Team approach to care optimizes bariatric surgery outcomes

Applying the collaborative prescribing (CP) practice framework in the care of patients who have undergone bariatric surgery in Singapore is viable and helps the patients achieve the best possible outcomes, reports a research team from the Singapore General Hospital.

“In Singapore, CP is a new professional practice area for both advanced practice nurses and senior pharmacists, in which they are upskilled to legally prescribe medicines, without the need to obtain a doctor’s countersignature and order laboratory investigation tests in a collaborative framework overseen by doctors,” they said.

Through the National Collaborative Prescribing Programme, CP practitioners acquire expertise in various areas such as history taking, data interpretation, diagnostic formulation, physical examination, clinical decision making, applied therapeutics, psychosocial aspects of prescribing, collaboration with multidisciplinary teams, effective communication, and documentation. The aim is to deliver holistic and continuous care to patients by empowering nurses and senior pharmacists to perform advanced roles.  [https://tinyurl.com/273s3qyc; https://tinyurl.com/296e6ale; https://tinyurl.com/25kgejkz]

According to the researchers, the CP model frees up doctors’ time, with CP practitioners providing ongoing support between consultation visits. In effect, treatment delays are prevented, and long-term outcomes are improved.

Successful implementation

In a paper, the researchers described the outcomes of employing the CP care model in the management of a postbariatric surgery population in an obesity centre. Under the CP agreement, endocrinologists referred patients who had undergone bariatric surgery and had stable medical conditions to CP practitioners. These practitioners examined the patients’ weight loss progress, blood test results and vitals, the sufficiency of micronutrient repletion, adherence to supplements and medications, and chronic disease control.

Over 3 years, CP practitioners completed 672 patient consultations. The number of referrals made by the endocrinologists to the CP practitioners rose steadily during this period, from 3–4 to 28 patients a month, with the CP practitioners consistently meeting the consultation target of 30 per year. [Pharmacy 2024;12:31]

The program achieved a perfect safety record, with zero reported errors or near-misses in prescribing and ordering of laboratory tests or deviations from CP agreements, the researchers noted.

Additionally, every single service performance indicator was met. The majority of patients (68 percent) achieved a weight loss of at least 20 percent with sleeve gastrectomy or at least 25 percent with Roux-en-Y gastric bypass during the acute phase postsurgery. Eighty percent of patients maintained a significant weight loss, regaining less than 10 percent of their nadir weight postsurgery, even after 1 year.

A few patients presented with anaemia and iron deficiency (6.3 percent), as well as insufficient levels of vitamin B12 (4.9 percent), folate (6.3 percent), and vitamin D (1.3 percent). HbA1c was less than 7 percent in at least 88 percent of patients.

Appropriate medication adjustments

“To our best knowledge, we are among the first hospitals in the world to include a pharmacist, advanced practice nurse, and endocrinologist in CP practice in an obesity centre… The CP model allowed for the increased accommodation of the needs of the expanding pool of postbariatric surgery patients to receive timely and regular follow-up on weight loss progress, nutritional, and metabolic status,” the researchers said.

Moreover, “data from our bariatric cohort showed that in patients with type 2 diabetes and severe obesity, 81 percent had a reduction in the number of diabetes medications 1 year after surgery. Similarly, the use of blood pressure-lowering medications declined from 84 percent at baseline to 40 percent at 1 year, and lipid-lowering medication usage declined from 78 percent at baseline to 37 percent,” they added. [Obes Surg 2018;28:1511-1518]

Taken together, the results underscore the pivotal role of CP practitioners in the close monitoring of blood pressure, blood glucose, and metabolic parameters after bariatric surgery, as well as making necessary adjustments to patients’ medications to avoid complications such as hypotension and hypoglycaemia, according to the researchers.

“The extension of prescribing rights to the CP practitioners not only recognizes the capabilities of CP practitioners but also provides them the autonomy to manage patients, which is an important milestone in materializing true interdisciplinary patient care,” they pointed out. [https://www.moh.gov.sg/docs/librariesprovider4/guidelines/guidelines-for-implementation-of-collaborative-prescribing-services.pdf]

In light of the successful implementation of the CP practice model in the obesity centre, the team shared its plans to expand to the care framework to include nonsurgical patients with obesity who take antiobesity medications as well as the prebariatric surgery population.