The evaluating self-management and educational support in severely obese patients awaiting multidisciplinary bariatric care (EVOLUTION) trial: rationale and design

Exploring the Cost of eLearning in Health Professions Education: Scoping Review

BACKGROUND

Existing research on the costs associated with the design and deployment of eLearning in health professions education is limited. The relative costs of these learning platforms to those of face-to-face learning are also not well understood. The lack of predefined costing models used for eLearning cost data capture has made it difficult to complete cost evaluation.

OBJECTIVE

The key aim of this scoping review was to explore the state of evidence concerning cost capture within eLearning in health professions education. The review explores the available data to define cost calculations related to eLearning.

METHODS

The scoping review was performed using a search strategy with Medical Subject Heading terms and related keywords centered on eLearning and cost calculation with a population scope of health professionals in all countries. The search was limited to articles published in English. No restriction was placed on literature publication date.

RESULTS

In total, 7344 articles were returned from the original search of the literature. Of these, 232 were relevant to associated keywords or abstract references following screening. Full-text review resulted in 168 studies being excluded. Of these, 61 studies were excluded because they were unrelated to eLearning and focused on general education. In addition, 103 studies were excluded because of lack of detailed information regarding costs; these studies referred to cost in ways either indicating cost favorability or unfavorability, but without data to support findings. Finally, 4 studies were excluded because of limited cost data that were insufficient for analysis. In total, 42 studies provided data and analysis of the impact of cost and value in health professions education. The most common data source was total cost of training (n=29). Other sources included cost per learner, referring to the cost for individual students (n=13). The population most frequently cited was medical students (n=15), although 12 articles focused on multiple populations. A further 22 studies provide details of costing approaches for the production and delivery of eLearning. These studies offer insight into the ways eLearning has been budgeted and project-managed through implementation.

CONCLUSIONS

Although cost is a recognized factor in studies detailing eLearning design and implementation, the way cost is captured is inconsistent. Despite a perception that eLearning is more cost-effective than face-to-face instruction, there is not yet sufficient evidence to assert this conclusively. A rigorous, repeatable data capture method is needed, in addition to a means to leverage existing economic evaluation methods that can then test eLearning cost-effectiveness and how to implement eLearning with cost benefits and advantages over traditional instruction.

Extensive Review of Persuasive System Design Categories and Principles: Behavioral Obesity Interventions

In this extensive review of behavioral digital obesity interventions, we reviewed randomized control trials aimed at weight loss or maintaining weight loss and identifying persuasive categories and principles that drive these interventions. The following databases were searched for long-term obesity interventions: Medline, PsycINFO, Academic Search Complete, CINAHL and Scopus. The inclusion criteria included the following search terms: obesity, overweight, weight reduction, weight loss, obesity management, and diet control. Additional criteria included randomized control trial, ≥ 6 months intervention, ≥ 100 participants and must include persuasive technology. Forty-six publications were in the final review. Primary task support was the most frequently utilized persuasive system design (PSD) category and self-monitoring was the most utilized PSD principle. Behavioral obesity interventions that utilized PSD with a behavior change theory more frequently produced statistically significant weight loss findings. Persuasive technology and PSD in digital health play a significant role in the management and improvement of obesity especially when aligned with behavior change theories. Understanding which PSD categories and principles work best for behavioral obesity interventions is critical and future interventions might be more effective if they were based on these specific PSD categories and principles.

Patient perspectives about bariatric surgery unveil experiences, education, satisfaction, and recommendations for improvement

BACKGROUND

Following bariatric surgery, up to 35% of patients struggle with strict regimens and experience weight recidivism within 2 years [1-5]. Accredited weight management centers (WMC) must provide educational programs and support patients in lifestyle changes before and after surgery. Educational programs, however, may not be evidence-based or patient-centered and may vary in curriculum, approach, and educator type [6].

OBJECTIVE

To obtain patient descriptions about the weight loss surgery (WLS) experience, including education, satisfaction, and recommendations for improvement.

SETTING

Participants were recruited from a university hospital-based WMC in Pennsylvania.

METHODS

This qualitative descriptive study used purposive sampling and inductive content analysis.

RESULTS

A NEW ME-VERSION 2.0, encompassed themes from semistructured interviews with 11 participants (36% male). Theme 1: Programming and Tools, explained how individuals undergoing WLS found support through educational programming. Theme 2: Updates and Upgrades, identified issues surrounding quality of life and challenges before and after surgery. Theme 3: Lessons Learned and Future Considerations, identified satisfaction levels and recommendations for improving the WLS experience. Participants reported positive experiences, acknowledging educational programs and extensive WMC resources, yet also offered recommendations for improving educational programming.

CONCLUSION

Patient narratives provided evidence about the WLS experience. Achievement of weight goals, adherence to rules, and improved health status contributed to perceptions of WLS success. Participants encouraged educators to identify expected outcomes of educational programming, monitor holistic transformations, foster peer support, and use technology in WMC programming. Results also validated the need for the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program's education requirement (standard 5.1). Future educational research could help develop best practices in WLS patient education and assess associations between education and clinical outcomes.

The evaluating self-management and educational support in severely obese patients awaiting multidisciplinary bariatric care (EVOLUTION) trial: principal results

BACKGROUND

In Canada, demand for multidisciplinary bariatric (obesity) care far outstrips capacity. Consequently, prolonged wait times exist that contribute to substantial health impairments. A supportive, educational, self-management intervention (with in-person and web-based versions) for patients wait-listed for bariatric care has already been implemented in Northern and Central Alberta, Canada, but its effectiveness is unknown. The objective of this trial is to evaluate the clinical and economic outcomes of two self-management programs of varying intensity that are currently in use.

METHODS

We conducted a pragmatic, prospective, parallel-arm, randomized controlled trial of 651 wait-listed patients from two regional bariatric programs. Patients were randomized to (1) an in-person, group-based intervention (13 sessions; n = 215) or (2) a web-based intervention (13 modules; n = 225) or (3) control group (printed educational materials; n = 211). After randomization, subjects had 3 months to review the content assigned to them (the intervention period) prior to bariatric clinic entry. The primary outcome was the proportion of patients achieving 5% weight loss at 9 months. Intention-to-treat two-way comparisons were performed and adjusted for baseline age, sex, site and body mass index.

RESULTS

At baseline, mean age was 40.4 ± 9.8 years, mean weight was 134.7 ± 25.2 kg, mean body mass index was 47.7 ± 7.0 kg/m² and 83% of participants were female. A total of 463 patients (71%) completed 9 months follow-up. At least 5% weight loss was achieved by 24.2% of those in the in-person strategy, 24.9% for the web-based strategy and 21.3% for controls (adjusted p value = 0.26 for in-person vs. controls, 0.28 for web-based vs. controls, 0.96 for in-person vs. web-based). Absolute and relative (% of baseline) mean weight reductions were 3.7 ± 7.1 kg (2.7 ± 5.4%) for in-person strategy, 2.8 ± 6.7 kg (2.0 ± 4.8%) for web-based and 2.9 ± 8.8 kg (1.9 ± 5.9%) for controls (p > 0.05 for all comparisons). No between-group differences were apparent for any clinical or humanistic secondary outcomes. Total annual costs in Canadian dollars were estimated at $477,000.00 for the in-person strategy, $9456.78 for the web-based strategy and $2270.31 for provision of printed materials.

DISCUSSION

Two different self-management interventions were no more effective and were more costly than providing printed education materials to severely obese patients. Our findings underscore the need to develop more potent interventions and the importance of comprehensively evaluating self-management strategies before widespread implementation.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01860131 . Registered 17 May 2013.

Systematic review of patient education practices in weight loss surgery

BACKGROUND

Education plays a key role in adherence to lifestyle modifications after weight loss surgery (WLS). Education given before and after surgery may decrease weight recidivism rates and improve outcomes.

OBJECTIVE

The purpose of this systematic review was to analyze educational practices in bariatric centers.

METHODS

The Cumulative Index to Nursing and Allied Health and PubMed databases were searched in May 2016 for English-language, peer-reviewed studies about WLS patient education practices from 1999 to 2016. Publications were: (1) rated with the Advancing Research and Clinical Practice through Close Collaboration levels of evidence hierarchy (see Melnyk's pryamid [http://guides.lib.umich.edu/c.php?g=282802&p=1888246]) and (2) analyzed according to surgical phase, curriculum, program delivery, and educator.

RESULTS

Twenty-four publications met the study criteria. Evidence ratings for preoperative (n = 16) and postoperative studies (n = 8) were levels I to III (n = 5) and IV to VII (n = 17). Two publications were not ratable. Preoperative and postoperative education programs varied in curriculum, teaching methods, and educator. Topics varied in depth. Commonalities were surgical procedure, nutrition, activity, and psychosocial behaviors. Preoperative education was mostly provided in small groups, whereas individual sessions were used postoperatively. Lecture and discussion provided by myriad of healthcare experts from multiple disciplines were typical in both phases. Written or web-based aides supported learning needs in both phases.

CONCLUSION

WLS patient education varied by curriculum and dose and commonly used passive learning methods (e.g., traditional lecture style instruction with minimal engagement from learners). Results shared can inform future bariatric education programs and accreditation standard development (e.g., Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program patient education standards). Additional study is needed, but existing evidence can guide improvements in high-quality, cost-effective, and patient-centered educational programs.

Psychosocial Interventions Pre and Post Bariatric Surgery

Despite positive results overall, a substantial number of patients experience poor long-term outcomes following bariatric surgery. One reason for variability in weight loss may be difficulty in making and sustaining changes in dietary intake and physical activity; post-surgery binge eating has also been associated with poorer weight outcomes. In this paper, we review available evidence on adjunctive psychosocial interventions for bariatric surgery patients. Although the literature is limited, evidence suggests that bariatric surgery patients may benefit from a comprehensive approach targeting diet, activity and psychological factors. We think the optimal time to initiate adjunctive intervention is after surgery, but before significant weight regain has occurred. Adaptive interventions incorporating advances in technology may prove to be effective for promoting behavioural self-management and psychosocial adjustment following bariatric surgery. For some patients, pharmacotherapy and reoperation may also play a role in a personalized approach to post-surgery care.

A Comparison of Casual In-Clinic Blood Pressure Measurements to Standardized Guideline-Concordant Measurements in Severely Obese Individuals

Background/Objectives. The objective of this study was to compare casual BP taken in a bariatric clinic to standardized guideline-concordant BP. Subjects/Methods. A cross sectional analysis was performed using baseline data from a weight management trial. Patients were recruited from a Canadian bariatric care program. Standardized BP was performed using a Watch BP oscillometric device. Casual in-clinic BP single readings, taken using a Welch Allyn oscillometric device, were chart-abstracted. Paired t-tests, Bland-Altman plots, and Pearson's correlations were used for analysis. Results. Data from 134 patients were analyzed. Mean age was 41.5 ± 8.9 y, mean BMI was 46.8 ± 6.5 kg/m(2), and 40 (30%) had prior hypertension. Mean casual in-clinic BP was 128.8 ± 14.1/81.6 ± 9.9 mmHg and mean standardized BP was 133.2 ± 15.0/82.0 ± 10.3 mmHg (difference of -4.3 ± 12.0 for systolic (p < 0.0001) and -0.4 ± 10.0 mmHg for diastolic BP (p = 0.6)). Pearson's coefficients were 0.66 (p < 0.0001) for SBP and 0.50 (p < 0.0001) for DBP. 28.4% of casual versus 26.9% of standardized measurements were ≥140/90 mmHg (p < 0.0001). Conclusion. In this bariatric clinic, casual BP was unexpectedly lower than standardized BP. This could potentially lead to the underdiagnosis of hypertension.