title: Systems innovation model: an integrated interdisciplinary team approach pre- and post-bariatric surgery at a veterans affairs (VA) medical center.
abstract: BACKGROUND
  Provision of bariatric surgery in the Veterans Health Administration must account for obese veterans' co-morbidity burden and the geographically dispersed location of patients relative to Veterans Affairs (VA) bariatric centers.
  
  
  OBJECTIVE
  To evaluate a collaborative, integrated, interdisciplinary bariatric team of surgeons, bariatricians, psychologists, dieticians, and physical therapists working in a hub-and-spokes care model, for pre- and post-bariatric surgery assessment and management.
  
  
  METHODS
  This is a description of an interdisciplinary clinic and bariatric program at a VA healthcare system and a report on program evaluation findings. Retrospective data of a prospective database was abstracted. For program evaluation, we abstracted charts to characterize patient data and conducted a patient survey.
  
  
  RESULTS
  Since 2009, 181 veterans have undergone bariatric surgery. Referrals came from 7 western U.S. states. Mean preoperative body mass index was 46 kg/m2(maximum 71). Mean age was 53 years, with 33% aged>60 years; 79% were male. Medical co-morbidity included diabetes (70%), hypertension (85%), and lower back or extremity joint pain (84%). A psychiatric diagnosis was present in 58%. At 12 months, follow-up was 81% and percent excess body mass index loss was 50.5%. Among 54 sequential clinic patients completing anonymous surveys, overall satisfaction with the interdisciplinary team approach and improved quality of life were high (98% and 94%, respectively).
  
  
  CONCLUSIONS
  The integrated, interdisciplinary team approach using a hub-and-spokes model is well suited to the VA bariatric surgery population, with its heavy burden of medical and mental health co-morbidity and its system of geographically dispersed patients receiving treatment at specialty centers. As the VA seeks to expand the use of bariatric surgery as an option for obese veterans, interdisciplinary models crafted to address case complexity, care coordination, and long-term outcomes should be part of policy planning efforts.
authors.affiliation: Surgical Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA; Department of Surgery, Stanford School of Medicine, Stanford, CA. Electronic address: daneisenberg@stanford.edu.
authors.forename: Dan
authors.initials: D
authors.lastname: Eisenberg
authors.affiliation: Psychology Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA.
authors.forename: Jessica A
authors.initials: JA
authors.lastname: Lohnberg
authors.affiliation: Surgical Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA; Department of Surgery, Stanford School of Medicine, Stanford, CA.
authors.forename: Eric P
authors.initials: EP
authors.lastname: Kubat
authors.affiliation: Medicine Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA.
authors.forename: Cheryl C
authors.initials: CC
authors.lastname: Bates
authors.affiliation: Psychology Service, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA; War Related Illness and Injury Study Center, East Orange, NJ.
authors.forename: Lauren M
authors.initials: LM
authors.lastname: Greenberg
authors.affiliation: VA Health Services Research & Development Center for Innovation to Implementation (Ci2 i), Palo Alto Veterans Affairs Health Care System, Palo Alto, CA; Department of Medicine, Stanford School of Medicine, Stanford, CA.
authors.forename: Susan M
authors.initials: SM
authors.lastname: Frayne
mesh_terms: D050110:Bariatric Surgery / Q000379:methods*; D015992:Body Mass Index; D005260:Female; D006787:Hospitals, Veterans; D006801:Humans; D007400:Interprofessional Relations; D008297:Male; D009767:Obesity, Morbid / Q000601:surgery*; D015397:Program Evaluation; D058996:Quality Improvement; D011788:Quality of Life; D012189:Retrospective Studies; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans / Q000706:statistics & numerical data*
keywords: Bariatric surgery; Hub-and-spokes; Obesity; Veterans affairs; Weight management