of the following factors: - nal surgery CMA Foundation & CAHP • Pre/Post-Bariatric Surgery Provider Toolkit • Revised April 2008 1 ceh vyrg of dctkcvtke uutikecn rtoegdutg hcu cuuoekcvgd dgpg�vu, dtcy - backs, and risk including operative risk, potential for complications and nopi vgto ygkihv/nouu vctkcvkop0 Thg rouukdng dgpg�v cpd tkuk of gceh rto - egdutg uhound dg ectgfunny eopukdgtgd cpd dkueuuugd ykvh vhg Bctkcvtke Sutigop to accommodate individual patient need and preference. Depending upon sur - geon expertise and patient circumstances other surgical procedure types may dg eopukdgtgd0 Sgg Crrgpdkx C Bctkcvtke Sutikecn Rtoegdutg – Cdvcpvcigu cpd Disadvantages Table. Cokkon Surgical Procedure Types Gastric Bypass Roux-en-Y (RYGBP) This combination procedure is the most commonly used in the United States and is the benchmark standard by which all other bariatric surgical procedures are measured. The restrictive element of the procedure in - volves partitioning the stomach to create a small gastric pouch allowing food to bypass the lower stomach and portions of the intes - tine. Adjustable Gastric Banding (AGB) An a

djustable hollow band is placed around the stomach near its upper end, creating a small pouch and narrow passage into the stomach inducing weight loss through the restriction of food intake. This type of pro - cedure is reversible and may reduce the risk of puvtkvkopcn cpd okpgtcn dg�ekgpekgu0 Thg Lcr/Bcpd® cpd vhg TECLIZE™ Bcpdu ctg the two FDA approved devices. Biliopancreatic Bypass/Diversion with Duodenal Switch Ip vhku vctkcvkop of vhg Bknkorcpetgcvke Fkvgt - sion, the stomach is fashioned into a small tube leaving in intact the pyloric valve (which regulates the release of stomach contents into the small intestine) and a small part of the duodenum in the digestive pathway. This procedure restricts the amount of food that can be eaten and limits absorption of food into the body. CMA Foundation & CAHP • Pre/Post-Bariatric Surgery Provider Toolkit • Revised April 2008 2 Cvaluation od tfe Bariatric Surgery Patient ctkcvtke uutigty ku c vtgcvogpv orvkop fot rcvkgpvu ykvh gxvtgog odgukvy (BMI ≥ 42), ot odgukvy (BMI ≥ 35) ykvh tgncvgd eo/ootdkd eopdkvkopu0 Sutigty should be considered when less invasive methods of weight loss such as dkgv, gxgtekug, rhctoceovhgtcry, cpd dghcvkot oodk�ecvkop hcvg fckngd, ot vhg patient is at high risk for obesity related morbidity or mortality 1 . All potential bariatric surgery patients should be evaluated by a comprehensive cpd ounvkdkuekrnkpcty Bctkcvtke Sutigty Rtoitco ofvgp eopukuvkpi of vhg fonnoykpi health professionals: • Odgukvy/urgekcnkuv: dctkcvtkekcp, endocrinologist, gastroenterologist, internist Patient Pre-Operative Evaluation and Education Involves: • Copuunvcvkop ykvh vhg dctkcvtke uut - geon and other health professionals should include: –Cp kp/dgrvh gxrncpcvkop of vhg surgical procedure to be performed –Orgp dkueuuukopu cdouv uutik - ecn tkuk

u, gxrgevgd dgpg�vu, rc - tient responsibilities, and long term ocpcigogpv tgsuktgogpvu/eopug - – Cddkvkopcn dkcipouvke vguvu kpenudkpi blood work, x-rays/ultrasounds, and • Tgvkgy of kpfotocvkopcn dtoehutgu, facts sheets, handouts, booklets, and videos Pre-Operative Preparations for Providers: • Mgpvcn ot dghcvkotcn dkuotdgtu vhcv may interfere with post-operative outcomes including eating disorders, risk taking behaviors, or other psy - chopathologies should be thoroughly addressed through appropriate men - tal health referral. • Cctgfun uetggpkpi fot euttgpv ot rcuv alcohol abuse and appropriate refer - ral, as post-operative alcohol abuse has been reported in some suscep - tible patients. • Hkuvoty of pcteovke ot knngicn dtui abuse may indicate need for mental health/drug addiction counseling pre- operatively and evidence that patient is free of such abusive behaviors pri - or to surgery. • Rcvkgpvu ykvh dkcdgvgu uhound dg kp iood eopvton rtg/orgtcvkvgny0 Skipk� - cant efforts should be made to bring HgA1C within range of control prior to surgery. • Rcvkgpvu ykvh ovhgt ogdkecn eopdkvkopu ocy tgsuktg tgfgttcnu vo urgekcnkuvu fot further evaluation. CMA Foundation & CAHP • Pre/Post-Bariatric Surgery Provider Toolkit • Revised April 2008 3 Patient Selection Criteria 2,3 : • 122 roupdu ot ootg cdovg Idgcn Body Wgkihv (IBW) ot BMI ≥ 42 ki/o 2 . • BMI ≥ 35 ki/o 2 in association with one or more obesity related health conditions including but not limited to the following conditions: – Tyrg 2 Fkcdgvgu – Snggr Crpgc Additional considerations when referring patients to a bariatric surgeon: •Rcvkgpv’u hkuvoty of pop/uutikecn weight loss attempts, including com - pletion of non-operative weight loss programs. •C ygnn/kpfotogd, oovkvcvgd rcvkgpv with a strong desire for substantial we

ight loss and a commitment to life - style changes. • Rcvkgpv updgtuvcpdkpi of vhg uouteg of weight problems and responsibili - ties following surgery. • Ceegrvcdng orgtcvkvg tkuku ykvh po contraindications to a major abdomi - nal surgery. When considering referral for bariatric surgery primary care providers should take the following patient factors and potential barriers to post operative suc - cess into account : • Fogu vhg rcvkgpv hcvg c tgcnkuvke rouv surgery long term weight loss expec - tation? • Fogu vhg rcvkgpv hcvg vhg oovkvcvkop and desire to put into practice any necessary lifestyle changes in prepa - ration for and/or following bariatric surgery? • Fogu vhg fcokny hcvg c hkuvoty of dg - ing overweight or obese? • Wknn vhg rcvkgpv hcvg ceeguu vo c iood social and family support system? • Iu vhg rcvkgpv c ehtopke uookgt ot vo - dceeo rtoduev uugtA Bctkcvtke uutigty patients are advised to stop using to - bacco products prior to surgery. • Fogu vhg rcvkgpv uug ot hcvg c hku - tory of substance abuse including al - cohol, narcotics, or other illegal sub - stance? Further evaluation may be indicated for patients with a history of substance use. • Fogu vhg rcvkgpv hcvg cpy enkpkecnny ukipk�ecpv ot upuvcdng ruyehorcvhono - gies including depression, personality or eating disorders that could prevent a long term successful outcome? • Iu vhg rcvkgpv ecrcdng of fonnoykpi medical recommendations as direct - ed? • Fogu vhg rcvkgpv updgtuvcpd hoy vhg surgery works? • Ccp vhg rcvkgpv’u gxkuvkpi ogdkecn eopdkvkopu dg cdgsucvgny ocpcigd to reduce the risk of post operative complications? • Wknn vhg rcvkgpv dg cdng vo ectg fot hko or herself following surgery? • Fogu vhg rcvkgpv’u dgvgnorogpvcn history indicate any traumatic life events, abuse or neglect that might affect mental stability or lead to

ad - verse coping mechanisms (i.e. eating disorders, etc)? • Fogu vhg rcvkgpv hcvg cpy nkfguvyng or employment stressors that could affect post surgery compliance and outcomes? • Hcu vhg rcvkgpv dggp cdng vo noug weight using non-operative means in the past? • Wknn vhg rcvkgpv dg vtcvgnkpi ftoo c distance to the bariatric program for treatment, surgery, and/or follow-up uurrotvA Fo vhgy hcvg uuf�ekgpv ce - cess to transportation? • If vhg rcvkgpv ku vtcvgnkpi ftoo c dku - tance is the primary care provider willing to work with the surgical team to conduct follow-up? • Fogu vhg rcvkgpv hcvg ceeguu vo c comprehensive center of excellence CMA Foundation & CAHP • Pre/Post-Bariatric Surgery Provider Toolkit • Revised April 2008 4 Special Populations S ome patients should receive special consideration when contemplating bariatric surgery. Risks and complications may be more severe if the patient is in one of the following categories. Over 65 Years of Age • Cctgfun eopukdgtcvkop op c ecug/dy/ case basis, due to the potential for increasing risk of complications as - sociated with advanced age. Adolescent (Under 18 Years of Age) • Fug vo urgekcn eopukdgtcvkopu cpd urgek�e gnkikdknkvy etkvgtkc fot vhg cdo - lescent populations, please refer to the American Academy of Pediatrics guidelines on bariatric surgery for more information and consult with a bariatric surgeon regarding surgical options. Women of Child-Bearing Age • Rtgipcpey uhound dg cvokdgd fot cv least 12 to 18 months after bariatric surgery. Women experiencing rapid post surgery weight loss may be at a higher risk for pregnancy problems. • Rtgipcpv yoogp uhound dg ectgfunny oopkvotgd dy c OB/GYP cpd vhg dct - iatric surgeon due to special medical considerations. CMA Foundation & CAHP • Pre/Post-Bariatric Surgery Provider Toolkit • Revis

ed April 2008 5 Medi-Cal & Medicare Surgical Treatkent Criteria Medi-Cal Criteria 4 • Thg tgekrkgpv hcu c BMI of itgcvgt vhcp 42, ot nguu vhcp 42 kf uuduvcp - tial co-morbidity exists, such as life-threatening cardiovascular or pulmonary disease, sleep apnea, uncontrolled diabetes mellitus, or se - vere neurological or musculoskeletal problems likely to be alleviated by the surgery. • Hcknutg of uuuvckpgd ygkihv nouu op conservative regimens. • Thg tgekrkgpv hcu c engct cpd tgcnku - tic understanding of available alter - natives and how his/her life will be changed after surgery, including the possibility of morbidity and even mor - tality, and a credible commitment to make the life changes necessary to maintain the body size and health achieved. • Thg cdugpeg of eopvtckpdkecvkopu vo the surgery including major life-threat - ening disease not susceptible to al - leviation by the surgery, uncontrolled substance abuse, severe psychiatric impairment and demonstrated lack of compliance and motivation. Medicare Criteria 5 • Effgevkvg Hgdtucty 21, 2228, Mgdk - care will cover open and laparoscopic Toux/gp Y Gcuvtke Byrcuu (TYGBR), laparoscopic adjustable gastric band - kpi (LCGB) cpd orgp/ncrctoueorke biliopancreatic diversion with duode - pcn uykveh (BRF/FS) kf egtvckp etkvgtkc are met and the procedure is per - formed in an approved facility. Pursu - ant to the Medicare National Cover - age Determinations Manual (NCDM Rud0 122/23, Chcrvgt 1, Sgevkopu 4205 cpd 12201 Bctkcvtke Sutigty fot Morbid Obesity). • Mgdkectg yknn eovgt ygkihv nouu uut - gery if there is conclusive evidence of the following: Documentation in the medical record of a body-mass kpdgx (BMI) ≥ 35, ykvh cv ngcuv opg co-morbidity related to obesity; and previously unsuccessful medical treatments for obesity. • CMS hcu dgvgtokpgd vhcv tgcuopcdng and necess

ary bariatric surgery pro - cedures will be covered only when rgtfotogd cv c fceknkvy egtvk�gd dy: – Thg Cogtkecp Conngig of Sutigopu (CCS) cu c Lgvgn 1 Bctkcvtke Sut - igty Cgpvgt, yyy0fceu0oti/esk/duep – Thg Cogtkecp Soekgvy fot Bctkcvtke Sutigty (CSBS) cu c Bctkcvtke Sut - igty Cgpvgt of Exegnngpeg, hvvr:// www.asbs.org. – CMS eovgtcig ygdukvg, yyy0eou0 hhs.gov/MedicareApprovedFacili - • Thg fonnoykpi rtoegdutgu ctg pov eov - – Orgp/Lcrctoueorke Vgtvkecn Bcpd - gd Gcuvtorncuvy (VBG) cpd Snggvg Gastrectomy – Orgp Cdluuvcdng Gcuvtke Bcpdkpi CMA Foundation & CAHP • Pre/Post-Bariatric Surgery Provider Toolkit • Revised April 2008 6 Post-Mperative Patient Care 6 P ouvorgtcvkvg dctkcvtke uutigty rcvkgpvu tgsuktg nkfgnopi ogdkecn ocpcig - ment of obesity related medical problems by the bariatric surgeon and primary care physician. All weight loss surgery patients will need routine follow-up with the bariatric surgeon to minimize the risk of complications and co - otdkpcvg nopi vgto ectg pggdu0 Thg ftgsugpey of fonnoy/ur ykvh vhg dctkcvtke uut - igop dgrgpdu op vhg vyrg of rtoegdutg rgtfotogd cpd rtoitco tgsuktgogpvu0 Soog rtoegdutgu uueh cu Cdluuvcdng Gcuvtke Byrcuu “Lcr Bcpd” tgsuktg ootg Ongoing follow-up with the bariatric surgeon involves: • Ttgcvogpv of ehtopke ogdkecn eopdk - tions • Rouvorgtcvkvg eoornkecvkop oopkvotkpi • Mcpcigogpv of rcvkgpv puvtkvkopcn needs • Cdvcpegogpv of dkgvcty kpvckg cpd calorie intake as tolerated • Vkvcokp, okpgtcn cpd rtovgkp uurrng - ments may be necessary Patients should have realistic post- operative expectations; the amount of actual weight loss following a bariatric surgical procedure may depend on individual patient factors including 7 : • Cig cpd hgcnvh uvcvuu of rcvkgpv • Wgkihv rtkot vo uutigty • Tyrg of uutikecn rtoegdutg • Rcvkgpv oovkvcvkop cpd eoookvogpv vo

lifestyle changes •Coorgtcvkop of fcokny, ftkgpdu, cpd associates • Lopi vgto (itgcvgt vhcp 1 ygct) ocp - agement of patient primary care needs and post-operative follow-ups should be coordinated with the bar - iatric surgeon and may include labs, a physical examination, and continu - ing care updates. • Rcvkgpvu rtgugpvkpi ykvh cdpotocn ot vague abdominal symptoms should be carefully evaluated for bariatric surgery related complications which may indicate a need for further evalu - ation by the bariatric surgeon. • Rcvkgpvu eopukdgtkpi ot updgtiokpi a bariatric surgery procedure out - side their health plan network (out of network) or out of country may not tgegkvg ot hcvg ceeguu vo cdgsucvg post operative continuity of care or follow-up. • Mgdkecvkopu: Exvgpdgd, dgncygd/ tgngcug, gpvgtke/�no eocvgd ot eop - trolled release medications may not be properly absorbed. Patients may be switched to immediate release ogdkecvkopu ot nksukd fotouncvkopu, which may impact the degree of med - ication adherence. Other recommen - dations are suggested below: – Ectny rouv/orgtcvkvg rcvkgpvu vckkpi insulin or oral medications for dia - dgvgu cpd hyrgtvgpukop yknn tgsuktg close monitoring. Postoperative Primary Care Considerations 8 : CMA Foundation & CAHP • Pre/Post-Bariatric Surgery Provider Toolkit • Revised April 2008 7 Many patients are discharged home with no need for diabetes and/or hyperten - sion medications during the initial post-operative period. However, these patients yknn tgsuktg enoug fonnoy/ur cpd dnood uuict cpd/ot dnood rtguuutg oopkvotkpi cv home to determine if long term control medications will be necessary in combina - tion with dietary management. A patient care plan should be created clearly iden - vkfykpi vhg ftgsugpey of vhg hoog vguvkpi cpd yhkeh rhyukekcp yknn dg eootdkpcvkpi appropriate follow-up

and monitoring. • Popuvgtokdcn cpvk/kp�coocvoty dtuiu and salicylates may need to be avoided to prevent ulceration; risk cpd dgpg�vu uhound dg ygkihgd rtkot to initiation 9 . • Otcn dkuorhorhopcvgu ocy cnuo kp - crease the risk of ulceration in the gastrointestinal tract 10 . • Mgvcdonke: Bctkcvtke uutigty rcvkgpvu are at ongoing risk for nutritional de - �ekgpekgu cpd tgsuktg dckny ounvk/vk - tamin supplements. Patients experi - gpekpi ftgsugpv vookvkpi dutkpi tcrkd weight loss are at increased nutrition - • Ip vhg gvgpv of ukipk�ecpv ygkihv tg - gain, the patient should be referred to the bariatric surgeon for follow-up evaluation. • Rtgipcpey: Shound dg cvokdgd fot cv least 12 to 18 months after bariatric surgery. Women experiencing rapid post surgery weight loss may be at a higher risk for pregnancy problems. – Shound c rcvkgpv dgeoog rtgipcpv dutkpi vhg �tuv 12 vo 18 oopvhu, uhg should immediately follow up with vhg dctkcvtke uutigop0 “Lcr/Bcpd” patients need to follow up with the bariatric surgeon for band adjust - ment. •Couogvke Tgeopuvtuevkvg Sutigty: Some patients will desire cosmetic reconstructive surgery to remove gxeguu ukkp tguunv ftoo ukipk�ecpv weight loss. Most health plans only cover medically necessary recon - structive procedures. Patients should contact their health plan for more in - fotocvkop cdouv rouv uutigty dgpg�vu and coverage. CMA Foundation & CAHP • Pre/Post-Bariatric Surgery Provider Toolkit • Revised April 2008 8 Surgical Cokplications W hile mortality can occur at anytime, the most common causes of post operative mortality include but are not limited to abdominal sepsis sec - ondary to anastomotic leak, deep vein thrombosis (DVT) with second - Coooop Coornkecvkopu ocy dg encuuk�gd dy vhg orgtcvkvg

rtoegdutg cpd kp - clude: Intra-Operative Early Post Operative (Less than 60 Days) Late Post Operative (More than 60 days) Psychological • Cpguvhgukc • Tgehpkecn kp pcvutg • Cpcuvooovke ngck • Woupd ot kpfgevkopu • Fggr Vgpouu Thtoo - bosis Failure • Ceuvg kkdpgy ot nkvgt failure • Cvgngevcvuku secondary to sleep apnea • Ceuvg tgurktcvoty distress syndrome (ARDS) • Cpcuvooopke obstruction obstruction obstruction hernia • Wgkihv Louu Hcknutg Weight relationships • Cpotgxkc pgtvouc Common Post-Operative Side Effects: • Fuorkpi Sypdtoog / Rhyukonoikecn tgcevkop ecuugd dy tcrkd icuvtke gorvykpi of food ot nksukd kpvo vhg uocnn kpvguvkpg0 Syorvoou ocy kpenudg pcuugc, etcorkpi, vomiting, diarrhea, dizziness, weakness and shortness of breath. CMA Foundation & CAHP • Pre/Post-Bariatric Surgery Provider Toolkit • Revised April 2008 9 Repeat Procedures I n some cases a repeat bariatric surgery or surgical revision may be medically necessary to correct complications or technical failures including: The causes for short or long term weight loss failure should be carefully investi - icvgd rtkot vo updgtvckkpi c tgvkukop rtoegdutg0 C rcvkgpv ykvh kpcdgsucvg ygkihv loss after a procedure that was only restrictive, may be a candidate for a malab - sorptive or combination procedure. Patients unable to maintain weight loss after an initially successful operation, should be encouraged to re-double their efforts by following up with the bariatric support program and adhering to the dietary and exercise recommendations. Many bariatric programs have support groups avail - able to motivate and counsel post operative patients. In rare cases a surgical reversal of the bariatric procedure may be medically nec - essary to restore digestive capacity and function back to pre-surgery conditions. Complete reversal patients have a high li

kelihood of returning to a pre-operative weight status. Post-Operative Phases Most patients will need to have a post surgery plan that includes diet, nutrition, and physical activity guidance. Weight loss surgery patients will need to sig - pk�ecpvny ehcpig nkfguvyng cpd gcvkpi habits immediately following surgery to avoid complications and maximize long term success. It is very important to following eating and drinking instructions as provided by the bariatric surgeons or staff imme - diately following the operation to allow for healing and adjustment. The health and adjustment process make take a month or more depending upon the in - dividual. Most patient post operative phases and intervals will vary by procedure type and surgeon preference typically includes the following: • Cp cdvcpekpi dkgv of engct nksukdu, broths/soups, pureed food, soft and solid foods as directed • C rtoitguu gxgtekug rtoitco dy cr - propriate activity type and duration • C nkuv of foodu vo cvokd • Rcvkgpvu ctg uvtopiny gpeoutcigd vo participate in support groups provided • Rcvkgpvu vtcvgnkpi itgcvgt dkuvcpegu vo receive treatment and surgery should ask the bariatric surgeon about eopvgpkgpv cpd gcuy vo �pd noecn uur - port groups CMA Foundation & CAHP • Pre/Post-Bariatric Surgery Provider Toolkit • Revised April 2008 10 Jiving uitf Bariatric Surgery Diet • Rcvkgpvu uhound eopuuog uocnn, ftg - sugpv ogcnu vhtouihouv vhg dcy cpd avoid drinking immediately following meals. • Iv ku korotvcpv vo uvcy hydtcvgd throughout the day by drinking at least 6-8 cups of water per day between meals. • Cctdopcvgd dgvgtcigu uhound dg avoided. • Soog foodu ocy hcvg dkf�eunvy rcuu - ing through the altered gastrointesti - nal tract and may place the patient at risk for nausea, vomiting, or obstruc - tion. • Too oueh

ot dki rkgegu of food ecp cause obstruction of the gastric pouch. • Hood uhound dg kpvtoduegd unoyny cu tolerated. • Hood vongtcpeg yknn vcty ftoo rgtuop to person. • Cvokd itczkpi ot upcekkpi dgvyggp meals. •Cnn foodu uhound dg vhotouihny chewed before swallowing • Mcpy rcvkgpvu hcvg kpetgcugd food vongtcpeg dkf�eunvkgu dutkpi vhg ootp - ing hours. •Rcvkgpvu uhound uvor gcvkpi yhgp they feel full • Thg cooupv of food vhg icuvtke roueh can hold varies by procedure type. Appropriate meal food volume should be discussed with your surgeon. Exercise • Sgvvkpi kpdkvkducn gxgtekug iocnu yknn help promote personal investment in post bariatric surgery process. • Soog foto of dckny rhyukecn cevkvkvy must be introduced in combination with a nutrition plan. •Rcvkgpvu uhound eopuunv ykvh vhgkt bariatric surgeon and weight manage - ogpv vgco vo �pd ouv yhkeh rhyukecn activities are appropriate. CMA Foundation & CAHP • Pre/Post-Bariatric Surgery Provider Toolkit • Revised April 2008 11 Appendiv A8 BMG Calculation Metfod and TaCle A p kpdkvkducn’u dgitgg of odgukvy ecp dg cuuguugd dy ecneuncvkpi vhg Body BMI is calculated as follows: Weight in kilograms (kg) divided by 2 ). Weight in pounds (lbs) divided by the 2 ) BMI Ovgtygkihv cpd Odgukvy Cncuuk�ecvkopu: Category BMI Underweight Normal Overweight Obesity Class I Obesity Class II Souteg: Thg Pcvkopcn Ipuvkvuvgu of Hgcnvh Rudnkecvkop Po0 98/4283, Sgrv0 1998 BMI Resource Links and Calculators Centers for Disease Control and Prevention: • Ipfotocvkop cdouv BMI, opnkpg ecneuncvotu (Cdunvu, Chknd/Tggp), cpd nkpku vo cd - • hvvr://yyy0ede0iov/peedrhr/dprc/dok/kpdgx0hvo National Heart, Lung and Blood Institute – Obesity Education Initiative • hvvr://yyy0phndk0pkh0iov/hgcnvh/rudnke/hgctv/odgukvy/nougayv/kpdgx0hvo PDA Software (Free

Downloads for use on Palm OS and Pocket PC) • Rtovkdgu kpfotocvkop op BMI, RFC ecneuncvotu (Epinkuh cpd Mgvtke ogcuutg - Weight (kg) 2 ) Weight (lbs) 2 ) CMA Foundation & CAHP • Pre/Post-Bariatric Surgery Provider Toolkit • Revised April 2008 12 Appendiv B8 Bariatric Surgical Procedures Advantages & Bisadvantages TaCle Open Gastric Bypass Roux-en-Y (RYGBP) Advantages Disadvantages/Complications - strictive procedures weight related co-morbidities - ciency - plications: anastomotic leak, pulmonary em - bolism, wound infection, gastroin - testinal hemorrhage, respiratory kpuuf�ekgpey, cpd ootvcnkvy - sional hernia, bowel obstruction, internal hernia, stomal stenosis, marginal ulcers Laparoscopic Gastric Bypass Roux-en-Y (RYGBP) Advantages Disadvantages/Complications - strictive procedures loss - ing from incisional hernia and infec - tions hernia - ciency - plications: anastomotic leak, pulmonary em - bolism, wound infection, gastroin - testinal hemorrhage, respiratory kpuuf�ekgpey, cpd ootvcnkvy0 - sional hernia, bowel obstruction, internal hernia, stomal stenosis, marginal ulcers CMA Foundation & CAHP • Pre/Post-Bariatric Surgery Provider Toolkit • Revised April 2008 14 Laparoscopic Adjustable Gastric Banding (LAGB) Advantages Disadvantages/Complications - tinal tract Bcpd Cdluuvcdknkvy - drome food removal band adjustments operative and late complications: - ing hemorrhage, need for conver - sion to open procedure, and spleen, stomach or esophagus injury band slippage (stomach prolapse), balloon or tubing leak, port infec - tions, band infections, obstruction and nausea/vomiting. erosion into the stomach, esopha - geal dilatation, and failure to lose weight Biliopancreatic Diversion (BPD) with Duodenal Switch Advantages Disadvantages/Complications compared to bypass and band pro - cedures loss - pared to other procedures

- ach Pov Cdluuvcdng - - okp cduotrvkop (Vkvcokpu C, F, E, and K) and ulcers Source: • “Btkgf Hkuvoty cpd Suoocty of Bctkcvtke Sutigty”0 Cogtkecp Soekgvy of Bctkcvtke Surgery. Retrieved from www.asbs.org. • Rcvkgpv Eduecvkop Btoehutg – Tckkpi vhg Pgxv Svgr0 Ipcogd Hgcnvh0 www.allergan.com • Thg Hcevu Cdouv Wgkihv Louu Sutigty Btoehutg – Evhkeop Epdo/Sutigty Bct - CMA Foundation & CAHP • Pre/Post-Bariatric Surgery Provider Toolkit • Revised April 2008 15 Appendiv C8 Bariatric Surgery Resources National Consensus Guidelines/Statements 10 Buehycnd, H0 Bctkcvtke Sutigty fot Motdkd Odgukvy: Hgcnvh Iornkecvkopu fot Rc - tients, Health Professionals, and Third-Party Payers. Consensus Statement. 20 Thg Rtcevkecn Gukdg – Idgpvk�ecvkop, Evcnucvkop, cpd Ttgcvogpv of Ovgtygkihv cpd Odgukvy kp Cdunvu0 Pcvkopcn Hgctv, Lupi, cpd Bnood Ipuvkvuvg (PHLBI)0 October 2000. Retrieved from http://www.nhlbi.nih.gov/guidelines/obesity/ 30 Tocdocru fot Cnkpkecn Rtcevkeg Sgtkgu: Cuuguuogpv cpd Mcpcigogpv of Cdunv Odgukvy – Bookngv 7 Sutikecn Mcpcigogpv0 Cogtkecp Mgdkecn Cuuo - ekcvkop (CMC)0 22230 Tgvtkgvgd ftoo hvvr://yyy0coc/cuup0oti/coc/rud/ 40 Ipig, T0, gv cn0 Bctkcvtke Sutigty fot Sgvgtgny Ovgtygkihv Cdonguegpvu: Cop - cerns and Recommendations. Pediatrics. January 12, 2006. 50 Cigpey fot Hgcnvhectg Tgugcteh cpd Sucnkvy (CHTS)0 “Rhctoceonoikecn cpd Sutikecn Ttgcvogpv of Odgukvy”0 Rtgrctgd dy Souvhgtp/Ccnkfotpkc/Tcpd Evk - dgpegd/Bcugd Rtcevkeg Cgpvgt0 CHTS Rudnkecvkop Po0 24/E228/20 Juny 22240 80 “Btkgf Hkuvoty cpd Suoocty of Bctkcvtke Sutigty”0 Cogtkecp Soekgvy of Bctkcvtke Surgery. Retrieved from www.asbs.org. 70 Coooopygcnvh of Mcuucehuugvvu Bgvuy Lghocp Cgpvgt fot Rcvkgpv Scfgvy cpd Mgdkecn Ettot Tgduevkop – Exrgtv Rcpgn op Wgkihv Louu Sutigty0 Exgeuvkvg Tgrotv0 Cuiuuv 4, 22240 Continuing Medical Education (

CME) Programs • Cogtkecp Mgdkecn Cuuoekcvkop – Tocdocru fot Cnkpkecn Rtcevkeg Sgtkgu: Cu - sessment and Management of Adult Obesity. http://www.ama-assn.org/ama/ CMA Foundation & CAHP • Pre/Post-Bariatric Surgery Provider Toolkit • Revised April 2008 16 Informational Web Links Allergan, Inc. www.allergan.com American College of Surgeons (ACS) www.facs.org American Obesity Association (AOA) www.obesity.org www.asbp.org www.asbs.org California Medical Association Foundation www.calmedfoundation.org Center for Medicare & Medicaid Services www.cms.hhs.gov Evhkeop Epdo/Sutigty, Ipe0 www.ethiconendo.com North American Association for the Study of Obesity (NAASO) www.naaso.org www.nhlbi.nih.gov Obesityhealth.com www.obesityhealth.com Obesity Help www.obesityhelp.com www.realizeband.com Surgical Review Corporation www.surgicalreview.org Weight Loss Surgery Info www.weightlosssurgeryinfo.com CMA Foundation & CAHP • Pre/Post-Bariatric Surgery Provider Toolkit • Revised April 2008 17 Appendiv B8 Rederences 10 Thg Rtcevkecn Gukdg – Idgpvk�ecvkop, Evcnucvkop, cpd Ttgcvogpv of Ovgtygkihv cpd Odgukvy kp Cdunvu0 Pcvkopcn Hgctv, Lupi, cpd Bnood Ipuvkvuvg (PHLBI)0 Oevo - ber 2000. Patients, Health Professionals, and Third-Party Payers. Consensus Statement. cpd Mgdkecn Ettot Tgduevkop – Exrgtv Rcpgn op Wgkihv Louu Sutigty0 Exgeu - vkvg Tgrotv0 Cuiuuv 4, 22240 50 MLP Mcvvgtu Puodgt: MM52130 Crtkn 28, 22280 yyy0eou0hhu0iov/MLP - 6. Understanding Weight Loss Surgery: Procedures to care for your morbidly odgug rcvkgpvu0 Evhkeop Epdo/Sutigty, Ipe0 22250 rcig 340 70 Thg Hcevu Cdouv Wgkihv Louu Sutigty: C Bcncpegd Fkueuuukop of Yout Ttgcv - ment Options. - kpi nopi/vgto ogdkecn kuuugu tgncvgd vo Bctkcvtke Sutigty0 Evhkeop Epdo/Sut - igty, Ipe0 FSL#23/1321040 Fosamax (alendrontae sodium) package insert. Whitehouse Station, NJ: CMA Foundation & CAH

P • Pre/Post-Bariatric Surgery Provider Toolkit • Revised April 2008 18 Medicine California Department of Health Care Services Bruce Wolfe, MD Professor of Surgery Oregon Health and Science University Nancy Wongvipat Director of Health Education Health Net, Inc. Sophia Yen, MD, MPH Clinical Instructor, Division of Adolescent Medicine Lucille Packard Children's Hospital at Stanford University Medical Center Maggie Parks, MD Pediatrician Ventura County Medical Center Donald Rebhun, MD Regional Medical Director HealthCare Partners Medical Group Peggy Rowberg, DNP, APN Past President CA Association of Nurse Practitioners Linda Rudolph, MD, MPH Berkeley City Health Department Milton Sakamoto, MD Senior Medical Director, West Region Aetna US Healthcare, Inc. Harvinder Sareen, PhD, MPH Director, Health Care Quality and Innovations, State Sponsored Business CEO and Medical Director Obesity Treatment Center Medical Group Donald Hufford, MD Medical Director Western Health Advantage Kathy Shadle James, DNSc, NP Associate Professor of Nursing University of San Diego, Hahn School of Nursing Helen Jones, MD Family Practice Fresno-Madera Medical Society Patrick Kearns, MD Director, Chronic Care Management Program Santa Clara Valley Medical Center Dexter Louie, MD, JD, MPA Chinese Community Health Plan CMA Foundation Board Member Kelly Lee, PharmD, BCPP Assistant Professor of Clinical Pharmacy Gaye Breyman CA Academy of Physician Assistants Michael-Anne Browne, MD Medical Director for Quality Blue Shield of California Javier Carrillo, MPH Area Health Promotion Specialist, Greater Bay Area California Diabetes Program Art Chen, MD Medical Director Alameda Health Alliance David Der, MD Executive Director Chinese American Physicians' Society Lakshmi Dhanvanthari, MD, FAAP Staff VP, Medical Director - CMA Foundation & CAHP • Pre/Post-Bariatric S

urgery Provider Toolkit • Revised April 2008 ii Acknowledgements T he California Medical Association Foundation and California Association of Health Plans would like to thank the following individuals for their dedication to this project. Their support, time, and expertise were critical to the development of this document. Chris Bekins, MS, RD Health Information Specialist, Prevention and Planning County of Sonoma Health Services Nathalie Bergeron, PhD Associate Professor Touro University, College of Pharmacy Gaye Breyman CA Academy of Physician Assistants Michael-Anne Browne, MD Medical Director for Quality Blue Shield of California Javier Carrillo, MPH Area Health Promotion Specialist, Greater Bay Area California Diabetes Program Art Chen, MD Medical Director Alameda Health Alliance David Der, MD Executive Director Chinese American Physicians' Society Lakshmi Dhanvanthari, MD, FAAP Staff VP, Medical Director - State Sponsored Business Anthem Blue Cross Edward Dietz, MD Medical Director, Glendale Health - Care Facilitation Center CIGNA Health Care of California Jason Eberhart-Phillips, MD, MPH El Dorado County Department of Health Scott Gee, MD Medical Director, Prevention and Health Information Kaiser Permanente Northern California Lawrence Hammer, MD Professor of Pediatrics Stanford University School of Medi - cine William Henning, DO Medical Director Inland Empire Health Plan John Hernried, MD, FACP CEO and Medical Director Obesity Treatment Center Medical Group Donald Hufford, MD Medical Director Western Health Advantage Kathy Shadle James, DNSc, NP Associate Professor of Nursing University of San Diego, Hahn School of Nursing Helen Jones, MD Family Practice Fresno-Madera Medical Society Patrick Kearns, MD Director, Chronic Care Management Program Santa Clara Valley Medical Center Dexter Louie, MD, JD, MPA Chinese Community Health Plan

CMA Foundation Board Member Kelly Lee, PharmD, BCPP Assistant Professor of Clinical Pharmacy University of California, San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences Samrina Marshall, MD, MPH Regional Medical Director, State Health Programs Health Net, Inc. Suzanne Michaud, MPH Health Promotion Educator CenCal Health Shobha Naimpally, MD, MPH, FAAP Medical Director, Community Health Plan Los Angeles County Department of Health Services Jennifer Nuovo, MD Senior Medical Director, State Health Programs Health Net, Inc. David Ormerod, MD Regional Medical Director Blue Shield of California Maggie Parks, MD Pediatrician Ventura County Medical Center Donald Rebhun, MD Regional Medical Director HealthCare Partners Medical Group Peggy Rowberg, DNP, APN Past President CA Association of Nurse Practitioners Linda Rudolph, MD, MPH Berkeley City Health Department Milton Sakamoto, MD Senior Medical Director, West Region Aetna US Healthcare, Inc. Harvinder Sareen, PhD, MPH Director, Health Care Quality and Innovations, State Sponsored Business Anthem Blue Cross Timothy Schwab, MD SCAN Health Plan Mel Sterling, MD, FACP Internal Medicine California Medical Association Sherry Stolberg, MGPGP, PA-C Director, Primary Care Associate Programs CA Academy of Physician Assistants Jennifer Trapp, MD Staff Physician, Department of Family Medicine Sharp Rees-Stealy Medical Group Donald Waldrep, MD Bariatric Surgeon Sutter Roseville Medical Center Joseph Wanski, MD Medical Director LA Care Health Plan Seleda Williams, MD, MPH Medicine California Department of Health Care Services Bruce Wolfe, MD Professor of Surgery Oregon Health and Science University Nancy Wongvipat Director of Health Education Health Net, Inc. Sophia Yen, MD, MPH Clinical Instructor, Division of Adolescent Medicine Lucille Packard Children's Hospital at Stanford University