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Toronto Bariatric Interprofessional Psychosocial Assessment Suitability Scale: Evaluating A New Clinical Assessment Tool for Bariatric Surgery Candidates
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Toronto Bariatric Interprofessional Psychosocial Assessment Suitability Scale (BIPASS TM): Evaluating A New Clinical Assessment Tool for Bariatric Surgery Candidates Gurneet Thiara MD, Richard Yanofksy MD FRCPC, Sayed Abdul-Kader MD FRCPC, Vincent A. Santiago BSc, Stephanie Cassin PhD CPsych, Allan Okrainec MD MHPE FRCSC, Timothy Jackson MD FRCSC, Raed Hawa MD, FRCPC, Sanjeev Sockalingam MD MHPE FRCPC
PII: DOI: Reference:
S0033-3182(15)00210-8 http://dx.doi.org/10.1016/j.psym.2015.12.003 PSYM600
To appear in:
Psychosomatics
Cite this article as: Gurneet Thiara MD, Richard Yanofksy MD FRCPC, Sayed Abdul-Kader MD FRCPC, Vincent A. Santiago BSc, Stephanie Cassin PhD CPsych, Allan Okrainec MD MHPE FRCSC, Timothy Jackson MD FRCSC, Raed Hawa MD, FRCPC, Sanjeev Sockalingam MD MHPE FRCPC, Toronto Bariatric Interprofessional Psychosocial Assessment Suitability Scale (BIPASS TM): Evaluating A New Clinical Assessment Tool for Bariatric Surgery Candidates, Psychosomatics, http://dx.doi.org/10.1016/j.psym.2015.12.003 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Toronto Bariatric Interprofessional Psychosocial Assessment Suitability Scale (BIPASS TM): Evaluating a new clinical assessment tool for bariatric surgery candidates Gurneet Thiara MD1, Richard Yanofksy MD FRCPC1, Sayed Abdul-Kader MD FRCPC1, Vincent A. Santiago BSc1, Stephanie Cassin PhD CPsych3, Allan Okrainec MD MHPE FRCSC 2, Timothy Jackson MD FRCSC 2, Raed Hawa MD, FRCPC1, Sanjeev Sockalingam MD MHPE FRCPC1.
1
Bariatric Surgery Psychosocial Program, Department of Psychiatry, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada 2 Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada 3 Department of Psychology, Ryerson University, Toronto, Ontario, Canada.
Corresponding Authors: Dr. Sanjeev Sockalingam Toronto General Hospital 200 Elizabeth Street-8EN-228 Toronto, ON M5G 2C4 Ph: 416-340-3762 Fax: 416-340-4198 Email: [email protected] Dr. Raed Hawa Toronto Western Hospital 399 Bathurst Street Toronto, ON M5T 2S8 Email: [email protected]
Running Title:
Abstract Background: Patients who are referred for possible Bariatric Surgery (BS) intervention undergo a series of assessments conducted by an interdisciplinary health care team to determine suitability for surgery. Herein, we report the initial validation and reliability studies of the Bariatric Interprofessional Psychosocial Assessment Suitability Scale (BIPASS) and its relationship to interdisciplinary psychosocial assessment practices for BS. Methods: This study was conducted at the Toronto Western Hospital, a Level 1A bariatric surgery centre of excellence accredited by the American College of Surgeons. Phase I: Four blinded raters applied the BIPASS to 31 randomly selected BS cases referred to our program to establish inter-rater reliability. Phase II: Three raters with clinical experience in bariatric psychosocial care applied the BIPASS to 54 randomly selected BS cases. Results: Forty-six of the 54 patients were female (85.1%). The median age of all patient cases was 49 years (range: 21-74). Raters’ BIPASS scores ranged from 4 to 52 (M = 19.24; SD =10.38). BIPASS scores were highly predictive of the BS psychosocial outcome (AUC = 0.915; 95% CI: 0.844-0.985; p<0.001). A BIPASS score of ≥16 was chosen as the cutoff score for further clinical assessment before proceeding with surgical evaluation based on a receiver operating characteristic (ROC) curve analysis (sensitivity = 0.839; specificity = 0.783). The instrument has very good inter-rater reliability (Pearson's correlation coefficient = 0.847), even among novice raters. Conclusion: The study findings show that the BIPASS is a comprehensive screening tool in the psychosocial assessment of BS candidates which will standardize the evaluation process and systematically identify at-risk patients for negative outcomes after BS.
Keywords: Bariatric surgery, interdisciplinary team, psychosocial, evaluation, assessment tool
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Introduction The increasing rate of obesity is of growing concern and is reaching epidemic proportions in North America [1]. Obesity has emerged as one of the most costly chronic diseases in terms of overall healthcare consumption [2] and is considered to be one of the leading causes of serious medical comorbidities and health outcomes, including but not limited to type 2 diabetes, cardiovascular diseases, neuropathies, psychiatric disorders and several types of cancer [3-6]. Bariatric surgery is a recognized treatment for patients suffering from severe obesity and it has been proven to be a viable and highly successful treatment modality. [7, 8]. It has proven to be the most effective treatment option in terms of durable weight loss, with total percent weight loss of 31.5% at 3 years [9] and 15% total weight loss 10 years post-surgery [10].
Current ASMBS bariatric surgery guidelines recommend a pre-surgery assessment by a multidisciplinary team to determine patient readiness and evaluation for bariatric surgery in an effort to improve patient short- and long-term outcomes [11]. Core components of the pre-surgery assessment for many accredited bariatric surgery facilities completed by multidisciplinary team members include patient education, pre-surgical behavioural requirements, nutrition education, and psychological or psychiatric assessments [12, 13]. However, the decision regarding psychosocial readiness for bariatric surgery psychosocial is often complicated by high rates of psychiatric co-morbidity. Lifetime prevalence of psychiatric illness in bariatric surgery candidates is as high as 70% and current prevalence rates of psychiatric illness range from 20% to 60% [14-16]. The most common psychiatric disorders and their rates are: affective disorders (22-65%), anxiety disorders (16-55%), and binge eating disorder (5-30%).
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High psychosocial burden has also been linked to adverse bariatric surgery outcomes. Systematic reviews of predictors of weight loss suggest that preoperative personality disorders may be associated with reduced weight loss outcomes [17], while patient engagement in pre-surgery mental health treatment may improve weight loss outcomes [18]. Additional variables such as pre-operative depression have also been associated with poor weight loss and impaired quality of life post-surgery [19, 20]. Moreover, data from a systematic review reported a fourfold risk of suicide after bariatric surgery [21] and recent data from a Canadian population-based study report an increase in rates of selfharm after bariatric surgery [22]. These studies support the need for improved pre-surgery mental health assessment, specifically improved methods for identifying psychosocial risks in this patient population and potentially preventing psychiatric complications [22]. Currently, a limited number of bariatric surgery psychosocial assessment tools have been studied in the literature. One of the first published clinical psychosocial assessment tools, the Boston interview, provides a standardized approach to interviewing patients for bariatric surgery. More specifically, it does this by organizing information into 7 major areas of assessment: 1) weight, diet and nutrition history; 2) current eating behaviors; 3) medical history; 4) understanding of surgical procedures, risks, and the post-surgical regimen; 5) motivation and expectations of surgical outcome; 6) relationships and support system; and 7) psychiatric functioning [23]. However, this tool has not undergone validation studies. The Revised Master Questionnaire is a psychological assessment tool for bariatric surgery suitability and has good convergent and construct validity [24]. The limitations of the Master Questionnaire include its under-assessment of weight control-related constructs, difficulty with scoring due to unclear sub-scale labels, and lack of an interprofessional focus on assessment. Given the paucity of interprofessional psychosocial assessment tools related to bariatric surgery assessment, a
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standardized assessment tool is needed to facilitate clinical assessment and further study psychosocial predictors of bariatric surgery outcomes. The purpose of our study was to develop a standardized interprofessional bariatric surgery assessment tool called the Toronto Bariatric Interprofessional Psychosocial Assessment of Suitability Scale (BIPASS ™) for use in bariatric surgery candidacy assessment, and to subsequently examine the psychometric properties of BIPASS. Our specific objectives were to test the reliability and validity of the BIPASS on predicting bariatric surgery readiness in comparison to expert interprofessional clinical assessment. We aimed to determine the operating characteristics of the BIPASS to assist bariatric surgery psychosocial clinicians in identifying patients who may need further mental health stabilization and support prior to proceeding with bariatric surgery.
Methods
Study Setting Consecutively referred patients assessed at the Toronto Western Hospital-Bariatric Surgery Program (TWH-BSP) between 2009 and 2014 were eligible for this study. The TWH-BSP is a publicly funded bariatric assessment centre in a six-hospital University of Toronto Bariatric Surgery Collaborative, and is an accredited Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) centre. Patients are referred to a provincial network for bariatric surgery and proceed with bariatric surgery assessment if they meet the National Institutes of Health’s criteria for bariatric surgery: a BMI > 40 kg/m2 or BMI ≥ 35 kg/m2 with at least one obesity related comorbidity. Patients are then assigned to the TWH-BSP based on postal code. The TWH-BSP consists of a multidisciplinary team of physicians (surgeons, internists, psychiatrists), psychologists, nurse practitioners, dietitians, and social workers, who work in an
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integrated care model and determine bariatric surgery readiness at the time of assessment. Our bariatric surgery program team also consists of a bariatric surgery endocrinologist who works collaboratively with our nurse practitioners. The input of these specialist physicians are incorporated into our interprofessional rounds through our nurse practitioners as part of this collaborative care model. Integration of medical physicians with obesity expertise in our program was essential for our program to become an accredited Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) centre. The pre-surgery assessment process for the TWH-BSP has been previously described in the literature [25, 26] and in summary, consists of a program orientation session, nutrition education, and a minimum of 5 healthcare professional assessments with a nurse practitioner, dietitian, social worker, psychologist/psychiatrist, and surgeon. Additional appointments with internists or specialists are provided based on patient need and co-morbidities. The experience of the TWH-BSP psychosocial team ranges from 2 years to 6 years of clinical expertise in the area of bariatric surgery. Moreover, the TWH-BSP has developed and delivered training workshops and courses on the pre-surgery assessment of bariatric surgery candidates in international and national settings and has a range of fellowships and student placements including a Bariatric Surgery Psychiatry fellowship. All patients are reviewed at weekly interprofessional TWH-BSP team rounds to review each professions’ pre-surgery assessment and determine surgery readiness using provincial bariatric surgery guidelines, which are based on NIH and ASMBS guidelines. Our research study focused on Roux en Y and sleeve gastrectomy patients, as both surgeries are offered in our program. However, the issues of adherence and mental health stability are equally as important in patients undergoing duodenal switch given the need for greater diet and multivitamin adherence as a result of significant malabsorption effects.
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Each TWH-BSP clinician completes an independent assessment of each patient that is referred to the program and evaluates the suitability of the candidate for surgery based on current clinical practice guidelines as they pertain to their scope of practice. During the course of clinical assessments completed by the bariatric surgery team, clinicians may bring up potential concerns or “flags” regarding the current suitability of a patient to be discussed at weekly team rounds. The entire clinical team reviews patients and determines if the patient should undergo bariatric surgery. Specific psychiatric exclusion criteria for bariatric surgery include active substance use disorder (including nicotine), poorly controlled psychiatric illness or severe psychiatric symptoms, and impaired cognitive functioning compromising ability to understand risks of bariatric surgery or to adhere to post-operative regimen (see Appendix A). For patients who do not meet exclusion criteria, the team determines if patients require a delay to further address psychosocial or nutrition issues warranting further assessment and management prior to surgery. While this process is comprehensive and uses the collective expertise of the interprofessional team, the process is not necessarily efficient or standardized and often includes assessment of additional variables that may not be salient to patient assessment for bariatric surgery.
Development of the BIPASSTM In efforts to further improve the consistency and quality of our bariatric surgery candidate discussions and to clearly communicate patient risk across program team members, our clinical research team developed the BIPASS tool. This tool was developed for broader use by interprofessional programs to: i) standardize the evaluation process of psychosocial risk factors and their severity; ii) improve the consistency of risk factor identification that may be amenable to shortterm clinical interventions offered as part of routine clinical care; iii) to determine if use of this
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decision making tool can predict bariatric surgery outcomes. The overall goal of this tool is to improve the quality of care that is provided to bariatric patients by standardizing existing clinical criteria (based on provincial guidelines and evidence) and decision-making processes in determining the current psychosocial suitability of candidacy for bariatric surgery [26, 27] . We conducted a comprehensive literature review to identify psychosocial risk factors influencing bariatric surgery outcomes, such as weight and quality of life. This review yielded 26 factors, which were used as part of a modified Delphi process consisting of three rounds of feedback. We opted to recruit experts through an established international bariatric surgery collaborative network affiliated with our program and we aimed to sample at least 5 countries within this framework to increase international generalizability. The first two rounds involved administering a survey to 25 interprofessional bariatric surgery experts from 5 countries, specifically Canada, the United States, Singapore, Italy, and Sweden, to collect expert feedback. Survey participants included psychiatrists (N=8), psychologists (N=5), social workers (N=3), dietitians (N=2), nurses (N=3), and other MDs (N=2) from 8 bariatric surgery programs. Respondents were asked to rank the entire list of items from most to least significant predictor of bariatric surgery outcomes. Following the first round of the Delphi process, the 5 lowest ranked items based on mean weighted rank were dropped and 21-items were included in the second survey administered as part of the Delphi process. Survey participants re-ranked the 21 items from most to least significant predictor and the 5 lowest ranked items were again dropped. The final 16 items were reviewed by the research team, and 2 items which significantly overlapped with other items were consolidated to yield 14 final items. The final version of the BIPASS consists of 14 items comprising 4 domains: Patient’s Readiness Level, Social Support System, Psychiatric Illness, and General Assessment Features, such as truthfulness and expectations (Table 1). Four exclusion criteria (active smoking, active substance use
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disorder or problem substance use, uncontrolled/severe active psychiatric illness, and impaired cognitive functioning) were listed based on current guidelines for bariatric surgery. Although the psychosocial domains in the BIPASS tool are largely relevant to clinical practice in the assessment of patients for bariatric surgery; they are by no means exhaustive and comprehensive capturing all information that may be required in the individual assessment process. (Figure 1). The goal of the BIPASS is to assess and establish a standardized approach to clinical evaluation for possible bariatric surgery. . The BIPASS is used to inform three clinical decisions for bariatric surgery candidacy: i) patient meets exclusion criteria or exceeds high scoring threshold (RED); ii) patient is not yet suitable for surgical candidacy and requires additional risk factors to be addressed at interdisciplinary team rounds before reviewing the patient for re-consideration (YELLOW); iii) the patient is recommended for surgery without reservation (GREEN). Patients with clinical histories clearly meeting the exclusion criteria do not require scoring of BIPASS items as the BIPASS total scores are used to differentiate YELLOW (delay and extended assessment) and GREEN patient dispositions. Each item on the BIPASS is rated on a 4-point Likert scale (Excellent, Fair, Borderline, Poor) using item descriptors. Delphi participants provided feedback on item descriptors, which were included in the final version of the BIPASS tool to establish a scoring system. The BIPASS score consists of 11 items with a maximum score of 6 and 3 items with a maximum score of 3. The total maximum score any patient can score is 75 points.
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Study Phase 1: Inter-Rater Reliability of the BIPASS As part of this pilot study, we applied the BIPASS retrospectively to patients assessed in our program as part of a large prospective psychosocial study on bariatric surgery outcomes. Four examiners who were blinded to the TWH-BSP decision for patient suitability and patient identifying information applied the BIPASS to 30 randomly selected patient cases. The examiners consisted of four team members: two psychiatrists who received fellowship training in bariatric surgery psychiatric assessment (expert), one medical graduate (MD) with clinical and research exposure in bariatric surgery psychosocial care (intermediate), and one clinical research coordinator (Bachelors of Science) with some exposure to the bariatric patient population (novice). In order to determine inter-rater reliability among raters, an intra-class correlation coefficient (ICC) was calculated for 30 patient cases. Two of 4 raters were randomly assigned to apply the BIPASS to each patient chart to determine agreement between raters’ scores.
Study Phase 2 – Establishing Cut-Offs of the BIPASS In the second phase of the study, three examiners (two experts, one intermediate) remained blinded and rated 54 additional randomly selected charts to assess the validity of the BIPASS as a clinical tool. After all the patient cases had been rated by the examiners, the clinical team’s decision outcome (red, yellow, or green) determined by the interdisciplinary clinical team was compared to the mean examiner rated BIPASS scores for each patient case using Receiver Operating Characteristic (ROC) analysis. The suitability decisions made by the interdisciplinary bariatric clinical team were assigned a clinical team decision outcomeas a state dependent variable of either “0” or “1” in the completed ROC curve analysis as follows: A team decision of GREEN (can proceed with surgery) was given assigned an outcome of ‘0’ and both YELLOW (needs further assessment) and RED (not suitable
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for surgery) were assigned an outcome of ‘1’. The cut-points for the BIPASS tool were established by defining scores related to RED (not suitable for surgery), YELLOW (needs further assessment), and GREEN. It is important to note that the RED, YELLOW, and GREEN coding is part of standard clinical care and is used in our electronic documentation to communicate risk amongst clinical team members.
Statistical Analysis Inter-rater reliability of the BIPASS score was calculated using the intra-class coefficient (ICC). A oneway random model, using absolute agreement and average measures was used to determine agreement between raters on total BIPASS scores. In phase 2, a ROC analysis was completed using the bariatric surgery suitability decision from the expert clinical team as the gold standard. BIPASS scores were analyzed using this gold standard as a comparison to determine the best cut-off point on the BIPASS. The ROC curve was built from rates of sensitivity and specificity for the BIPASS and area under the ROC curve (AUC) to determine the accuracy of BIPASS cut-offs. Sensitivity was defined as the proportion of patients identified as YELLOW (patients requiring a delay in surgery due to psychosocial concerns that did not meet exclusion criteria) on the BIPASS who were classified as YELLOW by the team of bariatric surgery psychosocial experts. Specificity was defined as the proportion of patients identified as not being YELLOW on the BIPASS who were classified as not being YELLOW by the interprofessional team of experts. All analyses were performed using SPSS software, version 22.0 (IBM Inc., 2015); the level of statistical significance was set at p = 0.05.
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Results Phase I: Testing the clinical reliability of the BIPASS
Average measures were used since all patients were scored by multiple (2) raters. Thus, the ICC for the total BIPASS scores was 0.847 [95% CI: 0.681-0.927], indicating a high level of agreement and suggesting similar ratings between raters.
Phase II: Testing the clinical validity of the BIPASS
Patient demographics and scores are reported in (Table 2). ROC curve analysis was fit in order to predict the bariatric surgery psychosocial outcome (positive or negative) using each rater's BIPASS scores (Figure 2). Accounting for the retrospective nature of this research study, we decided to limit the assessment of potential predictive value to only yellow/red (one or more psychosocial concerns) and green (no psychosocial concern) outcomes in order to limit confounding factors and keep our subjects relatively homogenous. Among 54 patients, the proportion of positive and negative outcomes (31 had a positive outcome [GREEN] and 23 had a negative outcome [RED/YELLOW]) was nearly comparable. Raters’ BIPASS scores ranged from 4 to 52 (M = 19.24; SD =10.38). BIPASS scores were highly predictive of the BS psychosocial outcome (AUC = 0.915; 95% CI: 0.844-0.985; p < 0.001). It should be noted that BIPASS coefficients were negative due to high BIPASS scores having a positive correlation with negative suitability outcomes [RED/YELLOW]. A BIPASS score of ≥16 was chosen as the cut-off score based on a receiver operating characteristic (ROC) curve analysis (sensitivity = 0.839; specificity = 0.783). This can be interpreted as patient’s having BIPASS score of ≥ 16 is highly
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probable of bariatric surgery not being treatment of choice at this time for the patient..These results show that BIPASS scores are highly predictive of the interdisciplinary clinical team’s decision.
Discussion To our knowledge, this is the first research study examining both the reliability and validity of a comprehensive clinical psychosocial assessment tool (BIPASS) using retrospective patient data in an interprofessional clinical setting. Previous studies of a similar nature have focused the longitudinal outcomes in terms of weight loss and medical outcomes rather than comprehensive psychosocial listing criteria [28]. The significance of the BIPASS lies in its ability to standardize the psychosocial assessment process for bariatric surgery and to increase the rigour in identifying psychosocial risks that warrant further intervention prior to surgery. The use of clinical assessment tools such as the BIPASS would streamline the team decision making process by reducing both clinician bias and presenting pertinent psychosocial information in a succinct and reliable manner when determining surgical candidacy. For instance, BIPASS scores could accompany the patient chart and be used as a point of reference reflecting available psychosocial data when communicating psychosocial risk across interdisciplinary team members. We believe the BIPASS will address some of the shortcomings of previously developed interprofessional psychosocial clinical assessment tools (e.g. the Revised Master Questionnaire and Boston interview) used to determine bariatric surgery candidacy. The BIPASS may not only help in determining suitability of candidacy for bariatric surgery in relation to psychosocial outcomes postoperatively, but it may also serve to identify a patient’s level of social, neuropsychiatric, emotional regulation, and cognitive functioning. As a result, clinicians could potentially use the BIPASS to augment and further standardize the psychosocial evaluation process, although it should not be used as
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the sole determinant in bariatric surgery evaluation. It is important to remember that BIPASS is a clinical tool to be used as an ancillary assessment tool alongside comprehensive clinical interview to standardize the process of interpreting data that is acquired. In this regard, BIPASS would help interdisciplinary team members identify and discuss psychosocial domains that have been identified as areas of concern during the individual assessments. As a result, it is imperative to understand that BIPASS does not negate the need for a comprehensive clinical interview and evaluation given the complexities of obesity management, however; it will assist in the standardization of collecting the required information. Further, results from the BIPASS can be used to identify areas of concern in surgical candidates and to inform relevant psychosocial treatment plans to improve patients’ bariatric surgery candidacy. Future research is needed to determine if a more comprehensive psychosocial assessment with the BIPASS will translate into decreased morbidity, decreased psychiatric complications, and a better quality of life for bariatric surgery patients.
Limitations and Future Directions This research study was the first to examine the potential clinical validity of the BIPASS tool. As a result, we conducted a retrospective study to examine its validity and reliability despite the BIPASS’ intended use as a prospective assessment tool of bariatric surgery candidates. Due to the retrospective nature of our study, the examiners had to apply the BIPASS as an evaluative clinical tool to historical data contained in the patient's chart rather than being able to complete real time clinical assessments on the patient. This may have limited the examiner's ability to ask questions pertaining to BIPASS specific items, such as patient truthfulness. Similarly, since the patient cases were selected blindly, the retrospective application of the BIPASS could not take into account whether the ultimate outcome was affected by the application of corrective measures or lack thereof. For example, a patient
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who received a high BIPASS score may have been identified at the time as being high risk by the team, and an appropriate treatment plan or intervention may have corrected the identified psychosocial problem, allowing the patient to remain a suitable candidate for bariatric surgery. Given that the examiners only applied BIPASS measures to the initial evaluation process, this research study could not account for the effects of this intervention. Another limitation of our study is for potential bias in the retrospective study design attributed to the clinical information obtained from medical charts dependent on evaluating clinician choice of language and description. Further, we appreciate that every clinician will may use different descriptors and terminology based on factors including but not limited to clinical training and expertise. Moreover, the study could be enhanced by replication at additional sites to increase its generalizability. The researchers randomly selected patients in this cohort and demographic characteristics of the patient sample were provided in the paper in this regard. We understand there may be limitations with this selection method that may not apply to all cohorts including but not limited to socioeconomic status, education, race/ ethnicity, BMI, age. Future studies are underway to study the BIPASS using a prospective study design to determine its ability to predict patient outcomes after bariatric surgery.
Conclusions
In summary, the BIPASS is a comprehensive clinical screening tool designed to improve psychosocial assessment and evaluation of bariatric surgery candidates. The strengths of the tool are its standardization of the evaluation process as well as its ability to risk stratify patients in the pre-surgery assessment process. The creation of cut-off scores using the gold standard of an interprofessional team of bariatric surgery experts will assist in further study of the BIPASS as a core instrument for
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predicting post-bariatric surgery patient outcomes. Furthermore, the BIPASS could be used to communicate psychosocial risk amongst team members and guide additional psychosocial interventions. With the use of this tool, we hope to formalize team decision-making by improving quality and consistency of case discussions. This will facilitate appropriate psychosocial interventions occurring in a timely manner and potentially improving bariatric surgery outcomes and quality of life.
Acknowledgements We would like to thank our Toronto Western Hospital Bariatric Surgery Program staff who participate in our weekly team rounds.
Supplementary Data None
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Appendix A
Exclusion Criteria
Active Smoking: • Ongoing smoking despite repeated instruction to stop smoking (confirmed by self-report or positive nicotine tests) • Continued smoking despite attempts to stop through counseling or other supports from program or outside referrals
Active substance use disorder or problem substance use: • Ongoing problem substance use as demonstrated by self-report or positive urine toxicology • This is despite attempts to stop through counseling or other supports from program or outside referrals
Uncontrolled/severe active psychiatric illness • Psychiatric illness that is inadequately controlled or severe in its nature despite optimal treatment • This is unlikely to resolve or improve to acceptable level within reasonable timeframe with counseling or other supports from program or from outside referrals
Impaired cognitive functioning • Impairment of cognitive functioning in individual with insufficient long-term supports in place to mitigate additional burden of care placed by surgery and necessary lifestyle modifications
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Table 1 – Psychosocial Domains and Factors Measured by the BIPASS Patient’s Readiness level 1. Knowledge & Understanding of the Process of Excessive Weight Gain 2. Understanding of Surgery Including Salient Complications and Lifestyle Ramifications 3. Willingness, Motivation, and Lifestyle Modification in Preparation for Surgery 4. Compliance & Adherence with Bariatric Surgery Assessment and Pre-op Program Social Support System 5. Availability & Functioning of Social Support System 6. Finances, Employment, and Housing Psychiatric Illness 7. Psychiatric Stability (excluding eating disorder, substance use disorder, and personality disorder) 8 . Eating Behaviour 9. History of Psychiatric Illness (including eating disorder and substance use disorder) 10. Substance Use (excluding nicotine) 11. Personality Traits and Disorders General Assessment Features 12. Sense of Coherence & Emotional Regulation 13. Response Bias and Truthfulness 14. Expectations for Bariatric Surgery
Table 2: Patient Demographics and Examiner Rated BIPASS Scores Phase I: Inter rater
Phase 2 : Validity
reliability Female
27/30 (90%)
46/54 (85.1%)
Median Age (range)
48.5 (21-74)
49 (21-74)
Mean BIPASS score
14.95 (0-33)
19.24 (4-52)
(range)
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Figures
Figure 1 – Road to Bariatric Surgery Interprofessional Bariatric Surgery Assessment1
Interprofessional Case Rounds
BIPASS Exclusion Criteria
Delay Surgery for Psychosocial Assessment and Treatment
Low Psychosocial Risk – Proceed with Surgery
1Interprofessional Bariatric Surgery Assessment involves comprehensive psychosocial assessment involving a minimum of 5 healthcare professional assessments including nurse practitioners, dietitians, social workers, psychologists/psychiatrists, and surgeons.
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Figure 2– Receiver Operating Curve (ROC) analysis of BIPASS examiner scores in predicting clinical outcome
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Toronto Bariatric Interprofessional Psychosocial Assessment Suitability Scale (BIPASS TM): Evaluating A New Clinical Assessment Tool for Bariatric Surgery Candidates Gurneet Thiara MD, Richard Yanofksy MD FRCPC, Sayed Abdul-Kader MD FRCPC, Vincent A. Santiago BSc, Stephanie Cassin PhD CPsych, Allan Okrainec MD MHPE FRCSC, Timothy Jackson MD FRCSC, Raed Hawa MD, FRCPC, Sanjeev Sockalingam MD MHPE FRCPC
PII: DOI: Reference:
S0033-3182(15)00210-8 http://dx.doi.org/10.1016/j.psym.2015.12.003 PSYM600
To appear in:
Psychosomatics
Cite this article as: Gurneet Thiara MD, Richard Yanofksy MD FRCPC, Sayed Abdul-Kader MD FRCPC, Vincent A. Santiago BSc, Stephanie Cassin PhD CPsych, Allan Okrainec MD MHPE FRCSC, Timothy Jackson MD FRCSC, Raed Hawa MD, FRCPC, Sanjeev Sockalingam MD MHPE FRCPC, Toronto Bariatric Interprofessional Psychosocial Assessment Suitability Scale (BIPASS TM): Evaluating A New Clinical Assessment Tool for Bariatric Surgery Candidates, Psychosomatics, http://dx.doi.org/10.1016/j.psym.2015.12.003 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Toronto Bariatric Interprofessional Psychosocial Assessment Suitability Scale (BIPASS TM): Evaluating a new clinical assessment tool for bariatric surgery candidates Gurneet Thiara MD1, Richard Yanofksy MD FRCPC1, Sayed Abdul-Kader MD FRCPC1, Vincent A. Santiago BSc1, Stephanie Cassin PhD CPsych3, Allan Okrainec MD MHPE FRCSC 2, Timothy Jackson MD FRCSC 2, Raed Hawa MD, FRCPC1, Sanjeev Sockalingam MD MHPE FRCPC1.
1
Bariatric Surgery Psychosocial Program, Department of Psychiatry, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada 2 Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada 3 Department of Psychology, Ryerson University, Toronto, Ontario, Canada.
Corresponding Authors: Dr. Sanjeev Sockalingam Toronto General Hospital 200 Elizabeth Street-8EN-228 Toronto, ON M5G 2C4 Ph: 416-340-3762 Fax: 416-340-4198 Email: [email protected] Dr. Raed Hawa Toronto Western Hospital 399 Bathurst Street Toronto, ON M5T 2S8 Email: [email protected]
Running Title:
Abstract Background: Patients who are referred for possible Bariatric Surgery (BS) intervention undergo a series of assessments conducted by an interdisciplinary health care team to determine suitability for surgery. Herein, we report the initial validation and reliability studies of the Bariatric Interprofessional Psychosocial Assessment Suitability Scale (BIPASS) and its relationship to interdisciplinary psychosocial assessment practices for BS. Methods: This study was conducted at the Toronto Western Hospital, a Level 1A bariatric surgery centre of excellence accredited by the American College of Surgeons. Phase I: Four blinded raters applied the BIPASS to 31 randomly selected BS cases referred to our program to establish inter-rater reliability. Phase II: Three raters with clinical experience in bariatric psychosocial care applied the BIPASS to 54 randomly selected BS cases. Results: Forty-six of the 54 patients were female (85.1%). The median age of all patient cases was 49 years (range: 21-74). Raters’ BIPASS scores ranged from 4 to 52 (M = 19.24; SD =10.38). BIPASS scores were highly predictive of the BS psychosocial outcome (AUC = 0.915; 95% CI: 0.844-0.985; p<0.001). A BIPASS score of ≥16 was chosen as the cutoff score for further clinical assessment before proceeding with surgical evaluation based on a receiver operating characteristic (ROC) curve analysis (sensitivity = 0.839; specificity = 0.783). The instrument has very good inter-rater reliability (Pearson's correlation coefficient = 0.847), even among novice raters. Conclusion: The study findings show that the BIPASS is a comprehensive screening tool in the psychosocial assessment of BS candidates which will standardize the evaluation process and systematically identify at-risk patients for negative outcomes after BS.
Keywords: Bariatric surgery, interdisciplinary team, psychosocial, evaluation, assessment tool
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Introduction The increasing rate of obesity is of growing concern and is reaching epidemic proportions in North America [1]. Obesity has emerged as one of the most costly chronic diseases in terms of overall healthcare consumption [2] and is considered to be one of the leading causes of serious medical comorbidities and health outcomes, including but not limited to type 2 diabetes, cardiovascular diseases, neuropathies, psychiatric disorders and several types of cancer [3-6]. Bariatric surgery is a recognized treatment for patients suffering from severe obesity and it has been proven to be a viable and highly successful treatment modality. [7, 8]. It has proven to be the most effective treatment option in terms of durable weight loss, with total percent weight loss of 31.5% at 3 years [9] and 15% total weight loss 10 years post-surgery [10].
Current ASMBS bariatric surgery guidelines recommend a pre-surgery assessment by a multidisciplinary team to determine patient readiness and evaluation for bariatric surgery in an effort to improve patient short- and long-term outcomes [11]. Core components of the pre-surgery assessment for many accredited bariatric surgery facilities completed by multidisciplinary team members include patient education, pre-surgical behavioural requirements, nutrition education, and psychological or psychiatric assessments [12, 13]. However, the decision regarding psychosocial readiness for bariatric surgery psychosocial is often complicated by high rates of psychiatric co-morbidity. Lifetime prevalence of psychiatric illness in bariatric surgery candidates is as high as 70% and current prevalence rates of psychiatric illness range from 20% to 60% [14-16]. The most common psychiatric disorders and their rates are: affective disorders (22-65%), anxiety disorders (16-55%), and binge eating disorder (5-30%).
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High psychosocial burden has also been linked to adverse bariatric surgery outcomes. Systematic reviews of predictors of weight loss suggest that preoperative personality disorders may be associated with reduced weight loss outcomes [17], while patient engagement in pre-surgery mental health treatment may improve weight loss outcomes [18]. Additional variables such as pre-operative depression have also been associated with poor weight loss and impaired quality of life post-surgery [19, 20]. Moreover, data from a systematic review reported a fourfold risk of suicide after bariatric surgery [21] and recent data from a Canadian population-based study report an increase in rates of selfharm after bariatric surgery [22]. These studies support the need for improved pre-surgery mental health assessment, specifically improved methods for identifying psychosocial risks in this patient population and potentially preventing psychiatric complications [22]. Currently, a limited number of bariatric surgery psychosocial assessment tools have been studied in the literature. One of the first published clinical psychosocial assessment tools, the Boston interview, provides a standardized approach to interviewing patients for bariatric surgery. More specifically, it does this by organizing information into 7 major areas of assessment: 1) weight, diet and nutrition history; 2) current eating behaviors; 3) medical history; 4) understanding of surgical procedures, risks, and the post-surgical regimen; 5) motivation and expectations of surgical outcome; 6) relationships and support system; and 7) psychiatric functioning [23]. However, this tool has not undergone validation studies. The Revised Master Questionnaire is a psychological assessment tool for bariatric surgery suitability and has good convergent and construct validity [24]. The limitations of the Master Questionnaire include its under-assessment of weight control-related constructs, difficulty with scoring due to unclear sub-scale labels, and lack of an interprofessional focus on assessment. Given the paucity of interprofessional psychosocial assessment tools related to bariatric surgery assessment, a
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standardized assessment tool is needed to facilitate clinical assessment and further study psychosocial predictors of bariatric surgery outcomes. The purpose of our study was to develop a standardized interprofessional bariatric surgery assessment tool called the Toronto Bariatric Interprofessional Psychosocial Assessment of Suitability Scale (BIPASS ™) for use in bariatric surgery candidacy assessment, and to subsequently examine the psychometric properties of BIPASS. Our specific objectives were to test the reliability and validity of the BIPASS on predicting bariatric surgery readiness in comparison to expert interprofessional clinical assessment. We aimed to determine the operating characteristics of the BIPASS to assist bariatric surgery psychosocial clinicians in identifying patients who may need further mental health stabilization and support prior to proceeding with bariatric surgery.
Methods
Study Setting Consecutively referred patients assessed at the Toronto Western Hospital-Bariatric Surgery Program (TWH-BSP) between 2009 and 2014 were eligible for this study. The TWH-BSP is a publicly funded bariatric assessment centre in a six-hospital University of Toronto Bariatric Surgery Collaborative, and is an accredited Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) centre. Patients are referred to a provincial network for bariatric surgery and proceed with bariatric surgery assessment if they meet the National Institutes of Health’s criteria for bariatric surgery: a BMI > 40 kg/m2 or BMI ≥ 35 kg/m2 with at least one obesity related comorbidity. Patients are then assigned to the TWH-BSP based on postal code. The TWH-BSP consists of a multidisciplinary team of physicians (surgeons, internists, psychiatrists), psychologists, nurse practitioners, dietitians, and social workers, who work in an
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integrated care model and determine bariatric surgery readiness at the time of assessment. Our bariatric surgery program team also consists of a bariatric surgery endocrinologist who works collaboratively with our nurse practitioners. The input of these specialist physicians are incorporated into our interprofessional rounds through our nurse practitioners as part of this collaborative care model. Integration of medical physicians with obesity expertise in our program was essential for our program to become an accredited Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) centre. The pre-surgery assessment process for the TWH-BSP has been previously described in the literature [25, 26] and in summary, consists of a program orientation session, nutrition education, and a minimum of 5 healthcare professional assessments with a nurse practitioner, dietitian, social worker, psychologist/psychiatrist, and surgeon. Additional appointments with internists or specialists are provided based on patient need and co-morbidities. The experience of the TWH-BSP psychosocial team ranges from 2 years to 6 years of clinical expertise in the area of bariatric surgery. Moreover, the TWH-BSP has developed and delivered training workshops and courses on the pre-surgery assessment of bariatric surgery candidates in international and national settings and has a range of fellowships and student placements including a Bariatric Surgery Psychiatry fellowship. All patients are reviewed at weekly interprofessional TWH-BSP team rounds to review each professions’ pre-surgery assessment and determine surgery readiness using provincial bariatric surgery guidelines, which are based on NIH and ASMBS guidelines. Our research study focused on Roux en Y and sleeve gastrectomy patients, as both surgeries are offered in our program. However, the issues of adherence and mental health stability are equally as important in patients undergoing duodenal switch given the need for greater diet and multivitamin adherence as a result of significant malabsorption effects.
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Each TWH-BSP clinician completes an independent assessment of each patient that is referred to the program and evaluates the suitability of the candidate for surgery based on current clinical practice guidelines as they pertain to their scope of practice. During the course of clinical assessments completed by the bariatric surgery team, clinicians may bring up potential concerns or “flags” regarding the current suitability of a patient to be discussed at weekly team rounds. The entire clinical team reviews patients and determines if the patient should undergo bariatric surgery. Specific psychiatric exclusion criteria for bariatric surgery include active substance use disorder (including nicotine), poorly controlled psychiatric illness or severe psychiatric symptoms, and impaired cognitive functioning compromising ability to understand risks of bariatric surgery or to adhere to post-operative regimen (see Appendix A). For patients who do not meet exclusion criteria, the team determines if patients require a delay to further address psychosocial or nutrition issues warranting further assessment and management prior to surgery. While this process is comprehensive and uses the collective expertise of the interprofessional team, the process is not necessarily efficient or standardized and often includes assessment of additional variables that may not be salient to patient assessment for bariatric surgery.
Development of the BIPASSTM In efforts to further improve the consistency and quality of our bariatric surgery candidate discussions and to clearly communicate patient risk across program team members, our clinical research team developed the BIPASS tool. This tool was developed for broader use by interprofessional programs to: i) standardize the evaluation process of psychosocial risk factors and their severity; ii) improve the consistency of risk factor identification that may be amenable to shortterm clinical interventions offered as part of routine clinical care; iii) to determine if use of this
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decision making tool can predict bariatric surgery outcomes. The overall goal of this tool is to improve the quality of care that is provided to bariatric patients by standardizing existing clinical criteria (based on provincial guidelines and evidence) and decision-making processes in determining the current psychosocial suitability of candidacy for bariatric surgery [26, 27] . We conducted a comprehensive literature review to identify psychosocial risk factors influencing bariatric surgery outcomes, such as weight and quality of life. This review yielded 26 factors, which were used as part of a modified Delphi process consisting of three rounds of feedback. We opted to recruit experts through an established international bariatric surgery collaborative network affiliated with our program and we aimed to sample at least 5 countries within this framework to increase international generalizability. The first two rounds involved administering a survey to 25 interprofessional bariatric surgery experts from 5 countries, specifically Canada, the United States, Singapore, Italy, and Sweden, to collect expert feedback. Survey participants included psychiatrists (N=8), psychologists (N=5), social workers (N=3), dietitians (N=2), nurses (N=3), and other MDs (N=2) from 8 bariatric surgery programs. Respondents were asked to rank the entire list of items from most to least significant predictor of bariatric surgery outcomes. Following the first round of the Delphi process, the 5 lowest ranked items based on mean weighted rank were dropped and 21-items were included in the second survey administered as part of the Delphi process. Survey participants re-ranked the 21 items from most to least significant predictor and the 5 lowest ranked items were again dropped. The final 16 items were reviewed by the research team, and 2 items which significantly overlapped with other items were consolidated to yield 14 final items. The final version of the BIPASS consists of 14 items comprising 4 domains: Patient’s Readiness Level, Social Support System, Psychiatric Illness, and General Assessment Features, such as truthfulness and expectations (Table 1). Four exclusion criteria (active smoking, active substance use
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disorder or problem substance use, uncontrolled/severe active psychiatric illness, and impaired cognitive functioning) were listed based on current guidelines for bariatric surgery. Although the psychosocial domains in the BIPASS tool are largely relevant to clinical practice in the assessment of patients for bariatric surgery; they are by no means exhaustive and comprehensive capturing all information that may be required in the individual assessment process. (Figure 1). The goal of the BIPASS is to assess and establish a standardized approach to clinical evaluation for possible bariatric surgery. . The BIPASS is used to inform three clinical decisions for bariatric surgery candidacy: i) patient meets exclusion criteria or exceeds high scoring threshold (RED); ii) patient is not yet suitable for surgical candidacy and requires additional risk factors to be addressed at interdisciplinary team rounds before reviewing the patient for re-consideration (YELLOW); iii) the patient is recommended for surgery without reservation (GREEN). Patients with clinical histories clearly meeting the exclusion criteria do not require scoring of BIPASS items as the BIPASS total scores are used to differentiate YELLOW (delay and extended assessment) and GREEN patient dispositions. Each item on the BIPASS is rated on a 4-point Likert scale (Excellent, Fair, Borderline, Poor) using item descriptors. Delphi participants provided feedback on item descriptors, which were included in the final version of the BIPASS tool to establish a scoring system. The BIPASS score consists of 11 items with a maximum score of 6 and 3 items with a maximum score of 3. The total maximum score any patient can score is 75 points.
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Study Phase 1: Inter-Rater Reliability of the BIPASS As part of this pilot study, we applied the BIPASS retrospectively to patients assessed in our program as part of a large prospective psychosocial study on bariatric surgery outcomes. Four examiners who were blinded to the TWH-BSP decision for patient suitability and patient identifying information applied the BIPASS to 30 randomly selected patient cases. The examiners consisted of four team members: two psychiatrists who received fellowship training in bariatric surgery psychiatric assessment (expert), one medical graduate (MD) with clinical and research exposure in bariatric surgery psychosocial care (intermediate), and one clinical research coordinator (Bachelors of Science) with some exposure to the bariatric patient population (novice). In order to determine inter-rater reliability among raters, an intra-class correlation coefficient (ICC) was calculated for 30 patient cases. Two of 4 raters were randomly assigned to apply the BIPASS to each patient chart to determine agreement between raters’ scores.
Study Phase 2 – Establishing Cut-Offs of the BIPASS In the second phase of the study, three examiners (two experts, one intermediate) remained blinded and rated 54 additional randomly selected charts to assess the validity of the BIPASS as a clinical tool. After all the patient cases had been rated by the examiners, the clinical team’s decision outcome (red, yellow, or green) determined by the interdisciplinary clinical team was compared to the mean examiner rated BIPASS scores for each patient case using Receiver Operating Characteristic (ROC) analysis. The suitability decisions made by the interdisciplinary bariatric clinical team were assigned a clinical team decision outcomeas a state dependent variable of either “0” or “1” in the completed ROC curve analysis as follows: A team decision of GREEN (can proceed with surgery) was given assigned an outcome of ‘0’ and both YELLOW (needs further assessment) and RED (not suitable
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for surgery) were assigned an outcome of ‘1’. The cut-points for the BIPASS tool were established by defining scores related to RED (not suitable for surgery), YELLOW (needs further assessment), and GREEN. It is important to note that the RED, YELLOW, and GREEN coding is part of standard clinical care and is used in our electronic documentation to communicate risk amongst clinical team members.
Statistical Analysis Inter-rater reliability of the BIPASS score was calculated using the intra-class coefficient (ICC). A oneway random model, using absolute agreement and average measures was used to determine agreement between raters on total BIPASS scores. In phase 2, a ROC analysis was completed using the bariatric surgery suitability decision from the expert clinical team as the gold standard. BIPASS scores were analyzed using this gold standard as a comparison to determine the best cut-off point on the BIPASS. The ROC curve was built from rates of sensitivity and specificity for the BIPASS and area under the ROC curve (AUC) to determine the accuracy of BIPASS cut-offs. Sensitivity was defined as the proportion of patients identified as YELLOW (patients requiring a delay in surgery due to psychosocial concerns that did not meet exclusion criteria) on the BIPASS who were classified as YELLOW by the team of bariatric surgery psychosocial experts. Specificity was defined as the proportion of patients identified as not being YELLOW on the BIPASS who were classified as not being YELLOW by the interprofessional team of experts. All analyses were performed using SPSS software, version 22.0 (IBM Inc., 2015); the level of statistical significance was set at p = 0.05.
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Results Phase I: Testing the clinical reliability of the BIPASS
Average measures were used since all patients were scored by multiple (2) raters. Thus, the ICC for the total BIPASS scores was 0.847 [95% CI: 0.681-0.927], indicating a high level of agreement and suggesting similar ratings between raters.
Phase II: Testing the clinical validity of the BIPASS
Patient demographics and scores are reported in (Table 2). ROC curve analysis was fit in order to predict the bariatric surgery psychosocial outcome (positive or negative) using each rater's BIPASS scores (Figure 2). Accounting for the retrospective nature of this research study, we decided to limit the assessment of potential predictive value to only yellow/red (one or more psychosocial concerns) and green (no psychosocial concern) outcomes in order to limit confounding factors and keep our subjects relatively homogenous. Among 54 patients, the proportion of positive and negative outcomes (31 had a positive outcome [GREEN] and 23 had a negative outcome [RED/YELLOW]) was nearly comparable. Raters’ BIPASS scores ranged from 4 to 52 (M = 19.24; SD =10.38). BIPASS scores were highly predictive of the BS psychosocial outcome (AUC = 0.915; 95% CI: 0.844-0.985; p < 0.001). It should be noted that BIPASS coefficients were negative due to high BIPASS scores having a positive correlation with negative suitability outcomes [RED/YELLOW]. A BIPASS score of ≥16 was chosen as the cut-off score based on a receiver operating characteristic (ROC) curve analysis (sensitivity = 0.839; specificity = 0.783). This can be interpreted as patient’s having BIPASS score of ≥ 16 is highly
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probable of bariatric surgery not being treatment of choice at this time for the patient..These results show that BIPASS scores are highly predictive of the interdisciplinary clinical team’s decision.
Discussion To our knowledge, this is the first research study examining both the reliability and validity of a comprehensive clinical psychosocial assessment tool (BIPASS) using retrospective patient data in an interprofessional clinical setting. Previous studies of a similar nature have focused the longitudinal outcomes in terms of weight loss and medical outcomes rather than comprehensive psychosocial listing criteria [28]. The significance of the BIPASS lies in its ability to standardize the psychosocial assessment process for bariatric surgery and to increase the rigour in identifying psychosocial risks that warrant further intervention prior to surgery. The use of clinical assessment tools such as the BIPASS would streamline the team decision making process by reducing both clinician bias and presenting pertinent psychosocial information in a succinct and reliable manner when determining surgical candidacy. For instance, BIPASS scores could accompany the patient chart and be used as a point of reference reflecting available psychosocial data when communicating psychosocial risk across interdisciplinary team members. We believe the BIPASS will address some of the shortcomings of previously developed interprofessional psychosocial clinical assessment tools (e.g. the Revised Master Questionnaire and Boston interview) used to determine bariatric surgery candidacy. The BIPASS may not only help in determining suitability of candidacy for bariatric surgery in relation to psychosocial outcomes postoperatively, but it may also serve to identify a patient’s level of social, neuropsychiatric, emotional regulation, and cognitive functioning. As a result, clinicians could potentially use the BIPASS to augment and further standardize the psychosocial evaluation process, although it should not be used as
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the sole determinant in bariatric surgery evaluation. It is important to remember that BIPASS is a clinical tool to be used as an ancillary assessment tool alongside comprehensive clinical interview to standardize the process of interpreting data that is acquired. In this regard, BIPASS would help interdisciplinary team members identify and discuss psychosocial domains that have been identified as areas of concern during the individual assessments. As a result, it is imperative to understand that BIPASS does not negate the need for a comprehensive clinical interview and evaluation given the complexities of obesity management, however; it will assist in the standardization of collecting the required information. Further, results from the BIPASS can be used to identify areas of concern in surgical candidates and to inform relevant psychosocial treatment plans to improve patients’ bariatric surgery candidacy. Future research is needed to determine if a more comprehensive psychosocial assessment with the BIPASS will translate into decreased morbidity, decreased psychiatric complications, and a better quality of life for bariatric surgery patients.
Limitations and Future Directions This research study was the first to examine the potential clinical validity of the BIPASS tool. As a result, we conducted a retrospective study to examine its validity and reliability despite the BIPASS’ intended use as a prospective assessment tool of bariatric surgery candidates. Due to the retrospective nature of our study, the examiners had to apply the BIPASS as an evaluative clinical tool to historical data contained in the patient's chart rather than being able to complete real time clinical assessments on the patient. This may have limited the examiner's ability to ask questions pertaining to BIPASS specific items, such as patient truthfulness. Similarly, since the patient cases were selected blindly, the retrospective application of the BIPASS could not take into account whether the ultimate outcome was affected by the application of corrective measures or lack thereof. For example, a patient
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who received a high BIPASS score may have been identified at the time as being high risk by the team, and an appropriate treatment plan or intervention may have corrected the identified psychosocial problem, allowing the patient to remain a suitable candidate for bariatric surgery. Given that the examiners only applied BIPASS measures to the initial evaluation process, this research study could not account for the effects of this intervention. Another limitation of our study is for potential bias in the retrospective study design attributed to the clinical information obtained from medical charts dependent on evaluating clinician choice of language and description. Further, we appreciate that every clinician will may use different descriptors and terminology based on factors including but not limited to clinical training and expertise. Moreover, the study could be enhanced by replication at additional sites to increase its generalizability. The researchers randomly selected patients in this cohort and demographic characteristics of the patient sample were provided in the paper in this regard. We understand there may be limitations with this selection method that may not apply to all cohorts including but not limited to socioeconomic status, education, race/ ethnicity, BMI, age. Future studies are underway to study the BIPASS using a prospective study design to determine its ability to predict patient outcomes after bariatric surgery.
Conclusions
In summary, the BIPASS is a comprehensive clinical screening tool designed to improve psychosocial assessment and evaluation of bariatric surgery candidates. The strengths of the tool are its standardization of the evaluation process as well as its ability to risk stratify patients in the pre-surgery assessment process. The creation of cut-off scores using the gold standard of an interprofessional team of bariatric surgery experts will assist in further study of the BIPASS as a core instrument for
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predicting post-bariatric surgery patient outcomes. Furthermore, the BIPASS could be used to communicate psychosocial risk amongst team members and guide additional psychosocial interventions. With the use of this tool, we hope to formalize team decision-making by improving quality and consistency of case discussions. This will facilitate appropriate psychosocial interventions occurring in a timely manner and potentially improving bariatric surgery outcomes and quality of life.
Acknowledgements We would like to thank our Toronto Western Hospital Bariatric Surgery Program staff who participate in our weekly team rounds.
Supplementary Data None
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Appendix A
Exclusion Criteria
Active Smoking: • Ongoing smoking despite repeated instruction to stop smoking (confirmed by self-report or positive nicotine tests) • Continued smoking despite attempts to stop through counseling or other supports from program or outside referrals
Active substance use disorder or problem substance use: • Ongoing problem substance use as demonstrated by self-report or positive urine toxicology • This is despite attempts to stop through counseling or other supports from program or outside referrals
Uncontrolled/severe active psychiatric illness • Psychiatric illness that is inadequately controlled or severe in its nature despite optimal treatment • This is unlikely to resolve or improve to acceptable level within reasonable timeframe with counseling or other supports from program or from outside referrals
Impaired cognitive functioning • Impairment of cognitive functioning in individual with insufficient long-term supports in place to mitigate additional burden of care placed by surgery and necessary lifestyle modifications
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Table 1 – Psychosocial Domains and Factors Measured by the BIPASS Patient’s Readiness level 1. Knowledge & Understanding of the Process of Excessive Weight Gain 2. Understanding of Surgery Including Salient Complications and Lifestyle Ramifications 3. Willingness, Motivation, and Lifestyle Modification in Preparation for Surgery 4. Compliance & Adherence with Bariatric Surgery Assessment and Pre-op Program Social Support System 5. Availability & Functioning of Social Support System 6. Finances, Employment, and Housing Psychiatric Illness 7. Psychiatric Stability (excluding eating disorder, substance use disorder, and personality disorder) 8 . Eating Behaviour 9. History of Psychiatric Illness (including eating disorder and substance use disorder) 10. Substance Use (excluding nicotine) 11. Personality Traits and Disorders General Assessment Features 12. Sense of Coherence & Emotional Regulation 13. Response Bias and Truthfulness 14. Expectations for Bariatric Surgery
Table 2: Patient Demographics and Examiner Rated BIPASS Scores Phase I: Inter rater
Phase 2 : Validity
reliability Female
27/30 (90%)
46/54 (85.1%)
Median Age (range)
48.5 (21-74)
49 (21-74)
Mean BIPASS score
14.95 (0-33)
19.24 (4-52)
(range)
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Figures
Figure 1 – Road to Bariatric Surgery Interprofessional Bariatric Surgery Assessment1
Interprofessional Case Rounds
BIPASS Exclusion Criteria
Delay Surgery for Psychosocial Assessment and Treatment
Low Psychosocial Risk – Proceed with Surgery
1Interprofessional Bariatric Surgery Assessment involves comprehensive psychosocial assessment involving a minimum of 5 healthcare professional assessments including nurse practitioners, dietitians, social workers, psychologists/psychiatrists, and surgeons.
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Figure 2– Receiver Operating Curve (ROC) analysis of BIPASS examiner scores in predicting clinical outcome
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