Quality Improvement Project- Developing a Weight

Loss Program for Transplant Clinic Patients

By: Krista Kerlinske

Preceptor and Reviewed By: Becca Wallschlaeger
Date: 05/01/17
Abstract

This quality improvement project of developing weight loss resources

and/or a program for transplant fills a missing piece of transplant care
at the UW Transplant Clinic. Although transplant is a case-by-case
basis, it is recommended that transplant candidates have a BMI of 35
kg/m2 or less. For some patients with advanced chronic disease this
BMI is difficult to obtain. When thinking of ideas for creating resources,
it was difficult because most the patients live hours away. Ultimately, it
was decided to perform a literary review to see what the research was
saying about weight loss counseling from a long distance. After the
literary review, it was decided that online resources or telephone calls
would be a readily available and beneficial way to implement a weight
loss resources for transplant candidates.

Background

Developing an effective weight loss program is a difficult task in itself,

yet developing an effective weight loss program for patients at the
transplant clinic adds an extra challenge. Each transplant center has
its own set of criteria for transplant patients. A few current
requirements at UW hospital include: no age limit but less lightly to
transplant over the age of 75 and a preferred BMI of 35 kg/m 2 or less.
The BMI of 35 kg/m 2 or less leads to idea that the patient will have
better outcomes and less risk of having adverse effects with
transplantation when compared to a person with a BMI over 35 kg/m 2.
This recommendation of being under the BMI of 35 kg/m 2 is difficult for
most patients to obtain, especially because many patients have other
comorbidities.

Diabetes is the number one cause of Chronic Kidney Disease (CKD).

The connection between diabetes, CKD and transplant is weight. Type
2 diabetes is generally cause by being over weight or obese and type 2
diabetes, if uncontrolled, can cause CKD. With all of these
interconnecting diseases weight loss becomes extremely difficult, this
is why UW Hospitals Transplant Clinic needs a weight loss program and
resources specifically for transplant patients.

This quality improvement project was designed using the FOCUS

method. FOCUS is an acronym helps organize quality improvement
projects (Table1). Step one: find a process to improve, step two:
organize a team. Then, clarify the current knowledge and understand
the root cause. Finally select the improvement method.
Table 1: Identifying need for quality improvement project
FOCUS definitions Relationship to the quality
improvement project
F: find a process to Lack of weight loss program for transplant
improve candidates, when a healthier BMI improves
chance of receiving a kidney.
O: organize a team Becca Wallschlaeger (preceptor) and Krista
Kerlinske (Dietetic intern)
C: current knowledge UW Hospitals transplant clinic
recommends a BMI of 35 kg/m2
Most transplant candidate are from out of
town (do not live in or near Madison, WI)
Many have comorbidities, such as diabetes
U: understand root Patients need help and resources to lose
causes weight. These resources need to be readily
available across Wisconsin and surrounding
states.
S: select the Develop/create a weight loss program for
improvement transplant candidates

FOCUS transfers over to the quality improvement project, through

identify the basic steps need to outline the plan for the QI project
(Table 1). As mentioned above there is a recommendation for body
mass index of 35 kg/m2, however currently at the transplant clinic
there is no process, procedure or resources to provide to patients who
are told that losing weight would put them at a better chance of
receiving a transplant. Therefore, a team was organized in order to
investigate and create a plan to develop a weight loss program. Using
the current knowledge of requirements for transplant, general patient
demographics and disease associated with kidney failure, a plan began
to develop to create resources for a distance weight loss program.

This quality improvement project is both a benefit to the UW hospital

transplant center and to the patient. This benefits UW Transplant Clinic
through a possible increase in patients that will receive transplants and
have better outcomes with the transplant. Patients who do not meet
the BMI criteria may feel discouraged or hopeless; some patients may
look else where for treatment for example Northwestern has a cap for
BMI of less than 45 kg/m 2 for BMI, and patients with BMI greater than
40kg/m2 are carefully considered (Kovler Transplantation Center, 2008).
Creating a weight loss program may help patients be motivated to lose
weight and stay with UW for transplant, having resources readily
available to patients may help them keep a positive light. Having a
good mental status and secure support from the healthcare team
benefits the patient and demonstrates patient centered care. Although
there are potential benefits for the organization ultimately it is the
patient who benefits the most. The patient will ultimately obtain a
healthier weight, and they will have a higher chance of meeting the
requirements for transplant at the UW Transplant Clinic. For patients
who want a transplant, a weight loss program can make a huge
difference in their life.

Plan (PDCA)

Throughout the project the plan changed rapidly based on available

information and results that we were receiving. Initially it was decided
to contact other transplant clinics with established weight loss
programs for transplant patients however, only one transplant clinic
responded, RUSH University. The information from RUSH was collected
and stored for later data collection. The next step that we though was
talking to the patients to see what they would find helpful. However,
most patients did not want to answer our questionnaire. In order to
obtain enough data, it was decided to perform a literature search in
order to find programs that are effective for weight loss when in person
counseling sessions were not available. Choosing distance weight loss
programs as the focus of the literature review was done because there
are not many weight loss programs specifically for transplant
candidates and the research on these programs is extremely limited.

Review of Collected Data/ Literature Review

Data was gathered from RUSH University, the dietitian informed me of

basic information from their program Trim for Transplant. This
program involves in person counseling session for 6 months. The initial
visit includes an hour long session and then 30 minute follow up
sessions once a month for the next 5 months. These sessions were
individualized; Motivational interview along with individualize
recommendations and goals were utilized. This information was not as
helpful as expected; all patients are seen in person, which is not
realistic for the patient population the UW Transplant Clinic Serves.

The literature review was the most insightful collection of information.

Although many of the studies that were reviewed were not directly
indicating transplant candidates and weight loss, the focus was on the
distance programs and how this could be implemented at UWs clinic. 5
key studies were reviewed and are describes below.

The first study that was looked at was Perceived helpfulness of the
individual components of a behavioral weight loss program: result from
the Hopkins POWER trial, the two interventions implemented were
personal support (n=138), and remote support (n=139); these two
interventions were compared to a controlled group (n=139). Both of
the interventions groups were given the same goal: to reach and then
maintain a 5% weight loss or greater in 24 months. After the 24 month
follow up a questionnaire was given to assess the helpfulness of the
different components of the weight loss program. The interventions
consisted of coaching in person or over the phone; both had access to
a website where the participants could track their weight and
contained handout and informational pieces that were easy to access
and read. The PCP was also involved in the weight loss intervention.
The components that were identified as the most helpful for
participants were the telephone sessions (88%), tracking weight online
(81%) and coach review of tracking (81%). The least helpful was the
PCP involvement (50%). When comparing the two intervention groups
ranked the telephone sessions and coach review tracking was
considered significantly more helpful in the remote group compared to
the in-person group. The authors conclude weight loss coaching
through telephone sessions and web support are received well (Dalcin,
Jerome, Fitzpatrick, Louis, Wang, Bennett, Durkin, 2015).

Randomized control trail of a nationally available weight control

program tailored for adults with type 2 diabetes was the second study
compared weight watcher (WW) paired with a certified diabetes
educator to the standard diet counseling (SC) for diabetes. The weight
watchers program used meetings, online tools and telephone/email
counseling from a certified diabetes educator. This was a 12 month
randomized controlled trail conducted at 16 US research centers and a
total of 563 participants were recruited with type 2 diabetes, HbA 1c 7-
11% and a BMI of 27-50kg/m2. Follow ups were performed at months 3,
6, 9 and 12. The results show that 24% of WW group and 14% of SC
group reached HbA1c <7.0% (P=0.004). Weight loss was also more
prominent in the WW group versus the SC group with -4.0% and -1.9%
loss respectively. The main difference between the SC group and the
WW group was that more tools were readily available to help promote
healthy lifestyle choices. The WW group also had outside support, not
only a certified diabetes educator (ONeil PM, Miller-Kovach K, Tuerk
PW, Becker LE, Wadden TA, Fujioka K, Hollander PL, 2016).
Next, an article that looked at face-to-face (FTF) counseling versus
counseling through conference call. The study, Equivalent weight loss
for weight management programs delivered by phone and clinic, aim
was to compare the two groups and see if the two group had similar
weight changes during the 6-18 month maintenance period. Patient
with chronic medical conditions were also allowed to participate with
PCP permission because they tend to represent a majority of the
population whom seek out weigh management. Behavioral meetings
were performed weekly during the first 6 months and then bimonthly
from 7-9 months, monthly for 10-12 months and every other month for
the remainder of the 18-month trial. The study found that weight loss,
weight maintenance and reported physical activity did not differ
significantly between the two groups. However, cost per session was
significantly different between the two groups $44.07 in the FTF group
and 22.47 in the phone group. The author concludes that phone
delivery counseling provides equivalent weight loss and weight
maintenance compared to standard methods (Donnelly JE, Goetz J,
Gibson C, Sullivan DK, Lee R, Smith BK, Lambourne K, et al. 2013).

Veterans hospitals have an established weight loss program called

MOVE! and recently they are created a TeleMOVE program in order for
the weight loss program to be accessible for more patients. This
studys objective was to compare a ne telehealth treatment, called
TeleMOVE, to the established standard treatment program, called
MOVE!. An observational study was performed among Veteran with
obesity. In the TeleMOVE program Veterans received a telehealth
monitor, standardized digital scale, a pedometer and a MOVE handout
booklet for home use. The TeleMOVE had 5-minute modules every day
for 90 days, food logs were sent every two weeks, and weight was
collected daily. In the standard MOVE! Program participated in weekly
90-minute programs, which included a weigh in, they were encouraged
to keep weekly food logs, and given pedometers. The analysis of the
data collected found that the TeleMOVE participants were significantly
younger than the MOVE participants (p=0.009). The mean percent of
weight loss between the two groups were significant with 2.1% and
4.2% for the MOVE and TeleMOVE programs respectively (p <0.05).
Both groups had significant difference of weight loss when compared to
baseline. The authors concluded that TeleMOVE was at least as
effective as the MOVE! Program (Rutledge T, Skoyen JA, Wiese JA, Ober
KM, Woods GN, 2016).

The final article in the literature review demonstrated that BMI is a limit
to kidney transplant. The study Survey of Canadian kidney transplant
specialists on the management of morbid obesity and the transplant
waiting list decided to survey Canadian transplant surgeons and
nephrologists that belonged to the Kidney Group of the Canadian
Society of Transplant. An electronic survey was distributed and a
shorter paper copy was distributed at a national transplant conference.
There were a total of 47 responses most reported that BMI was used as
a limit to access waiting list, yet only 40% reported a strict
enforcement. The maximum transplant candidate was most commonly
reported to be 40kg/m2 followed by 35kg/m2. 94% of specialist did
report that obesity is taken into consideration during the selection
process. During the discussion portion of this article there is a list of
kidney transplant programs and 4 out of the 8 (50%)of programs have
weight loss programs specific to transplant patients. From this survey
the authors conclude that BMI is a limit to access for a kidney
transplant and there are inconsistencies that suggest a lack of official
policy, clear guidelines and procedures should be put in place for
transplant with the obese population (Chan G, Soucisse M, 2016).

Summary and Outcomes

From the data stated above, it is clear that BMI is a limit to

transplantation and that resource and programs need to be provided to
patients in order encourage and see result in weight loss. Technology is
an excellent way to provide resource and counseling session to
patients that have to travel for healthcare. A program can be set up
that offers online diet journaling, handouts to help with weight loss,
recipes and set up counseling session via phone or Skype if the patient
chooses to do so. This type of program could be designed to be very
general or it could be more individualized depending on how UW
transplant clinic would like to set it up. General handouts and
resources can be provided on the online program but also more
specific handouts for specific disease states may be created,
depending on the initial success of the program. The program could be
as simple as having a monthly chat with a dietitian to see progress.
The design of the program will depend on funding, time and resources
that are available to the UW Transplant Clinic at this time.

Once, the final resource is created a trial run with select patients will
be conducted. This trial run should last at least 8 weeks. Then the
patients will fill out a survey to indicate how they liked the program, if
they felt that it was working and their overall opinion. Then the
necessary change can be made and it can either go live, meaning the
healthcare team can suggest it to all patients the program would be
appropriate for or the program could go through a second evaluation
phase, in which a small group of patients would test the newer version
of the program (Table 2).

Table 2: Planned out PCDA steps

PDCA
Plan the improvement
Do the improvement
Check the improvement
Act and determine next steps
Detailed steps
Use the literature review to see
what types of weight loss
resources work for a distance.
Create the resources/program for
transplant patients
Once the resources are created, a
trail run with patients will be
implemented. After the trial run is
complete, a survey will be
administered to the participants.
From the results of the survey, the
appropriate changes will be made
and then the program will be open
to all transplant patients deemed
appropriate.

Conclusion

It is a well-known fact that weight loss is a difficult task, it is made

more difficult when pair with chronic disease states. In order to provide
more effective patient centered care a weight loss program using
telephone and/or online resources is necessary in order to reach
patients in a variety of location across the Midwest region. This
program will hopefully limit the barrier of patients with a BMI over
35kg/m2. The literature review was only the first step to this project,
the following steps include develop readily available resources, test the
program and resources developed, obtain feedback, make
improvement and then implement the resource and program to all
appropriate patients.

References

Chan G, Soucisse M. Survey of Canadian kidney transplant specialists

on the management of morbid obesity and the transplant waiting list.
Canadian Journal of Kidney Health and Disease. 2016; 3: 1-10.

Dalcin AT, Jerome GT, Fitzpatrick SL, Louis TA, Wang N-Y, Bennett WL,
Durkin N, Clark JM, Daumit GL, Appel LJ, Coughlin JW. Perceived
helpfulness of the individual components of a behavioral weight loss
program: result from the Hopkins POWER trial. Obes Sci Pract. 2015; 1:
23-32.

Donnelly JE, Goetz J, Gibson C, Sullivan DK, Lee R, Smith BK,

Lambourne K, et al. Equivalent weight loss for weight management
programs delivered by phone and clinic. Obesity. 2013; 21: 1951-1959.

Kovler Transplantation Center. Kidney transplantation a patient

handbook. Northwestern Memorial Hospital. 2008; 1-56.

ONeil PM, Miller-Kovach K, Tuerk PW, Becker LE, Wadden TA, Fujioka K,
Hollander PL et al. Randomized control trail of a nationally available
weight control program tailored for adults with type 2 diabetes.
Obesity. 2016; 24: 2269-2277.

Rutledge T, Skoyen JA, Wiese JA, Ober KM, Woods GN. A comparison of
MOVE! versus TeleMOVE programs for weight loss in veterans with
obesity. Obes Res Clin Pract. 2016.