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Bariatric surgery quality improvement project ‘DROPs’ readmissions
NEW ORLEANS – A significant reduction in 30-day all-cause hospital readmissions after sleeve gastrectomy was accomplished through the first-ever joint national quality improvement collaboration between the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery, John M. Morton, MD, reported at Obesity Week 2016.
The quality improvement program, known as DROP, for Decreasing Readmissions through Opportunities Provided, was developed by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). It was put to the test in a year-long study conducted in 128 nationally representative U.S. hospitals. The study involved a comparison of the participating hospitals’ 30-day all-cause readmission rates following bariatric surgery in the year prior to vs. the year after launch of the DROP project.
Overall, the 30-day all-cause readmission rate after primary laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy, or laparoscopic Roux-en-Y gastric bypass dropped only modestly, from 4.76% to 4.61%, a relative reduction of 3.2%. But that’s not the whole story. Hidden within that modest overall result were major improvements, Dr. Morton said at the meeting, presented by the Obesity Society of America and the American Society for Metabolic and Bariatric Surgery.
Of particular interest was the finding that the readmission rate following laparoscopic sleeve gastrectomy decreased from 4.02% to 3.54%, a 12% reduction. That’s an important finding, because sleeve gastrectomy is now by far the most frequently performed type of bariatric surgery in the United States. Indeed, it accounted for 54% of the estimated 196,000 bariatric surgery procedures performed in the country in 2015. Roux-en-Y gastric bypass was a distant second at 23%, followed by surgical revisions at 13.6%.
Moreover, the impact of the DROP initiative appeared to accelerate over time. The initiative as tested consisted of a comprehensive bundle of numerous components addressing preoperative, in-hospital, and postoperative care, and it took a while for hospitals to implement. The 30-day readmission rate following laparoscopic sleeve gastrectomy actually increased by 9.2% in the first 3 months following launch of the DROP initiative. But the readmission rate then took a U-turn, declining by 13.2% in the second quarter compared to the year-before rate, by 16.9% in the third quarter, and falling by 27.1% in the final 3 months of the study.
Mean length of stay for patients undergoing laparoscopic sleeve gastrectomy fell significantly, from 1.9 days pre-DROP to 1.79 days. The DROP intervention also achieved a significant decrease in length of stay for laparoscopic adjustable gastric banding, from 0.5 to 0.42 days.
The rate of readmission within 24 hours post discharge in laparoscopic sleeve gastrectomy patients decreased significantly by 19% after introduction of the DROP program. The trend was favorable, albeit not statistically significant, for the other two bariatric procedures studied.
Of note, hospitals in the two quartiles with the lowest preintervention 30-day all-cause readmission rates post bariatric surgery, with rates of 1.34% and 3.15%, respectively, didn’t derive any further reduction by participating in the DROP program. They already were performing many of the elements included in the intervention. But hospitals in the third quartile significantly improved their 30-day readmission rate from 4.84% to 4.13%, and those in the fourth quartile improved from 7.31% preintervention to 4.47% under the DROP program.
The program had no impact on postoperative leak rates or other surgical complications. However, patient satisfaction scores improved after introduction of the DROP intervention.
The preoperative components of the DROP readmission prevention bundle included a standardized 5-minute educational video featuring a surgeon, nutritionist, pharmacist, and psychologist or psychiatrist, with advice on key issues related to the upcoming operation. That’s also when the visits with the surgeon and a nutritionist were to be scheduled for within 30 days post surgery, and when the patient received phone numbers for the clinic and on-call surgeon in case questions arose later.
The in-hospital elements of the DROP intervention included provision of a clinical roadmap to guide patient expectations, as well as a nutritional consultation. The postoperative components included a day-after-discharge phone call from a nurse or physician assistant, a letter sent to the referring physician containing a discharge summary and recommendations, and a system to make sure that the scheduled follow-up appointments with the surgeon and nutritionist actually take place.
Since adherence to the various components of the DROP bundle varied from hospital to hospital, it was possible for Dr. Morton and his coinvestigators to determine which elements made the most difference in improving 30-day readmission rates. They found that the key difference makers were the nurse’s phone call on the day following discharge and the postoperative visits with the surgeon and nutritionist within the first several weeks.
Asked whether the study findings mean that hospitals that already have a 30-day all-cause readmission rate in the lower half of the national average don’t need to adopt the DROP program, Dr. Morton replied: “One size does not fit all. Maybe some centers don’t need to do all this.”
Thirty-day all-cause readmissions were selected for the first quality improvement project by the MBSAQIP in part because the Centers for Medicare & Medicaid Services has identified it as a priority area for surgery in general. Also, Dr. Morton was a coinvestigator in a study that found many readmissions after bariatric surgery are tied to preventable causes, including dietary indiscretions resulting in nausea and vomiting or dehydration, medication side effects, and inappropriate patient expectations (J Gastrointest Surg. 2016 Nov;20[11]:1797-1801).
“I think readmissions are a good outcome to study, because they incorporate many different elements of the patient experience, including patient safety and satisfaction. No surgeon wants to have a patient come back to the ER and be readmitted. And finally, there’s the cost,” Dr. Morton observed.
He noted that members of the MBSAQIP developed the DROP project in a highly efficient and cost-effective manner through a series of webinars and conference calls without the need for face-to-face meetings. The group plans to follow the same approach to its future quality improvement programs.
The DROP study was funded without industry support. Dr. Morton reported serving on advisory boards for Allurion and Novo Nordisk.
NEW ORLEANS – A significant reduction in 30-day all-cause hospital readmissions after sleeve gastrectomy was accomplished through the first-ever joint national quality improvement collaboration between the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery, John M. Morton, MD, reported at Obesity Week 2016.
The quality improvement program, known as DROP, for Decreasing Readmissions through Opportunities Provided, was developed by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). It was put to the test in a year-long study conducted in 128 nationally representative U.S. hospitals. The study involved a comparison of the participating hospitals’ 30-day all-cause readmission rates following bariatric surgery in the year prior to vs. the year after launch of the DROP project.
Overall, the 30-day all-cause readmission rate after primary laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy, or laparoscopic Roux-en-Y gastric bypass dropped only modestly, from 4.76% to 4.61%, a relative reduction of 3.2%. But that’s not the whole story. Hidden within that modest overall result were major improvements, Dr. Morton said at the meeting, presented by the Obesity Society of America and the American Society for Metabolic and Bariatric Surgery.
Of particular interest was the finding that the readmission rate following laparoscopic sleeve gastrectomy decreased from 4.02% to 3.54%, a 12% reduction. That’s an important finding, because sleeve gastrectomy is now by far the most frequently performed type of bariatric surgery in the United States. Indeed, it accounted for 54% of the estimated 196,000 bariatric surgery procedures performed in the country in 2015. Roux-en-Y gastric bypass was a distant second at 23%, followed by surgical revisions at 13.6%.
Moreover, the impact of the DROP initiative appeared to accelerate over time. The initiative as tested consisted of a comprehensive bundle of numerous components addressing preoperative, in-hospital, and postoperative care, and it took a while for hospitals to implement. The 30-day readmission rate following laparoscopic sleeve gastrectomy actually increased by 9.2% in the first 3 months following launch of the DROP initiative. But the readmission rate then took a U-turn, declining by 13.2% in the second quarter compared to the year-before rate, by 16.9% in the third quarter, and falling by 27.1% in the final 3 months of the study.
Mean length of stay for patients undergoing laparoscopic sleeve gastrectomy fell significantly, from 1.9 days pre-DROP to 1.79 days. The DROP intervention also achieved a significant decrease in length of stay for laparoscopic adjustable gastric banding, from 0.5 to 0.42 days.
The rate of readmission within 24 hours post discharge in laparoscopic sleeve gastrectomy patients decreased significantly by 19% after introduction of the DROP program. The trend was favorable, albeit not statistically significant, for the other two bariatric procedures studied.
Of note, hospitals in the two quartiles with the lowest preintervention 30-day all-cause readmission rates post bariatric surgery, with rates of 1.34% and 3.15%, respectively, didn’t derive any further reduction by participating in the DROP program. They already were performing many of the elements included in the intervention. But hospitals in the third quartile significantly improved their 30-day readmission rate from 4.84% to 4.13%, and those in the fourth quartile improved from 7.31% preintervention to 4.47% under the DROP program.
The program had no impact on postoperative leak rates or other surgical complications. However, patient satisfaction scores improved after introduction of the DROP intervention.
The preoperative components of the DROP readmission prevention bundle included a standardized 5-minute educational video featuring a surgeon, nutritionist, pharmacist, and psychologist or psychiatrist, with advice on key issues related to the upcoming operation. That’s also when the visits with the surgeon and a nutritionist were to be scheduled for within 30 days post surgery, and when the patient received phone numbers for the clinic and on-call surgeon in case questions arose later.
The in-hospital elements of the DROP intervention included provision of a clinical roadmap to guide patient expectations, as well as a nutritional consultation. The postoperative components included a day-after-discharge phone call from a nurse or physician assistant, a letter sent to the referring physician containing a discharge summary and recommendations, and a system to make sure that the scheduled follow-up appointments with the surgeon and nutritionist actually take place.
Since adherence to the various components of the DROP bundle varied from hospital to hospital, it was possible for Dr. Morton and his coinvestigators to determine which elements made the most difference in improving 30-day readmission rates. They found that the key difference makers were the nurse’s phone call on the day following discharge and the postoperative visits with the surgeon and nutritionist within the first several weeks.
Asked whether the study findings mean that hospitals that already have a 30-day all-cause readmission rate in the lower half of the national average don’t need to adopt the DROP program, Dr. Morton replied: “One size does not fit all. Maybe some centers don’t need to do all this.”
Thirty-day all-cause readmissions were selected for the first quality improvement project by the MBSAQIP in part because the Centers for Medicare & Medicaid Services has identified it as a priority area for surgery in general. Also, Dr. Morton was a coinvestigator in a study that found many readmissions after bariatric surgery are tied to preventable causes, including dietary indiscretions resulting in nausea and vomiting or dehydration, medication side effects, and inappropriate patient expectations (J Gastrointest Surg. 2016 Nov;20[11]:1797-1801).
“I think readmissions are a good outcome to study, because they incorporate many different elements of the patient experience, including patient safety and satisfaction. No surgeon wants to have a patient come back to the ER and be readmitted. And finally, there’s the cost,” Dr. Morton observed.
He noted that members of the MBSAQIP developed the DROP project in a highly efficient and cost-effective manner through a series of webinars and conference calls without the need for face-to-face meetings. The group plans to follow the same approach to its future quality improvement programs.
The DROP study was funded without industry support. Dr. Morton reported serving on advisory boards for Allurion and Novo Nordisk.
NEW ORLEANS – A significant reduction in 30-day all-cause hospital readmissions after sleeve gastrectomy was accomplished through the first-ever joint national quality improvement collaboration between the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery, John M. Morton, MD, reported at Obesity Week 2016.
The quality improvement program, known as DROP, for Decreasing Readmissions through Opportunities Provided, was developed by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). It was put to the test in a year-long study conducted in 128 nationally representative U.S. hospitals. The study involved a comparison of the participating hospitals’ 30-day all-cause readmission rates following bariatric surgery in the year prior to vs. the year after launch of the DROP project.
Overall, the 30-day all-cause readmission rate after primary laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy, or laparoscopic Roux-en-Y gastric bypass dropped only modestly, from 4.76% to 4.61%, a relative reduction of 3.2%. But that’s not the whole story. Hidden within that modest overall result were major improvements, Dr. Morton said at the meeting, presented by the Obesity Society of America and the American Society for Metabolic and Bariatric Surgery.
Of particular interest was the finding that the readmission rate following laparoscopic sleeve gastrectomy decreased from 4.02% to 3.54%, a 12% reduction. That’s an important finding, because sleeve gastrectomy is now by far the most frequently performed type of bariatric surgery in the United States. Indeed, it accounted for 54% of the estimated 196,000 bariatric surgery procedures performed in the country in 2015. Roux-en-Y gastric bypass was a distant second at 23%, followed by surgical revisions at 13.6%.
Moreover, the impact of the DROP initiative appeared to accelerate over time. The initiative as tested consisted of a comprehensive bundle of numerous components addressing preoperative, in-hospital, and postoperative care, and it took a while for hospitals to implement. The 30-day readmission rate following laparoscopic sleeve gastrectomy actually increased by 9.2% in the first 3 months following launch of the DROP initiative. But the readmission rate then took a U-turn, declining by 13.2% in the second quarter compared to the year-before rate, by 16.9% in the third quarter, and falling by 27.1% in the final 3 months of the study.
Mean length of stay for patients undergoing laparoscopic sleeve gastrectomy fell significantly, from 1.9 days pre-DROP to 1.79 days. The DROP intervention also achieved a significant decrease in length of stay for laparoscopic adjustable gastric banding, from 0.5 to 0.42 days.
The rate of readmission within 24 hours post discharge in laparoscopic sleeve gastrectomy patients decreased significantly by 19% after introduction of the DROP program. The trend was favorable, albeit not statistically significant, for the other two bariatric procedures studied.
Of note, hospitals in the two quartiles with the lowest preintervention 30-day all-cause readmission rates post bariatric surgery, with rates of 1.34% and 3.15%, respectively, didn’t derive any further reduction by participating in the DROP program. They already were performing many of the elements included in the intervention. But hospitals in the third quartile significantly improved their 30-day readmission rate from 4.84% to 4.13%, and those in the fourth quartile improved from 7.31% preintervention to 4.47% under the DROP program.
The program had no impact on postoperative leak rates or other surgical complications. However, patient satisfaction scores improved after introduction of the DROP intervention.
The preoperative components of the DROP readmission prevention bundle included a standardized 5-minute educational video featuring a surgeon, nutritionist, pharmacist, and psychologist or psychiatrist, with advice on key issues related to the upcoming operation. That’s also when the visits with the surgeon and a nutritionist were to be scheduled for within 30 days post surgery, and when the patient received phone numbers for the clinic and on-call surgeon in case questions arose later.
The in-hospital elements of the DROP intervention included provision of a clinical roadmap to guide patient expectations, as well as a nutritional consultation. The postoperative components included a day-after-discharge phone call from a nurse or physician assistant, a letter sent to the referring physician containing a discharge summary and recommendations, and a system to make sure that the scheduled follow-up appointments with the surgeon and nutritionist actually take place.
Since adherence to the various components of the DROP bundle varied from hospital to hospital, it was possible for Dr. Morton and his coinvestigators to determine which elements made the most difference in improving 30-day readmission rates. They found that the key difference makers were the nurse’s phone call on the day following discharge and the postoperative visits with the surgeon and nutritionist within the first several weeks.
Asked whether the study findings mean that hospitals that already have a 30-day all-cause readmission rate in the lower half of the national average don’t need to adopt the DROP program, Dr. Morton replied: “One size does not fit all. Maybe some centers don’t need to do all this.”
Thirty-day all-cause readmissions were selected for the first quality improvement project by the MBSAQIP in part because the Centers for Medicare & Medicaid Services has identified it as a priority area for surgery in general. Also, Dr. Morton was a coinvestigator in a study that found many readmissions after bariatric surgery are tied to preventable causes, including dietary indiscretions resulting in nausea and vomiting or dehydration, medication side effects, and inappropriate patient expectations (J Gastrointest Surg. 2016 Nov;20[11]:1797-1801).
“I think readmissions are a good outcome to study, because they incorporate many different elements of the patient experience, including patient safety and satisfaction. No surgeon wants to have a patient come back to the ER and be readmitted. And finally, there’s the cost,” Dr. Morton observed.
He noted that members of the MBSAQIP developed the DROP project in a highly efficient and cost-effective manner through a series of webinars and conference calls without the need for face-to-face meetings. The group plans to follow the same approach to its future quality improvement programs.
The DROP study was funded without industry support. Dr. Morton reported serving on advisory boards for Allurion and Novo Nordisk.
Key clinical point:
Major finding: In a large national study, the 30-day all-cause readmission rate after laparoscopic sleeve gastrectomy improved by 12% in the year after introduction of a quality improvement program targeting that outcome.
Data source: The DROP study involved a comparison of 30-day all-cause readmission rates after bariatric surgery at 128 nationally representative hospitals during the year prior to vs. the year following launch of a comprehensive package of quality improvement steps.
Disclosures: The DROP study received no industry funding. Dr. Morton reported serving on advisory boards for Allurion and Novo Nordisk.
Malpractice issues tied to bariatric surgery explored
NEW ORLEANS – The first-ever analysis of medical malpractice closed claims involving bariatric surgeons spotlights key opportunities for improvement for the surgical specialty, Eric J. DeMaria, MD, declared at Obesity Week 2016.
Four of the nation’s largest medical malpractice insurance companies agreed to allow members of an American Society for Metabolic and Bariatric Surgery task force to make site visits to their corporate offices, where the surgeons sat in closed rooms to read and take notes on a total of 175 cases closed during 2010-2015. Those case notes were later shared with the full task force, which sifted through the details in order to identify common causal themes and opportunities for improvement, explained Dr. DeMaria, a bariatric surgeon in Suffolk, Va.
Among the key findings:
• The defense prevailed in 63% of cases. The mean expense for defending a lawsuit was $91,836.
• In the 37% of cases involving monetary awards, the mean figure was $293,500, ranging from $20,000 to $8 million.
• Mortality was involved in 35% of cases. Other notable complications resulting in lawsuits included leak in 18% of cases, bowel obstruction in 10%, bleeding in 5.3%, retained foreign body in 5.3%, and vascular injury from access in 4.4%.
• Preoperative issues such as informed consent and disclosure of information were rare.
• The defendant surgeon was a foreign medical graduate in 27.5% of cases, board certified in 75.9%, and only 43% of the hospitals where the surgery took place were accredited. All those figures are at odds with national norms.
• The panel determined that the cause of the complication was provider-related in 50% of cases, system-related in 29%, and intrinsic to the patient’s disease in 21%.
• In the panel’s view, the complication was preventable by the surgeon in nearly 60% of cases and not preventable by the surgeon in 20%, with the remainder of cases deemed impossible to judge.
• Better preoperative care would have prevented the complication in 20% of cases, in the panel’s view. Better postoperative care would have prevented the complication in 45%.
• Just over 5% of the malpractice claims involved nonstandard malabsorptive operations. “Some of them I’d never heard of before,” according to Dr. DeMaria.
• Care was deemed by the panel to be appropriate in roughly 21% of the malpractice cases and grossly negligent or incompetent in 8%. Twenty-three percent of lawsuits involved preventable error of such magnitude that significant coaching and instruction would be required in order to prevent a recurrence.
Dr. DeMaria observed that this analysis of closed claims suggests that in order to reduce future malpractice claims against bariatric surgeons, it makes sense to focus on a few key areas of practice where most of the serious problems occur.
“We found the same themes repeated over and over; for example, delays in diagnosis and treatment of leaks,” he said.
A substantial number of the lawsuits could have been prevented through the use of preinsufflation and optical trocars, or access away from the midline, he added.
But the number one theme to emerge from the lawsuit analysis was poor communication with the health care team and/or family. The experts on the task force considered the communication performance to be appropriate in only 20% of cases.
“I would emphasize the strong contribution of communication issues, and the strong contribution of coverage and handoff issues,” Dr. DeMaria said. “One example of an intervention that might be introduced would be to standardize the language used in the operating room just before you start to staple the stomach, very similar to what airplane pilots do in their communication. We saw cases over and over again where the anesthesia person was asked to take out the [nasogastric] tube didn’t realize that meant the esophageal stethoscope, too.
“We need to do a better job of not just making sure a coverage person has been identified, but actually communicating with that person and doing a standardized handoff procedure,” Dr. DeMaria continued. “Management of postoperative phone calls is another important area: Who answers the phone? What are they supposed to do with that information? How do you get patients to appropriate care?”
Discussant Ramsey M. Dallal, MD, congratulated Dr. DeMaria and his fellow ASMBS task force members on “the massive amount of work” entailed in this project. And he urged his colleagues to take to heart the lessons learned.
“People hear the word ‘malpractice’ and they get fearful. They think of lawyers and of being attacked. The reality is this is not a malpractice study; this is a patient safety study. A study like this is an excellent way to improve patient safety. The problem with registry data is we don’t get the details – and it’s the case details that point out problems and potential solutions,” said Dr. Dallal, director of bariatrics and vice chair of the department of surgery at the Einstein Healthcare Network in the Philadelphia area.
The closed claims analysis was conducted free of commercial support. Dr. DeMaria reported serving as a consultant to Covidien and Ethicon.
NEW ORLEANS – The first-ever analysis of medical malpractice closed claims involving bariatric surgeons spotlights key opportunities for improvement for the surgical specialty, Eric J. DeMaria, MD, declared at Obesity Week 2016.
Four of the nation’s largest medical malpractice insurance companies agreed to allow members of an American Society for Metabolic and Bariatric Surgery task force to make site visits to their corporate offices, where the surgeons sat in closed rooms to read and take notes on a total of 175 cases closed during 2010-2015. Those case notes were later shared with the full task force, which sifted through the details in order to identify common causal themes and opportunities for improvement, explained Dr. DeMaria, a bariatric surgeon in Suffolk, Va.
Among the key findings:
• The defense prevailed in 63% of cases. The mean expense for defending a lawsuit was $91,836.
• In the 37% of cases involving monetary awards, the mean figure was $293,500, ranging from $20,000 to $8 million.
• Mortality was involved in 35% of cases. Other notable complications resulting in lawsuits included leak in 18% of cases, bowel obstruction in 10%, bleeding in 5.3%, retained foreign body in 5.3%, and vascular injury from access in 4.4%.
• Preoperative issues such as informed consent and disclosure of information were rare.
• The defendant surgeon was a foreign medical graduate in 27.5% of cases, board certified in 75.9%, and only 43% of the hospitals where the surgery took place were accredited. All those figures are at odds with national norms.
• The panel determined that the cause of the complication was provider-related in 50% of cases, system-related in 29%, and intrinsic to the patient’s disease in 21%.
• In the panel’s view, the complication was preventable by the surgeon in nearly 60% of cases and not preventable by the surgeon in 20%, with the remainder of cases deemed impossible to judge.
• Better preoperative care would have prevented the complication in 20% of cases, in the panel’s view. Better postoperative care would have prevented the complication in 45%.
• Just over 5% of the malpractice claims involved nonstandard malabsorptive operations. “Some of them I’d never heard of before,” according to Dr. DeMaria.
• Care was deemed by the panel to be appropriate in roughly 21% of the malpractice cases and grossly negligent or incompetent in 8%. Twenty-three percent of lawsuits involved preventable error of such magnitude that significant coaching and instruction would be required in order to prevent a recurrence.
Dr. DeMaria observed that this analysis of closed claims suggests that in order to reduce future malpractice claims against bariatric surgeons, it makes sense to focus on a few key areas of practice where most of the serious problems occur.
“We found the same themes repeated over and over; for example, delays in diagnosis and treatment of leaks,” he said.
A substantial number of the lawsuits could have been prevented through the use of preinsufflation and optical trocars, or access away from the midline, he added.
But the number one theme to emerge from the lawsuit analysis was poor communication with the health care team and/or family. The experts on the task force considered the communication performance to be appropriate in only 20% of cases.
“I would emphasize the strong contribution of communication issues, and the strong contribution of coverage and handoff issues,” Dr. DeMaria said. “One example of an intervention that might be introduced would be to standardize the language used in the operating room just before you start to staple the stomach, very similar to what airplane pilots do in their communication. We saw cases over and over again where the anesthesia person was asked to take out the [nasogastric] tube didn’t realize that meant the esophageal stethoscope, too.
“We need to do a better job of not just making sure a coverage person has been identified, but actually communicating with that person and doing a standardized handoff procedure,” Dr. DeMaria continued. “Management of postoperative phone calls is another important area: Who answers the phone? What are they supposed to do with that information? How do you get patients to appropriate care?”
Discussant Ramsey M. Dallal, MD, congratulated Dr. DeMaria and his fellow ASMBS task force members on “the massive amount of work” entailed in this project. And he urged his colleagues to take to heart the lessons learned.
“People hear the word ‘malpractice’ and they get fearful. They think of lawyers and of being attacked. The reality is this is not a malpractice study; this is a patient safety study. A study like this is an excellent way to improve patient safety. The problem with registry data is we don’t get the details – and it’s the case details that point out problems and potential solutions,” said Dr. Dallal, director of bariatrics and vice chair of the department of surgery at the Einstein Healthcare Network in the Philadelphia area.
The closed claims analysis was conducted free of commercial support. Dr. DeMaria reported serving as a consultant to Covidien and Ethicon.
NEW ORLEANS – The first-ever analysis of medical malpractice closed claims involving bariatric surgeons spotlights key opportunities for improvement for the surgical specialty, Eric J. DeMaria, MD, declared at Obesity Week 2016.
Four of the nation’s largest medical malpractice insurance companies agreed to allow members of an American Society for Metabolic and Bariatric Surgery task force to make site visits to their corporate offices, where the surgeons sat in closed rooms to read and take notes on a total of 175 cases closed during 2010-2015. Those case notes were later shared with the full task force, which sifted through the details in order to identify common causal themes and opportunities for improvement, explained Dr. DeMaria, a bariatric surgeon in Suffolk, Va.
Among the key findings:
• The defense prevailed in 63% of cases. The mean expense for defending a lawsuit was $91,836.
• In the 37% of cases involving monetary awards, the mean figure was $293,500, ranging from $20,000 to $8 million.
• Mortality was involved in 35% of cases. Other notable complications resulting in lawsuits included leak in 18% of cases, bowel obstruction in 10%, bleeding in 5.3%, retained foreign body in 5.3%, and vascular injury from access in 4.4%.
• Preoperative issues such as informed consent and disclosure of information were rare.
• The defendant surgeon was a foreign medical graduate in 27.5% of cases, board certified in 75.9%, and only 43% of the hospitals where the surgery took place were accredited. All those figures are at odds with national norms.
• The panel determined that the cause of the complication was provider-related in 50% of cases, system-related in 29%, and intrinsic to the patient’s disease in 21%.
• In the panel’s view, the complication was preventable by the surgeon in nearly 60% of cases and not preventable by the surgeon in 20%, with the remainder of cases deemed impossible to judge.
• Better preoperative care would have prevented the complication in 20% of cases, in the panel’s view. Better postoperative care would have prevented the complication in 45%.
• Just over 5% of the malpractice claims involved nonstandard malabsorptive operations. “Some of them I’d never heard of before,” according to Dr. DeMaria.
• Care was deemed by the panel to be appropriate in roughly 21% of the malpractice cases and grossly negligent or incompetent in 8%. Twenty-three percent of lawsuits involved preventable error of such magnitude that significant coaching and instruction would be required in order to prevent a recurrence.
Dr. DeMaria observed that this analysis of closed claims suggests that in order to reduce future malpractice claims against bariatric surgeons, it makes sense to focus on a few key areas of practice where most of the serious problems occur.
“We found the same themes repeated over and over; for example, delays in diagnosis and treatment of leaks,” he said.
A substantial number of the lawsuits could have been prevented through the use of preinsufflation and optical trocars, or access away from the midline, he added.
But the number one theme to emerge from the lawsuit analysis was poor communication with the health care team and/or family. The experts on the task force considered the communication performance to be appropriate in only 20% of cases.
“I would emphasize the strong contribution of communication issues, and the strong contribution of coverage and handoff issues,” Dr. DeMaria said. “One example of an intervention that might be introduced would be to standardize the language used in the operating room just before you start to staple the stomach, very similar to what airplane pilots do in their communication. We saw cases over and over again where the anesthesia person was asked to take out the [nasogastric] tube didn’t realize that meant the esophageal stethoscope, too.
“We need to do a better job of not just making sure a coverage person has been identified, but actually communicating with that person and doing a standardized handoff procedure,” Dr. DeMaria continued. “Management of postoperative phone calls is another important area: Who answers the phone? What are they supposed to do with that information? How do you get patients to appropriate care?”
Discussant Ramsey M. Dallal, MD, congratulated Dr. DeMaria and his fellow ASMBS task force members on “the massive amount of work” entailed in this project. And he urged his colleagues to take to heart the lessons learned.
“People hear the word ‘malpractice’ and they get fearful. They think of lawyers and of being attacked. The reality is this is not a malpractice study; this is a patient safety study. A study like this is an excellent way to improve patient safety. The problem with registry data is we don’t get the details – and it’s the case details that point out problems and potential solutions,” said Dr. Dallal, director of bariatrics and vice chair of the department of surgery at the Einstein Healthcare Network in the Philadelphia area.
The closed claims analysis was conducted free of commercial support. Dr. DeMaria reported serving as a consultant to Covidien and Ethicon.
Key clinical point:
Major finding: Communication with the health care team and the patient’s family was deemed appropriate in only 20% of a large series of medical malpractice lawsuits filed against bariatric surgeons.
Data source: This analysis of malpractice insurers’ files on 175 closed malpractice claims against bariatric surgeons was conducted by an American Society for Metabolic and Bariatric Surgery task force.
Disclosures: The study was conducted free of industry support.
Insurance-mandated diet pre–bariatric surgery deemed harmful
NEW ORLEANS – The widespread health insurance industry practice of requiring obese patients to spend months on a physician-supervised strict weight-loss diet prior to approving coverage of bariatric surgery accomplishes nothing constructive, Charles J. Keith Jr., MD, reported at Obesity Week 2016.
“We found that insurance-mandated preoperative diets were associated with a significant delay in treatment, no improvement in postoperative complication rates, and also no improvement in weight loss outcomes. If anything, after adjusting for potential confounding variables, the outcomes were inferior to the group that wasn’t required to diet,” said Dr. Keith of the University of Alabama at Birmingham.
Dr. Keith presented a retrospective review from the prospectively collected Alabama University bariatric surgery database, which included all 284 patients who underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy during 2009-2013. A total of 79% of the patients had private health insurance that required their participation in a preoperative physician-guided diet program, typically for 6 months. The other 21% did not have a mandatory preoperative diet requirement; the great majority of this group were covered under Medicare, which doesn’t require a diet program before bariatric surgery. The two groups weren’t significantly different in initial or immediately preoperative weight or body mass index, obesity-related comorbid conditions, type of bariatric surgery, or socioeconomic status.
The mean time from initial clinic visit to bariatric surgery was significantly shorter in the group with no mandated preoperative diet, at 154 vs. 218 days. In a multivariate analysis adjusted for age, sex, race, operation type, and comorbidities, the no-mandatory-diet group had a significantly greater reduction in BMI 6 months post surgery: a mean loss of 12.2 kg/m2, compared with 10.9 kg/m2 in the group required to participate in a preoperative diet. The difference was even greater at 2 years follow-up: a mean decrease of 14.9 kg/m2 in the no-diet group, vs. 10.7 kg/m2 in the mandatory diet group. The no-diet group experienced a mean 33% weight loss at 2 years, significantly better than the 25% weight loss in the mandatory diet group, Dr. Keith reported at the meeting, presented by the Obesity Society of America and the American Society for Metabolic and Bariatric Surgery.
Audience discussion showed that the insurance-mandated preoperative diet requirement is a hot button issue in the bariatric surgical community.
“I think these insurance programs are specifically designed to delay care,” one surgeon asserted.
Another bariatric surgeon commented that while Dr. Keith’s study will be helpful in advocating for removal of the mandatory preoperative diet requirement, what’s really needed are studies that demonstrate just how often this requirement results in drop out from bariatric programs by patients who’ve grown discouraged by yet-another unsuccessful attempt at nonsurgical weight loss.
Dr. Keith reported having no financial conflicts of interest regarding his study.
NEW ORLEANS – The widespread health insurance industry practice of requiring obese patients to spend months on a physician-supervised strict weight-loss diet prior to approving coverage of bariatric surgery accomplishes nothing constructive, Charles J. Keith Jr., MD, reported at Obesity Week 2016.
“We found that insurance-mandated preoperative diets were associated with a significant delay in treatment, no improvement in postoperative complication rates, and also no improvement in weight loss outcomes. If anything, after adjusting for potential confounding variables, the outcomes were inferior to the group that wasn’t required to diet,” said Dr. Keith of the University of Alabama at Birmingham.
Dr. Keith presented a retrospective review from the prospectively collected Alabama University bariatric surgery database, which included all 284 patients who underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy during 2009-2013. A total of 79% of the patients had private health insurance that required their participation in a preoperative physician-guided diet program, typically for 6 months. The other 21% did not have a mandatory preoperative diet requirement; the great majority of this group were covered under Medicare, which doesn’t require a diet program before bariatric surgery. The two groups weren’t significantly different in initial or immediately preoperative weight or body mass index, obesity-related comorbid conditions, type of bariatric surgery, or socioeconomic status.
The mean time from initial clinic visit to bariatric surgery was significantly shorter in the group with no mandated preoperative diet, at 154 vs. 218 days. In a multivariate analysis adjusted for age, sex, race, operation type, and comorbidities, the no-mandatory-diet group had a significantly greater reduction in BMI 6 months post surgery: a mean loss of 12.2 kg/m2, compared with 10.9 kg/m2 in the group required to participate in a preoperative diet. The difference was even greater at 2 years follow-up: a mean decrease of 14.9 kg/m2 in the no-diet group, vs. 10.7 kg/m2 in the mandatory diet group. The no-diet group experienced a mean 33% weight loss at 2 years, significantly better than the 25% weight loss in the mandatory diet group, Dr. Keith reported at the meeting, presented by the Obesity Society of America and the American Society for Metabolic and Bariatric Surgery.
Audience discussion showed that the insurance-mandated preoperative diet requirement is a hot button issue in the bariatric surgical community.
“I think these insurance programs are specifically designed to delay care,” one surgeon asserted.
Another bariatric surgeon commented that while Dr. Keith’s study will be helpful in advocating for removal of the mandatory preoperative diet requirement, what’s really needed are studies that demonstrate just how often this requirement results in drop out from bariatric programs by patients who’ve grown discouraged by yet-another unsuccessful attempt at nonsurgical weight loss.
Dr. Keith reported having no financial conflicts of interest regarding his study.
NEW ORLEANS – The widespread health insurance industry practice of requiring obese patients to spend months on a physician-supervised strict weight-loss diet prior to approving coverage of bariatric surgery accomplishes nothing constructive, Charles J. Keith Jr., MD, reported at Obesity Week 2016.
“We found that insurance-mandated preoperative diets were associated with a significant delay in treatment, no improvement in postoperative complication rates, and also no improvement in weight loss outcomes. If anything, after adjusting for potential confounding variables, the outcomes were inferior to the group that wasn’t required to diet,” said Dr. Keith of the University of Alabama at Birmingham.
Dr. Keith presented a retrospective review from the prospectively collected Alabama University bariatric surgery database, which included all 284 patients who underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy during 2009-2013. A total of 79% of the patients had private health insurance that required their participation in a preoperative physician-guided diet program, typically for 6 months. The other 21% did not have a mandatory preoperative diet requirement; the great majority of this group were covered under Medicare, which doesn’t require a diet program before bariatric surgery. The two groups weren’t significantly different in initial or immediately preoperative weight or body mass index, obesity-related comorbid conditions, type of bariatric surgery, or socioeconomic status.
The mean time from initial clinic visit to bariatric surgery was significantly shorter in the group with no mandated preoperative diet, at 154 vs. 218 days. In a multivariate analysis adjusted for age, sex, race, operation type, and comorbidities, the no-mandatory-diet group had a significantly greater reduction in BMI 6 months post surgery: a mean loss of 12.2 kg/m2, compared with 10.9 kg/m2 in the group required to participate in a preoperative diet. The difference was even greater at 2 years follow-up: a mean decrease of 14.9 kg/m2 in the no-diet group, vs. 10.7 kg/m2 in the mandatory diet group. The no-diet group experienced a mean 33% weight loss at 2 years, significantly better than the 25% weight loss in the mandatory diet group, Dr. Keith reported at the meeting, presented by the Obesity Society of America and the American Society for Metabolic and Bariatric Surgery.
Audience discussion showed that the insurance-mandated preoperative diet requirement is a hot button issue in the bariatric surgical community.
“I think these insurance programs are specifically designed to delay care,” one surgeon asserted.
Another bariatric surgeon commented that while Dr. Keith’s study will be helpful in advocating for removal of the mandatory preoperative diet requirement, what’s really needed are studies that demonstrate just how often this requirement results in drop out from bariatric programs by patients who’ve grown discouraged by yet-another unsuccessful attempt at nonsurgical weight loss.
Dr. Keith reported having no financial conflicts of interest regarding his study.
Key clinical point:
Major finding: At follow-up 2 years after bariatric surgery, patients who were required by their insurance company to participate in a physician-supervised preoperative diet program had an adjusted mean 25% weight loss, a significantly worse outcome than the mean 33% weight loss among patients with no such requirement.
Data source: This was a retrospective analysis of 284 patients in a prospectively collected university bariatric surgery database.
Disclosures: The study presenter reported having no relevant financial interests.
Prepregnancy overweight boosts risk of depressive symptoms in pregnancy
NEW ORLEANS – Prepregnancy overweight and obesity are associated with increased incidence and severity of depressive symptoms during pregnancy, independent of preeclampsia and other hypertensive pregnancy disorders or gestational diabetes, Satu Kumpulainen reported at Obesity Week 2016.
The implications of this novel finding are clear: “Prepregnancy interventions targeting overweight and obesity and mental health will not only benefit the pregnant mother’s health but will also provide optimal odds for healthy development of the fetus as well,” said Ms. Kumpulainen, a doctoral student at the University of Helsinki Institute of Behavioral Sciences.
It’s well established that prepregnancy obesity is a risk factor for gestational diabetes, preeclampsia, and depression during pregnancy. This study was carried out to learn if a high prepregnancy BMI boosts the risk of prenatal depression independent of the cardiometabolic complications of pregnancy, Ms. Kumpulainen explained at the meeting, which was presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
This proved to be the case in the Finnish women, 67.3% of whom were normal weight before pregnancy; 19.1% were overweight and 13.6% obese. Gestational diabetes occurred in 10.6% of the PREDO participants, and hypertension-spectrum disorders of pregnancy occurred in 8.2%.
The women who were obese or overweight prepregnancy reported higher rates of clinically meaningful depressive symptoms throughout pregnancy, compared with women who were normal weight. Using a CES-D score of 16 or more to define clinically significant depressive symptoms, such symptoms were reported as early as gestational week 12 and on multiple occasions thereafter by 19.9% of the women who were normal weight before pregnancy, 23.3% of those who were overweight, and 27.4% of those who were obese. The differences were statistically significant.
The risk of clinically significant depressive symptoms during pregnancy was no higher in prepregnancy normal-weight women who developed gestational diabetes or preeclampsia than in those who did not, Ms. Kumpulainen reported.
“Our findings suggest that cardiometabolic pregnancy disorders per se don’t trigger higher levels of depressive symptoms, but women with prepregnancy overweight and obesity feel more depressed right from the beginning of pregnancy,” Ms. Kumpulainen said.
She reported having no financial conflicts of interest related to the study, which was supported by Finnish scientific research grants.
NEW ORLEANS – Prepregnancy overweight and obesity are associated with increased incidence and severity of depressive symptoms during pregnancy, independent of preeclampsia and other hypertensive pregnancy disorders or gestational diabetes, Satu Kumpulainen reported at Obesity Week 2016.
The implications of this novel finding are clear: “Prepregnancy interventions targeting overweight and obesity and mental health will not only benefit the pregnant mother’s health but will also provide optimal odds for healthy development of the fetus as well,” said Ms. Kumpulainen, a doctoral student at the University of Helsinki Institute of Behavioral Sciences.
It’s well established that prepregnancy obesity is a risk factor for gestational diabetes, preeclampsia, and depression during pregnancy. This study was carried out to learn if a high prepregnancy BMI boosts the risk of prenatal depression independent of the cardiometabolic complications of pregnancy, Ms. Kumpulainen explained at the meeting, which was presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
This proved to be the case in the Finnish women, 67.3% of whom were normal weight before pregnancy; 19.1% were overweight and 13.6% obese. Gestational diabetes occurred in 10.6% of the PREDO participants, and hypertension-spectrum disorders of pregnancy occurred in 8.2%.
The women who were obese or overweight prepregnancy reported higher rates of clinically meaningful depressive symptoms throughout pregnancy, compared with women who were normal weight. Using a CES-D score of 16 or more to define clinically significant depressive symptoms, such symptoms were reported as early as gestational week 12 and on multiple occasions thereafter by 19.9% of the women who were normal weight before pregnancy, 23.3% of those who were overweight, and 27.4% of those who were obese. The differences were statistically significant.
The risk of clinically significant depressive symptoms during pregnancy was no higher in prepregnancy normal-weight women who developed gestational diabetes or preeclampsia than in those who did not, Ms. Kumpulainen reported.
“Our findings suggest that cardiometabolic pregnancy disorders per se don’t trigger higher levels of depressive symptoms, but women with prepregnancy overweight and obesity feel more depressed right from the beginning of pregnancy,” Ms. Kumpulainen said.
She reported having no financial conflicts of interest related to the study, which was supported by Finnish scientific research grants.
NEW ORLEANS – Prepregnancy overweight and obesity are associated with increased incidence and severity of depressive symptoms during pregnancy, independent of preeclampsia and other hypertensive pregnancy disorders or gestational diabetes, Satu Kumpulainen reported at Obesity Week 2016.
The implications of this novel finding are clear: “Prepregnancy interventions targeting overweight and obesity and mental health will not only benefit the pregnant mother’s health but will also provide optimal odds for healthy development of the fetus as well,” said Ms. Kumpulainen, a doctoral student at the University of Helsinki Institute of Behavioral Sciences.
It’s well established that prepregnancy obesity is a risk factor for gestational diabetes, preeclampsia, and depression during pregnancy. This study was carried out to learn if a high prepregnancy BMI boosts the risk of prenatal depression independent of the cardiometabolic complications of pregnancy, Ms. Kumpulainen explained at the meeting, which was presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
This proved to be the case in the Finnish women, 67.3% of whom were normal weight before pregnancy; 19.1% were overweight and 13.6% obese. Gestational diabetes occurred in 10.6% of the PREDO participants, and hypertension-spectrum disorders of pregnancy occurred in 8.2%.
The women who were obese or overweight prepregnancy reported higher rates of clinically meaningful depressive symptoms throughout pregnancy, compared with women who were normal weight. Using a CES-D score of 16 or more to define clinically significant depressive symptoms, such symptoms were reported as early as gestational week 12 and on multiple occasions thereafter by 19.9% of the women who were normal weight before pregnancy, 23.3% of those who were overweight, and 27.4% of those who were obese. The differences were statistically significant.
The risk of clinically significant depressive symptoms during pregnancy was no higher in prepregnancy normal-weight women who developed gestational diabetes or preeclampsia than in those who did not, Ms. Kumpulainen reported.
“Our findings suggest that cardiometabolic pregnancy disorders per se don’t trigger higher levels of depressive symptoms, but women with prepregnancy overweight and obesity feel more depressed right from the beginning of pregnancy,” Ms. Kumpulainen said.
She reported having no financial conflicts of interest related to the study, which was supported by Finnish scientific research grants.
AT OBESITY WEEK 2016
Key clinical point:
Major finding: Women who were obese prior to pregnancy were over 50% more likely to experience clinically significant depressive symptoms throughout pregnancy, compared with women who were normal weight before pregnancy, independent of whether the women developed gestational diabetes or preeclampsia.
Data source: This was a secondary analysis from a prospective study of more than 3,000 pregnant Finnish women.
Disclosures: The study was supported by Finnish scientific research grants. The presenter reported having no financial conflicts of interest related to the study.
Unless it is diagnosed, obesity won’t be treated
NEW ORLEANS – Obesity has been formally diagnosed in less than half of patients with a body-mass index of 30 kg/m2 or higher in the Cleveland Clinic’s large multispecialty database, and Bartolome Burguera, MD, believes it’s the same story elsewhere.
“I think pretty much all over the country obesity is really not well diagnosed,” Dr. Burguera, director of obesity programs at the Cleveland Clinic, said at Obesity Week 2016.
And that which hasn’t been diagnosed doesn’t get treated.
The diagnosis rate went up with higher BMIs; still, of the 25,137 patients with obesity class 3 as defined by a BMI of 40 kg/m2 or higher, only 75% had a formal diagnosis of obesity in their record, the endocrinologist said at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
“For many years, physicians thought that obesity is not a disease. And even though it was considered a disease by some, they didn’t feel they had the tools, the knowledge, the support, the medications, or the time to take care of obesity, especially when they thought of it as a self-inflicted disease,” Dr. Burguera explained in an interview. He believes physician attitudes are slowly changing.
“In our clinic we’ve taken measures to change attitudes, for sure. Now, when we look in the electronic health record we get an automatic alert if the patient has a BMI of 30 or more,” he said.
“I think, in general, many more people now think of obesity as a disease. But it’s a chronic disease and you have to have chronic therapy. We have to make sure we make the diagnosis, and once you make the diagnosis you have to discuss treatment with the patient. If you don’t feel comfortable for whatever reason, I think you have to refer the patient to a colleague to take care of the obesity. Because when you take care of the obesity all the comorbidities get better: the diabetes, the blood pressure, the cholesterol. Obesity is the primary problem in so many other comorbidities. We have put little effort to this point in taking care of the obesity. We’ve put more effort into treating the diabetes and the other comorbidities,” Dr. Burguera said.
The Medicare obesity benefit provides reimbursement in primary care settings for intensive behavioral therapy with face-to-face counseling and motivational interviewing. The billing code is G0447. Coverage is provided for 22 visits over the course of a year, each lasting 15 minutes.
Dr. Batsis presented highlights of his published serial cross-sectional analysis of fee-for-service Medicare claims data for 2012 and 2013. Among Medicare beneficiaries eligible for the obesity benefit because they had a BMI of 30 kg/m2 or above, only 0.35% used the benefit in 2012. There was a tiny uptick to 0.6% in 2013, but even in the tiny fraction of eligible patients who availed themselves of the benefit, the average number of behavioral therapy sessions was just 2.1 visits out of the 22 for which physician reimbursement is available (Obesity. 2016 Sep;24[9]:1983-8).
“Let’s hope the 2014 data look a little better,” commented Dr. Batsis of the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, N.H.
There was marked regional variation in utilization of the Medicare obesity benefit across the U.S. in 2013. Rates were highest in Colorado – the state with the lowest obesity rate in the country – as well as Nebraska, Wisconsin, Vermont, and New Hampshire. Rates were lowest across the Southwest.
Dr. Burguera’s study was funded by Novo Nordisk. Dr. Batsis reported having no financial conflicts of interest.
NEW ORLEANS – Obesity has been formally diagnosed in less than half of patients with a body-mass index of 30 kg/m2 or higher in the Cleveland Clinic’s large multispecialty database, and Bartolome Burguera, MD, believes it’s the same story elsewhere.
“I think pretty much all over the country obesity is really not well diagnosed,” Dr. Burguera, director of obesity programs at the Cleveland Clinic, said at Obesity Week 2016.
And that which hasn’t been diagnosed doesn’t get treated.
The diagnosis rate went up with higher BMIs; still, of the 25,137 patients with obesity class 3 as defined by a BMI of 40 kg/m2 or higher, only 75% had a formal diagnosis of obesity in their record, the endocrinologist said at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
“For many years, physicians thought that obesity is not a disease. And even though it was considered a disease by some, they didn’t feel they had the tools, the knowledge, the support, the medications, or the time to take care of obesity, especially when they thought of it as a self-inflicted disease,” Dr. Burguera explained in an interview. He believes physician attitudes are slowly changing.
“In our clinic we’ve taken measures to change attitudes, for sure. Now, when we look in the electronic health record we get an automatic alert if the patient has a BMI of 30 or more,” he said.
“I think, in general, many more people now think of obesity as a disease. But it’s a chronic disease and you have to have chronic therapy. We have to make sure we make the diagnosis, and once you make the diagnosis you have to discuss treatment with the patient. If you don’t feel comfortable for whatever reason, I think you have to refer the patient to a colleague to take care of the obesity. Because when you take care of the obesity all the comorbidities get better: the diabetes, the blood pressure, the cholesterol. Obesity is the primary problem in so many other comorbidities. We have put little effort to this point in taking care of the obesity. We’ve put more effort into treating the diabetes and the other comorbidities,” Dr. Burguera said.
The Medicare obesity benefit provides reimbursement in primary care settings for intensive behavioral therapy with face-to-face counseling and motivational interviewing. The billing code is G0447. Coverage is provided for 22 visits over the course of a year, each lasting 15 minutes.
Dr. Batsis presented highlights of his published serial cross-sectional analysis of fee-for-service Medicare claims data for 2012 and 2013. Among Medicare beneficiaries eligible for the obesity benefit because they had a BMI of 30 kg/m2 or above, only 0.35% used the benefit in 2012. There was a tiny uptick to 0.6% in 2013, but even in the tiny fraction of eligible patients who availed themselves of the benefit, the average number of behavioral therapy sessions was just 2.1 visits out of the 22 for which physician reimbursement is available (Obesity. 2016 Sep;24[9]:1983-8).
“Let’s hope the 2014 data look a little better,” commented Dr. Batsis of the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, N.H.
There was marked regional variation in utilization of the Medicare obesity benefit across the U.S. in 2013. Rates were highest in Colorado – the state with the lowest obesity rate in the country – as well as Nebraska, Wisconsin, Vermont, and New Hampshire. Rates were lowest across the Southwest.
Dr. Burguera’s study was funded by Novo Nordisk. Dr. Batsis reported having no financial conflicts of interest.
NEW ORLEANS – Obesity has been formally diagnosed in less than half of patients with a body-mass index of 30 kg/m2 or higher in the Cleveland Clinic’s large multispecialty database, and Bartolome Burguera, MD, believes it’s the same story elsewhere.
“I think pretty much all over the country obesity is really not well diagnosed,” Dr. Burguera, director of obesity programs at the Cleveland Clinic, said at Obesity Week 2016.
And that which hasn’t been diagnosed doesn’t get treated.
The diagnosis rate went up with higher BMIs; still, of the 25,137 patients with obesity class 3 as defined by a BMI of 40 kg/m2 or higher, only 75% had a formal diagnosis of obesity in their record, the endocrinologist said at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
“For many years, physicians thought that obesity is not a disease. And even though it was considered a disease by some, they didn’t feel they had the tools, the knowledge, the support, the medications, or the time to take care of obesity, especially when they thought of it as a self-inflicted disease,” Dr. Burguera explained in an interview. He believes physician attitudes are slowly changing.
“In our clinic we’ve taken measures to change attitudes, for sure. Now, when we look in the electronic health record we get an automatic alert if the patient has a BMI of 30 or more,” he said.
“I think, in general, many more people now think of obesity as a disease. But it’s a chronic disease and you have to have chronic therapy. We have to make sure we make the diagnosis, and once you make the diagnosis you have to discuss treatment with the patient. If you don’t feel comfortable for whatever reason, I think you have to refer the patient to a colleague to take care of the obesity. Because when you take care of the obesity all the comorbidities get better: the diabetes, the blood pressure, the cholesterol. Obesity is the primary problem in so many other comorbidities. We have put little effort to this point in taking care of the obesity. We’ve put more effort into treating the diabetes and the other comorbidities,” Dr. Burguera said.
The Medicare obesity benefit provides reimbursement in primary care settings for intensive behavioral therapy with face-to-face counseling and motivational interviewing. The billing code is G0447. Coverage is provided for 22 visits over the course of a year, each lasting 15 minutes.
Dr. Batsis presented highlights of his published serial cross-sectional analysis of fee-for-service Medicare claims data for 2012 and 2013. Among Medicare beneficiaries eligible for the obesity benefit because they had a BMI of 30 kg/m2 or above, only 0.35% used the benefit in 2012. There was a tiny uptick to 0.6% in 2013, but even in the tiny fraction of eligible patients who availed themselves of the benefit, the average number of behavioral therapy sessions was just 2.1 visits out of the 22 for which physician reimbursement is available (Obesity. 2016 Sep;24[9]:1983-8).
“Let’s hope the 2014 data look a little better,” commented Dr. Batsis of the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, N.H.
There was marked regional variation in utilization of the Medicare obesity benefit across the U.S. in 2013. Rates were highest in Colorado – the state with the lowest obesity rate in the country – as well as Nebraska, Wisconsin, Vermont, and New Hampshire. Rates were lowest across the Southwest.
Dr. Burguera’s study was funded by Novo Nordisk. Dr. Batsis reported having no financial conflicts of interest.
AT OBESITY WEEK 2016
Key clinical point:
Major finding: Only 48% of a large group of patients with a BMI of 30 kg/m2 or higher had a formal diagnosis of obesity in their medical record.
Data source: This was a cross-sectional study of the electronic health records of nearly 325,000 active patients in the Cleveland Clinic database, 41.5% of whom had a BMI of 30 kg/m2 or higher.
Disclosures: The study was funded by Novo Nordisk.
Bariatric surgery or total joint replacement: which first?
NEW ORLEANS – Performing bariatric surgery prior to total knee or hip replacement instead of vice versa resulted in significantly shorter orthopedic surgical operating time and length of stay in an observational study, Emanuel E. Nearing II, MD, reported at Obesity Week 2016.
“We propose that strong consideration be given to bariatric surgery as a means of weight loss and BMI [body mass index] reduction in patients with obesity prior to total joint replacement,” he said at the meeting presented by the Obesity Society of America and the American Society for Metabolic and Bariatric Surgery.
“A common complaint of patients presenting with obesity is that their osteoarthritis has limited their mobility and that their weight gain is secondary to that reduced mobility. They believe that a new joint will help them regain their mobility and then lose weight. Interestingly, this does not appear to be the case. In fact, the majority of patients in our study actually gained weight following joint replacement. Given that, these patients need to be weight-optimized prior to total joint replacement. Bariatric surgery is a durable way to facilitate this,” he continued.
Dr. Nearing presented a retrospective observational study of 102 patients who underwent either laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy plus a total knee or hip replacement in the Gundersen system. Sixty-six patients had their bariatric surgery first, by a mean of 4.3 years, while the other 36 had arthroplasty a mean of 4.9 years before their bariatric surgery. The two groups were similar in terms of demographics and baseline comorbid conditions.
Patients who had their total joint replacement first had a mean preoperative BMI of 43.7 kg/m2 and a mean pre–bariatric surgery BMI of 46.3 kg/m2. The patients who had bariatric surgery first had a preoperative BMI of 49.6 kg/m2 and a mean pre–orthopedic surgery BMI of 37.6 kgm2. One year after joint replacement surgery, patients who had that operation first had a mean BMI of 43.9 kg/m2, compared with 37.8 kg/m2 for those who waited until after they underwent bariatric surgery.
Mean operative time for total joint replacement when it was the first operation was 113.5 minutes and substantially less at 71 minutes when it was done after bariatric surgery. Mean hospital length of stay for total joint replacement when it followed bariatric surgery was 2.9 days, a full day less than when joint replacement came first.
Rates of complications including skin or soft tissue infection, venous thromboembolism, hematoma, need for transfusion, and periprosthetic infection at 30 and 90 days didn’t differ between the two groups. Neither did the need for late reinterventions.
Dr. Nearing noted that a working group of the American Association of Hip and Knee Surgeons has conducted a review of the orthopedic surgery literature and concluded that all patients with a BMI of 30 kg/m2 or more undergoing total knee or hip arthroplasty are at increased risk for perioperative respiratory complications, thromboembolic events, delayed wound healing, infection, and need for joint revision surgery (J Arthroplasty. 2013 May;28[5]:714-21).
He observed that a retrospective study such as his cannot shed light on the optimal time interval for total joint replacement following bariatric surgery. That key question is being addressed by the ongoing prospective SWIFT (Surgical Weight-Loss to Improve Functional Status Trajectories Following Total Knee Arthroplasty) trial. The study hypothesis is that bariatric surgery prior to the knee replacement surgery will reduce risk and improve long-term outcomes and physical function.
Several audience member commented that, based upon their experience, they would have anticipated that complication rates would have been significantly lower in total joint replacement patients when that operation followed bariatric surgery.
“We were surprised, too,” Dr. Nearing replied. “I think the explanation is that at Gundersen we have three bariatric surgeons and only a handful of orthopedic surgeons, and we use protocols and pathways. We just routinely do our operations the same way each and every time.”
John M. Morton, MD, a former American Society for Metabolic and Bariatric Surgery president, commented that the Gundersen study findings sound a call for more cross-specialty collaboration in steering obese patients with severe knee or hip osteoarthritis to bariatric surgery first in order to maximize the results of the joint replacement surgery.
“I think we’re all seeing weight loss as another form of prehabilitation for other specialties. Our orthopedic colleagues are kind of like us – surgeons – so this seems to be a great place for us to partner with them,” said Dr. Morton, chief of bariatric and minimally invasive surgery at Stanford (Calif.) University.
Dr. Nearing reported having no financial interests relevant to his study.
NEW ORLEANS – Performing bariatric surgery prior to total knee or hip replacement instead of vice versa resulted in significantly shorter orthopedic surgical operating time and length of stay in an observational study, Emanuel E. Nearing II, MD, reported at Obesity Week 2016.
“We propose that strong consideration be given to bariatric surgery as a means of weight loss and BMI [body mass index] reduction in patients with obesity prior to total joint replacement,” he said at the meeting presented by the Obesity Society of America and the American Society for Metabolic and Bariatric Surgery.
“A common complaint of patients presenting with obesity is that their osteoarthritis has limited their mobility and that their weight gain is secondary to that reduced mobility. They believe that a new joint will help them regain their mobility and then lose weight. Interestingly, this does not appear to be the case. In fact, the majority of patients in our study actually gained weight following joint replacement. Given that, these patients need to be weight-optimized prior to total joint replacement. Bariatric surgery is a durable way to facilitate this,” he continued.
Dr. Nearing presented a retrospective observational study of 102 patients who underwent either laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy plus a total knee or hip replacement in the Gundersen system. Sixty-six patients had their bariatric surgery first, by a mean of 4.3 years, while the other 36 had arthroplasty a mean of 4.9 years before their bariatric surgery. The two groups were similar in terms of demographics and baseline comorbid conditions.
Patients who had their total joint replacement first had a mean preoperative BMI of 43.7 kg/m2 and a mean pre–bariatric surgery BMI of 46.3 kg/m2. The patients who had bariatric surgery first had a preoperative BMI of 49.6 kg/m2 and a mean pre–orthopedic surgery BMI of 37.6 kgm2. One year after joint replacement surgery, patients who had that operation first had a mean BMI of 43.9 kg/m2, compared with 37.8 kg/m2 for those who waited until after they underwent bariatric surgery.
Mean operative time for total joint replacement when it was the first operation was 113.5 minutes and substantially less at 71 minutes when it was done after bariatric surgery. Mean hospital length of stay for total joint replacement when it followed bariatric surgery was 2.9 days, a full day less than when joint replacement came first.
Rates of complications including skin or soft tissue infection, venous thromboembolism, hematoma, need for transfusion, and periprosthetic infection at 30 and 90 days didn’t differ between the two groups. Neither did the need for late reinterventions.
Dr. Nearing noted that a working group of the American Association of Hip and Knee Surgeons has conducted a review of the orthopedic surgery literature and concluded that all patients with a BMI of 30 kg/m2 or more undergoing total knee or hip arthroplasty are at increased risk for perioperative respiratory complications, thromboembolic events, delayed wound healing, infection, and need for joint revision surgery (J Arthroplasty. 2013 May;28[5]:714-21).
He observed that a retrospective study such as his cannot shed light on the optimal time interval for total joint replacement following bariatric surgery. That key question is being addressed by the ongoing prospective SWIFT (Surgical Weight-Loss to Improve Functional Status Trajectories Following Total Knee Arthroplasty) trial. The study hypothesis is that bariatric surgery prior to the knee replacement surgery will reduce risk and improve long-term outcomes and physical function.
Several audience member commented that, based upon their experience, they would have anticipated that complication rates would have been significantly lower in total joint replacement patients when that operation followed bariatric surgery.
“We were surprised, too,” Dr. Nearing replied. “I think the explanation is that at Gundersen we have three bariatric surgeons and only a handful of orthopedic surgeons, and we use protocols and pathways. We just routinely do our operations the same way each and every time.”
John M. Morton, MD, a former American Society for Metabolic and Bariatric Surgery president, commented that the Gundersen study findings sound a call for more cross-specialty collaboration in steering obese patients with severe knee or hip osteoarthritis to bariatric surgery first in order to maximize the results of the joint replacement surgery.
“I think we’re all seeing weight loss as another form of prehabilitation for other specialties. Our orthopedic colleagues are kind of like us – surgeons – so this seems to be a great place for us to partner with them,” said Dr. Morton, chief of bariatric and minimally invasive surgery at Stanford (Calif.) University.
Dr. Nearing reported having no financial interests relevant to his study.
NEW ORLEANS – Performing bariatric surgery prior to total knee or hip replacement instead of vice versa resulted in significantly shorter orthopedic surgical operating time and length of stay in an observational study, Emanuel E. Nearing II, MD, reported at Obesity Week 2016.
“We propose that strong consideration be given to bariatric surgery as a means of weight loss and BMI [body mass index] reduction in patients with obesity prior to total joint replacement,” he said at the meeting presented by the Obesity Society of America and the American Society for Metabolic and Bariatric Surgery.
“A common complaint of patients presenting with obesity is that their osteoarthritis has limited their mobility and that their weight gain is secondary to that reduced mobility. They believe that a new joint will help them regain their mobility and then lose weight. Interestingly, this does not appear to be the case. In fact, the majority of patients in our study actually gained weight following joint replacement. Given that, these patients need to be weight-optimized prior to total joint replacement. Bariatric surgery is a durable way to facilitate this,” he continued.
Dr. Nearing presented a retrospective observational study of 102 patients who underwent either laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy plus a total knee or hip replacement in the Gundersen system. Sixty-six patients had their bariatric surgery first, by a mean of 4.3 years, while the other 36 had arthroplasty a mean of 4.9 years before their bariatric surgery. The two groups were similar in terms of demographics and baseline comorbid conditions.
Patients who had their total joint replacement first had a mean preoperative BMI of 43.7 kg/m2 and a mean pre–bariatric surgery BMI of 46.3 kg/m2. The patients who had bariatric surgery first had a preoperative BMI of 49.6 kg/m2 and a mean pre–orthopedic surgery BMI of 37.6 kgm2. One year after joint replacement surgery, patients who had that operation first had a mean BMI of 43.9 kg/m2, compared with 37.8 kg/m2 for those who waited until after they underwent bariatric surgery.
Mean operative time for total joint replacement when it was the first operation was 113.5 minutes and substantially less at 71 minutes when it was done after bariatric surgery. Mean hospital length of stay for total joint replacement when it followed bariatric surgery was 2.9 days, a full day less than when joint replacement came first.
Rates of complications including skin or soft tissue infection, venous thromboembolism, hematoma, need for transfusion, and periprosthetic infection at 30 and 90 days didn’t differ between the two groups. Neither did the need for late reinterventions.
Dr. Nearing noted that a working group of the American Association of Hip and Knee Surgeons has conducted a review of the orthopedic surgery literature and concluded that all patients with a BMI of 30 kg/m2 or more undergoing total knee or hip arthroplasty are at increased risk for perioperative respiratory complications, thromboembolic events, delayed wound healing, infection, and need for joint revision surgery (J Arthroplasty. 2013 May;28[5]:714-21).
He observed that a retrospective study such as his cannot shed light on the optimal time interval for total joint replacement following bariatric surgery. That key question is being addressed by the ongoing prospective SWIFT (Surgical Weight-Loss to Improve Functional Status Trajectories Following Total Knee Arthroplasty) trial. The study hypothesis is that bariatric surgery prior to the knee replacement surgery will reduce risk and improve long-term outcomes and physical function.
Several audience member commented that, based upon their experience, they would have anticipated that complication rates would have been significantly lower in total joint replacement patients when that operation followed bariatric surgery.
“We were surprised, too,” Dr. Nearing replied. “I think the explanation is that at Gundersen we have three bariatric surgeons and only a handful of orthopedic surgeons, and we use protocols and pathways. We just routinely do our operations the same way each and every time.”
John M. Morton, MD, a former American Society for Metabolic and Bariatric Surgery president, commented that the Gundersen study findings sound a call for more cross-specialty collaboration in steering obese patients with severe knee or hip osteoarthritis to bariatric surgery first in order to maximize the results of the joint replacement surgery.
“I think we’re all seeing weight loss as another form of prehabilitation for other specialties. Our orthopedic colleagues are kind of like us – surgeons – so this seems to be a great place for us to partner with them,” said Dr. Morton, chief of bariatric and minimally invasive surgery at Stanford (Calif.) University.
Dr. Nearing reported having no financial interests relevant to his study.
AT OBESITY WEEK 2016
Key clinical point:
Major finding: When total joint replacement in obese patients was performed after bariatric surgery, mean hospital length of stay was a full day less than when the orthopedic surgery preceded the bariatric surgery.
Data source: This retrospective observational study included 102 obese patients who underwent bariatric surgery and total knee or hip replacement.
Disclosures: The study presenter reported having no financial conflicts of interest.
What referring physicians need to know about bariatric surgery success rates
NEW ORLEANS – About one-third of bariatric surgery patients achieve a body mass index below 30 kg/m2 at 1 year of follow-up, and the strongest predictor of success is having a BMI of 40 kg/m2 or less at the time of surgery, Oliver A. Varban, MD, reported at Obesity Week 2016.
Indeed, patients with a baseline BMI of 40 kg/m2 or less were fully 13.3-fold more likely to have a BMI of less than 30 kg/m2 1 year post surgery in a study of 19,764 patients in the Michigan Bariatric Surgery Collaborative database, according to Dr. Varban, surgical director of the adult bariatric surgery program at the University of Michigan, Ann Arbor.
“In order to optimize outcomes of bariatric surgery, patients should be encouraged to consider it when their BMI is less than 40 kg/m2. And policies that obstruct or delay surgery can actually result in inferior outcomes,” he said at the meeting, which was presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
“These patients are being referred to us. We don’t seek them out. The biggest impetus for this study was to be able to show referring physicians that outcomes are better when treatment is sought earlier. Every patient who shows up at our clinics with a BMI of 65 must have had a BMI of 35 at some point in time. I think we miss the boat on a lot of those patients,” the surgeon said. “Society at large should recognize that bariatric surgery is the most effective treatment for obesity, but it’s also the most underutilized one.”
The Michigan Bariatric Surgery Collaborative is a unique statewide, payer-funded consortium focused on quality improvement. Dr. Varban presented an analysis of 19,764 patients who underwent a primary bariatric procedure in Michigan during 2006-2015 for whom complete 1-year follow-up data were available. The mean preoperative BMI for the overall group was 48 kg/m2, and the mean postoperative BMI at 1 year was 33 kg/m2.
Thirty-eight percent of patients achieved a BMI below 30 kg/m2 at 1 year; their mean BMI at that time was 26.7 kg/m2. The mean BMI 1 year post surgery in the 62% of patients who didn’t reach the goal was 36.7 kg/m2.
Only 6.2% of patients who didn’t get to a BMI of less than 30 kg/m2 1 year post surgery had a preoperative BMI of 40 kg/m2 or below, whereas 31.7% of patients who achieved the goal did have a baseline BMI of 40 kg/m2 or below.
Among patients with a preoperative BMI of 50-59 kg/m2, only 7.6% reached the target. And among those with a preoperative BMI of 60 kg/m2, only 0.4% had a BMI of less than 30 kg/m2 at 1 year.
“Patients with a BMI of 50 kg/m2 or more should be given realistic expectations about the type of weight loss they’ll have after bariatric surgery,” Dr. Varban said.
Why is a postsurgical BMI below 30 kg/m2 such an important benchmark? Abundant evidence indicates that having a BMI of 30 kg/m2 or higher is associated with a 50%-100% increase in the risk of premature death compared to that of normal-weight individuals. Successful bariatric surgery reduces that risk by 30%-40%.
In the Michigan study, patients who reached the BMI target had a significantly higher rate of resolution of common comorbid conditions associated with morbid obesity, including type 2 diabetes, hypertension, dyslipidemia, and sleep apnea. They also scored higher on a patient satisfaction survey.
The mean percent preoperative weight loss was 2.3% in patients who didn’t achieve the target BMI and similar at 2.5% in those who did. Thus, preoperative weight loss is not a major contributor to postoperative success, Dr. Varban continued.
Failure to reach the postoperative BMI goal was significantly more common among patients who were black or Hispanic, had an annual income below $25,000, or didn’t have private insurance.
Thirty-day perioperative complication rates didn’t differ between patients who attained a BMI below 30 kg/m2 at 1 year and those who did not.
Dr. Varban said it will come to no surprise to bariatric surgeons that the likelihood of attaining the target 1-year BMI varied according to the type of bariatric surgery: Compared to patients who underwent adjustable laparoscopic banding, the success rate was 19-fold higher with Roux-en-Y gastric bypass, 7.2-fold higher with sleeve gastrectomy, and a whopping 72-fold higher in patients who had a duodenal switch procedure.
Neither the mean preoperative nor 1-year postoperative BMI figures changed much over the study period, even though sleeve gastrectomy became much more common after 2010. For example, the mean preoperative BMI was 48.3 kg/m2 in 2006 and 46.9 kg/m2 in 2015, while the mean postoperative BMIs were 32.7 and 32.6 kg/m2, respectively, in those years.
Dr. Varban said that as he ran the numbers, he was surprised to see that the baseline BMI was so high – far higher than he would have guessed. But since then as he has discussed the study findings with referring physicians throughout Michigan, he’s come to understand the explanation: Many of them are content to wait until their morbidly obese patients grow to a BMI above 50 kg/m2 before making the referral because they consider the alternate criterion for bariatric surgery referral – that is, failure to achieve significant weight loss after 1 year of medically supervised attempts – to be too much for them to take on.
Amir A. Ghaferi, MD, a University of Michigan bariatric surgeon and coinvestigator in the study, rose from the audience to urge his colleagues to focus on the health policy implications of the findings.
“Maybe our bariatric surgery criteria aren’t right. We’ve been talking a lot amongst ourselves about pushing the BMI threshold lower and reducing some of the insurance barriers. I think what this study demonstrates from a policy perspective is we need to get these patients sooner, without so many barriers ahead of us and in front of the patients, in order to achieve the best possible outcomes,” Dr. Ghaferi said.
Dr. Varban reported receiving research funding from Blue Cross Blue Shield of Michigan.
NEW ORLEANS – About one-third of bariatric surgery patients achieve a body mass index below 30 kg/m2 at 1 year of follow-up, and the strongest predictor of success is having a BMI of 40 kg/m2 or less at the time of surgery, Oliver A. Varban, MD, reported at Obesity Week 2016.
Indeed, patients with a baseline BMI of 40 kg/m2 or less were fully 13.3-fold more likely to have a BMI of less than 30 kg/m2 1 year post surgery in a study of 19,764 patients in the Michigan Bariatric Surgery Collaborative database, according to Dr. Varban, surgical director of the adult bariatric surgery program at the University of Michigan, Ann Arbor.
“In order to optimize outcomes of bariatric surgery, patients should be encouraged to consider it when their BMI is less than 40 kg/m2. And policies that obstruct or delay surgery can actually result in inferior outcomes,” he said at the meeting, which was presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
“These patients are being referred to us. We don’t seek them out. The biggest impetus for this study was to be able to show referring physicians that outcomes are better when treatment is sought earlier. Every patient who shows up at our clinics with a BMI of 65 must have had a BMI of 35 at some point in time. I think we miss the boat on a lot of those patients,” the surgeon said. “Society at large should recognize that bariatric surgery is the most effective treatment for obesity, but it’s also the most underutilized one.”
The Michigan Bariatric Surgery Collaborative is a unique statewide, payer-funded consortium focused on quality improvement. Dr. Varban presented an analysis of 19,764 patients who underwent a primary bariatric procedure in Michigan during 2006-2015 for whom complete 1-year follow-up data were available. The mean preoperative BMI for the overall group was 48 kg/m2, and the mean postoperative BMI at 1 year was 33 kg/m2.
Thirty-eight percent of patients achieved a BMI below 30 kg/m2 at 1 year; their mean BMI at that time was 26.7 kg/m2. The mean BMI 1 year post surgery in the 62% of patients who didn’t reach the goal was 36.7 kg/m2.
Only 6.2% of patients who didn’t get to a BMI of less than 30 kg/m2 1 year post surgery had a preoperative BMI of 40 kg/m2 or below, whereas 31.7% of patients who achieved the goal did have a baseline BMI of 40 kg/m2 or below.
Among patients with a preoperative BMI of 50-59 kg/m2, only 7.6% reached the target. And among those with a preoperative BMI of 60 kg/m2, only 0.4% had a BMI of less than 30 kg/m2 at 1 year.
“Patients with a BMI of 50 kg/m2 or more should be given realistic expectations about the type of weight loss they’ll have after bariatric surgery,” Dr. Varban said.
Why is a postsurgical BMI below 30 kg/m2 such an important benchmark? Abundant evidence indicates that having a BMI of 30 kg/m2 or higher is associated with a 50%-100% increase in the risk of premature death compared to that of normal-weight individuals. Successful bariatric surgery reduces that risk by 30%-40%.
In the Michigan study, patients who reached the BMI target had a significantly higher rate of resolution of common comorbid conditions associated with morbid obesity, including type 2 diabetes, hypertension, dyslipidemia, and sleep apnea. They also scored higher on a patient satisfaction survey.
The mean percent preoperative weight loss was 2.3% in patients who didn’t achieve the target BMI and similar at 2.5% in those who did. Thus, preoperative weight loss is not a major contributor to postoperative success, Dr. Varban continued.
Failure to reach the postoperative BMI goal was significantly more common among patients who were black or Hispanic, had an annual income below $25,000, or didn’t have private insurance.
Thirty-day perioperative complication rates didn’t differ between patients who attained a BMI below 30 kg/m2 at 1 year and those who did not.
Dr. Varban said it will come to no surprise to bariatric surgeons that the likelihood of attaining the target 1-year BMI varied according to the type of bariatric surgery: Compared to patients who underwent adjustable laparoscopic banding, the success rate was 19-fold higher with Roux-en-Y gastric bypass, 7.2-fold higher with sleeve gastrectomy, and a whopping 72-fold higher in patients who had a duodenal switch procedure.
Neither the mean preoperative nor 1-year postoperative BMI figures changed much over the study period, even though sleeve gastrectomy became much more common after 2010. For example, the mean preoperative BMI was 48.3 kg/m2 in 2006 and 46.9 kg/m2 in 2015, while the mean postoperative BMIs were 32.7 and 32.6 kg/m2, respectively, in those years.
Dr. Varban said that as he ran the numbers, he was surprised to see that the baseline BMI was so high – far higher than he would have guessed. But since then as he has discussed the study findings with referring physicians throughout Michigan, he’s come to understand the explanation: Many of them are content to wait until their morbidly obese patients grow to a BMI above 50 kg/m2 before making the referral because they consider the alternate criterion for bariatric surgery referral – that is, failure to achieve significant weight loss after 1 year of medically supervised attempts – to be too much for them to take on.
Amir A. Ghaferi, MD, a University of Michigan bariatric surgeon and coinvestigator in the study, rose from the audience to urge his colleagues to focus on the health policy implications of the findings.
“Maybe our bariatric surgery criteria aren’t right. We’ve been talking a lot amongst ourselves about pushing the BMI threshold lower and reducing some of the insurance barriers. I think what this study demonstrates from a policy perspective is we need to get these patients sooner, without so many barriers ahead of us and in front of the patients, in order to achieve the best possible outcomes,” Dr. Ghaferi said.
Dr. Varban reported receiving research funding from Blue Cross Blue Shield of Michigan.
NEW ORLEANS – About one-third of bariatric surgery patients achieve a body mass index below 30 kg/m2 at 1 year of follow-up, and the strongest predictor of success is having a BMI of 40 kg/m2 or less at the time of surgery, Oliver A. Varban, MD, reported at Obesity Week 2016.
Indeed, patients with a baseline BMI of 40 kg/m2 or less were fully 13.3-fold more likely to have a BMI of less than 30 kg/m2 1 year post surgery in a study of 19,764 patients in the Michigan Bariatric Surgery Collaborative database, according to Dr. Varban, surgical director of the adult bariatric surgery program at the University of Michigan, Ann Arbor.
“In order to optimize outcomes of bariatric surgery, patients should be encouraged to consider it when their BMI is less than 40 kg/m2. And policies that obstruct or delay surgery can actually result in inferior outcomes,” he said at the meeting, which was presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
“These patients are being referred to us. We don’t seek them out. The biggest impetus for this study was to be able to show referring physicians that outcomes are better when treatment is sought earlier. Every patient who shows up at our clinics with a BMI of 65 must have had a BMI of 35 at some point in time. I think we miss the boat on a lot of those patients,” the surgeon said. “Society at large should recognize that bariatric surgery is the most effective treatment for obesity, but it’s also the most underutilized one.”
The Michigan Bariatric Surgery Collaborative is a unique statewide, payer-funded consortium focused on quality improvement. Dr. Varban presented an analysis of 19,764 patients who underwent a primary bariatric procedure in Michigan during 2006-2015 for whom complete 1-year follow-up data were available. The mean preoperative BMI for the overall group was 48 kg/m2, and the mean postoperative BMI at 1 year was 33 kg/m2.
Thirty-eight percent of patients achieved a BMI below 30 kg/m2 at 1 year; their mean BMI at that time was 26.7 kg/m2. The mean BMI 1 year post surgery in the 62% of patients who didn’t reach the goal was 36.7 kg/m2.
Only 6.2% of patients who didn’t get to a BMI of less than 30 kg/m2 1 year post surgery had a preoperative BMI of 40 kg/m2 or below, whereas 31.7% of patients who achieved the goal did have a baseline BMI of 40 kg/m2 or below.
Among patients with a preoperative BMI of 50-59 kg/m2, only 7.6% reached the target. And among those with a preoperative BMI of 60 kg/m2, only 0.4% had a BMI of less than 30 kg/m2 at 1 year.
“Patients with a BMI of 50 kg/m2 or more should be given realistic expectations about the type of weight loss they’ll have after bariatric surgery,” Dr. Varban said.
Why is a postsurgical BMI below 30 kg/m2 such an important benchmark? Abundant evidence indicates that having a BMI of 30 kg/m2 or higher is associated with a 50%-100% increase in the risk of premature death compared to that of normal-weight individuals. Successful bariatric surgery reduces that risk by 30%-40%.
In the Michigan study, patients who reached the BMI target had a significantly higher rate of resolution of common comorbid conditions associated with morbid obesity, including type 2 diabetes, hypertension, dyslipidemia, and sleep apnea. They also scored higher on a patient satisfaction survey.
The mean percent preoperative weight loss was 2.3% in patients who didn’t achieve the target BMI and similar at 2.5% in those who did. Thus, preoperative weight loss is not a major contributor to postoperative success, Dr. Varban continued.
Failure to reach the postoperative BMI goal was significantly more common among patients who were black or Hispanic, had an annual income below $25,000, or didn’t have private insurance.
Thirty-day perioperative complication rates didn’t differ between patients who attained a BMI below 30 kg/m2 at 1 year and those who did not.
Dr. Varban said it will come to no surprise to bariatric surgeons that the likelihood of attaining the target 1-year BMI varied according to the type of bariatric surgery: Compared to patients who underwent adjustable laparoscopic banding, the success rate was 19-fold higher with Roux-en-Y gastric bypass, 7.2-fold higher with sleeve gastrectomy, and a whopping 72-fold higher in patients who had a duodenal switch procedure.
Neither the mean preoperative nor 1-year postoperative BMI figures changed much over the study period, even though sleeve gastrectomy became much more common after 2010. For example, the mean preoperative BMI was 48.3 kg/m2 in 2006 and 46.9 kg/m2 in 2015, while the mean postoperative BMIs were 32.7 and 32.6 kg/m2, respectively, in those years.
Dr. Varban said that as he ran the numbers, he was surprised to see that the baseline BMI was so high – far higher than he would have guessed. But since then as he has discussed the study findings with referring physicians throughout Michigan, he’s come to understand the explanation: Many of them are content to wait until their morbidly obese patients grow to a BMI above 50 kg/m2 before making the referral because they consider the alternate criterion for bariatric surgery referral – that is, failure to achieve significant weight loss after 1 year of medically supervised attempts – to be too much for them to take on.
Amir A. Ghaferi, MD, a University of Michigan bariatric surgeon and coinvestigator in the study, rose from the audience to urge his colleagues to focus on the health policy implications of the findings.
“Maybe our bariatric surgery criteria aren’t right. We’ve been talking a lot amongst ourselves about pushing the BMI threshold lower and reducing some of the insurance barriers. I think what this study demonstrates from a policy perspective is we need to get these patients sooner, without so many barriers ahead of us and in front of the patients, in order to achieve the best possible outcomes,” Dr. Ghaferi said.
Dr. Varban reported receiving research funding from Blue Cross Blue Shield of Michigan.
OBESITY WEEK 2016
Key clinical point:
Major finding: Patients who underwent bariatric surgery when their BMI was 40 kg/m2 or below were 13.3-fold more likely to have a BMI below 30 kg/m2 1 year later.
Data source: A study of 1-year outcomes in nearly 20,000 patients in the Michigan Bariatric Surgery Collaborative database.
Disclosures: The study presenter reported receiving research funding from Blue Cross Blue Shield of Michigan.
Weight Watchers program shows efficacy in controlling type 2 diabetes
NEW ORLEANS – Overweight and obese patients with inadequately controlled type 2 diabetes have a new evidence-based treatment option in the form of the standard commercial Weight Watchers program enhanced by telephone and email consultations with a certified diabetes educator.
This intervention resulted in clinically meaningful improvements in glycemic control and weight loss, compared with a control group on standard care in a 12-month randomized clinical trial conducted at 16 U.S. centers, Patrick M. O’Neil, PhD, reported at Obesity Week 2016.
“Patients and providers alike need a broader arsenal of treatment options for managing diabetes; in particular, options that are more accessible to the majority of people with diabetes,” he said. “The number of adults with diabetes is large and growing, and a variety of accessible treatment approaches is needed. The results of this and related trials suggest that adapted, nationally available weight loss programs emphasizing lifestyle changes may represent accessible and effective adjunctive health management resources for people with overweight or obesity and type 2 diabetes.”
Dr. O’Neil reported on a racially and geographically diverse group of 563 overweight or obese adults with inadequately controlled type 2 diabetes who were randomized to the off-the-shelf commercial Weight Watchers program featuring regular community meetings and online tools enhanced with telephone and email consultation with a certified diabetes educator, or to a control group who got an initial face-to-face diabetes nutrition counseling visit with follow-up written information materials.
Control group participants received current standard care, although national survey data indicate that only about 55% of patients with diabetes get any diabetes education at all at diagnosis, he observed.
At enrollment, all study participants were already receiving treatment for their diabetes from a physician not connected to the randomized trial. Ninety-five percent of them were on one or more diabetes medications. Yet their baseline hemoglobin A1clevel was 7%-11% and their body mass index was 27-50 kg/m2.
Both weight loss and improvement in HbA1c were significantly greater in the Weight Watchers group than controls at each of the prespecified interim follow-ups at 13, 26, and 39 weeks.
When the study concluded at 52 weeks, the Weight Watchers group averaged a 0.32% reduction from baseline in HbA1c, and 24% of patients in that study arm had achieved an HbA1c below 7.0%. In contrast, the control group averaged a 0.16% increase in HbA1c, and only 14% of controls got their HbA1c below 7.0%, even though all participants continued to received ongoing background diabetes management from their outside physician throughout the study.
While the 0.48% difference in HbA1c between the Weight Watchers group and controls may not be jaw-dropping, it is equivalent to the placebo-subtracted decrease in HbA1c seen in 2-year long clinical trials of obesity medications in overweight or obese patients with type 2 diabetes, Dr. O’Neil said at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
The Weight Watchers group averaged a 4% weight loss at 52 weeks, significantly greater than the 1.9% reduction in controls.
Twenty-six percent of the Weight Watchers group had reduced their diabetes medications at the 52-week mark, compared with 12% of controls. Of the 213 patients on insulin for their type 2 diabetes at baseline, 9 in the Weight Watchers group and 4 controls on standard care were no longer on insulin at 52 weeks. That’s an important secondary outcome because insulin promotes weight gain.
Turning to changes in cardiovascular risk factors, Dr. O’Neil noted that the Weight Watchers group averaged a 3.7-cm reduction in waist circumference from a baseline of 116.3 cm, significantly better than the mean 1.4-cm reduction in controls. C-reactive protein levels dropped significantly in the Weight Watchers group over the course of a year, from 7.3 to 6.3 mg/L, but rose by 0.53 mg/L in the control arm. However, the two groups didn’t differ over time in blood pressure or lipid levels.
Simultaneous with Dr. O’Neil’s presentation, the study findings were published online in the journal Obesity (2016 Nov 2. doi:10.1002/oby.21616).
The study was funded by Weight Watchers International. Dr. O’Neil reported receiving a research grant from the company and serving on advisory boards for several pharmaceutical companies.
NEW ORLEANS – Overweight and obese patients with inadequately controlled type 2 diabetes have a new evidence-based treatment option in the form of the standard commercial Weight Watchers program enhanced by telephone and email consultations with a certified diabetes educator.
This intervention resulted in clinically meaningful improvements in glycemic control and weight loss, compared with a control group on standard care in a 12-month randomized clinical trial conducted at 16 U.S. centers, Patrick M. O’Neil, PhD, reported at Obesity Week 2016.
“Patients and providers alike need a broader arsenal of treatment options for managing diabetes; in particular, options that are more accessible to the majority of people with diabetes,” he said. “The number of adults with diabetes is large and growing, and a variety of accessible treatment approaches is needed. The results of this and related trials suggest that adapted, nationally available weight loss programs emphasizing lifestyle changes may represent accessible and effective adjunctive health management resources for people with overweight or obesity and type 2 diabetes.”
Dr. O’Neil reported on a racially and geographically diverse group of 563 overweight or obese adults with inadequately controlled type 2 diabetes who were randomized to the off-the-shelf commercial Weight Watchers program featuring regular community meetings and online tools enhanced with telephone and email consultation with a certified diabetes educator, or to a control group who got an initial face-to-face diabetes nutrition counseling visit with follow-up written information materials.
Control group participants received current standard care, although national survey data indicate that only about 55% of patients with diabetes get any diabetes education at all at diagnosis, he observed.
At enrollment, all study participants were already receiving treatment for their diabetes from a physician not connected to the randomized trial. Ninety-five percent of them were on one or more diabetes medications. Yet their baseline hemoglobin A1clevel was 7%-11% and their body mass index was 27-50 kg/m2.
Both weight loss and improvement in HbA1c were significantly greater in the Weight Watchers group than controls at each of the prespecified interim follow-ups at 13, 26, and 39 weeks.
When the study concluded at 52 weeks, the Weight Watchers group averaged a 0.32% reduction from baseline in HbA1c, and 24% of patients in that study arm had achieved an HbA1c below 7.0%. In contrast, the control group averaged a 0.16% increase in HbA1c, and only 14% of controls got their HbA1c below 7.0%, even though all participants continued to received ongoing background diabetes management from their outside physician throughout the study.
While the 0.48% difference in HbA1c between the Weight Watchers group and controls may not be jaw-dropping, it is equivalent to the placebo-subtracted decrease in HbA1c seen in 2-year long clinical trials of obesity medications in overweight or obese patients with type 2 diabetes, Dr. O’Neil said at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
The Weight Watchers group averaged a 4% weight loss at 52 weeks, significantly greater than the 1.9% reduction in controls.
Twenty-six percent of the Weight Watchers group had reduced their diabetes medications at the 52-week mark, compared with 12% of controls. Of the 213 patients on insulin for their type 2 diabetes at baseline, 9 in the Weight Watchers group and 4 controls on standard care were no longer on insulin at 52 weeks. That’s an important secondary outcome because insulin promotes weight gain.
Turning to changes in cardiovascular risk factors, Dr. O’Neil noted that the Weight Watchers group averaged a 3.7-cm reduction in waist circumference from a baseline of 116.3 cm, significantly better than the mean 1.4-cm reduction in controls. C-reactive protein levels dropped significantly in the Weight Watchers group over the course of a year, from 7.3 to 6.3 mg/L, but rose by 0.53 mg/L in the control arm. However, the two groups didn’t differ over time in blood pressure or lipid levels.
Simultaneous with Dr. O’Neil’s presentation, the study findings were published online in the journal Obesity (2016 Nov 2. doi:10.1002/oby.21616).
The study was funded by Weight Watchers International. Dr. O’Neil reported receiving a research grant from the company and serving on advisory boards for several pharmaceutical companies.
NEW ORLEANS – Overweight and obese patients with inadequately controlled type 2 diabetes have a new evidence-based treatment option in the form of the standard commercial Weight Watchers program enhanced by telephone and email consultations with a certified diabetes educator.
This intervention resulted in clinically meaningful improvements in glycemic control and weight loss, compared with a control group on standard care in a 12-month randomized clinical trial conducted at 16 U.S. centers, Patrick M. O’Neil, PhD, reported at Obesity Week 2016.
“Patients and providers alike need a broader arsenal of treatment options for managing diabetes; in particular, options that are more accessible to the majority of people with diabetes,” he said. “The number of adults with diabetes is large and growing, and a variety of accessible treatment approaches is needed. The results of this and related trials suggest that adapted, nationally available weight loss programs emphasizing lifestyle changes may represent accessible and effective adjunctive health management resources for people with overweight or obesity and type 2 diabetes.”
Dr. O’Neil reported on a racially and geographically diverse group of 563 overweight or obese adults with inadequately controlled type 2 diabetes who were randomized to the off-the-shelf commercial Weight Watchers program featuring regular community meetings and online tools enhanced with telephone and email consultation with a certified diabetes educator, or to a control group who got an initial face-to-face diabetes nutrition counseling visit with follow-up written information materials.
Control group participants received current standard care, although national survey data indicate that only about 55% of patients with diabetes get any diabetes education at all at diagnosis, he observed.
At enrollment, all study participants were already receiving treatment for their diabetes from a physician not connected to the randomized trial. Ninety-five percent of them were on one or more diabetes medications. Yet their baseline hemoglobin A1clevel was 7%-11% and their body mass index was 27-50 kg/m2.
Both weight loss and improvement in HbA1c were significantly greater in the Weight Watchers group than controls at each of the prespecified interim follow-ups at 13, 26, and 39 weeks.
When the study concluded at 52 weeks, the Weight Watchers group averaged a 0.32% reduction from baseline in HbA1c, and 24% of patients in that study arm had achieved an HbA1c below 7.0%. In contrast, the control group averaged a 0.16% increase in HbA1c, and only 14% of controls got their HbA1c below 7.0%, even though all participants continued to received ongoing background diabetes management from their outside physician throughout the study.
While the 0.48% difference in HbA1c between the Weight Watchers group and controls may not be jaw-dropping, it is equivalent to the placebo-subtracted decrease in HbA1c seen in 2-year long clinical trials of obesity medications in overweight or obese patients with type 2 diabetes, Dr. O’Neil said at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
The Weight Watchers group averaged a 4% weight loss at 52 weeks, significantly greater than the 1.9% reduction in controls.
Twenty-six percent of the Weight Watchers group had reduced their diabetes medications at the 52-week mark, compared with 12% of controls. Of the 213 patients on insulin for their type 2 diabetes at baseline, 9 in the Weight Watchers group and 4 controls on standard care were no longer on insulin at 52 weeks. That’s an important secondary outcome because insulin promotes weight gain.
Turning to changes in cardiovascular risk factors, Dr. O’Neil noted that the Weight Watchers group averaged a 3.7-cm reduction in waist circumference from a baseline of 116.3 cm, significantly better than the mean 1.4-cm reduction in controls. C-reactive protein levels dropped significantly in the Weight Watchers group over the course of a year, from 7.3 to 6.3 mg/L, but rose by 0.53 mg/L in the control arm. However, the two groups didn’t differ over time in blood pressure or lipid levels.
Simultaneous with Dr. O’Neil’s presentation, the study findings were published online in the journal Obesity (2016 Nov 2. doi:10.1002/oby.21616).
The study was funded by Weight Watchers International. Dr. O’Neil reported receiving a research grant from the company and serving on advisory boards for several pharmaceutical companies.
Key clinical point:
Major finding: Overweight or obese patients with inadequately controlled type 2 diabetes experienced a mean 0.32% decrease in HbA1c and 4% reduction in body weight over the course of 52 weeks on the commercially available Weight Watchers program supplemented by telephone and email counseling by a certified diabetes educator, significantly better outcomes than seen in a standard care control group.
Data source: A 52-week, multicenter, randomized controlled trial in 563 obese or overweight adults with inadequately controlled type 2 diabetes.
Disclosures: The study was funded by Weight Watchers International. The presenter reported receiving a research grant from the company and serving on advisory boards for several pharmaceutical companies.
When school’s out, the obesity epidemic grows
NEW ORLEANS – All of the growth in the obesity epidemic in young American schoolchildren takes place during their summer vacations, Paul T. von Hippel, PhD, reported at Obesity Week 2016.
He presented an analysis from the Early Childhood Longitudinal Study, Kindergarten Class of 2010-2011 which included a nationally representative study population composed of 18,170 U.S. children in 970 schools who were followed with serial weight and height measurements from the start of kindergarten in 2010 through the end of second grade in 2013.
During the summer, the prevalence of both overweight and obesity increased by roughly 1 percentage point per month. In contrast, during the more than 9 months of each school year, the prevalence of overweight didn’t budge, while the prevalence of obesity decreased modestly, by 0.1 percentage points per month.
These data have far-reaching public health implications. The new evidence suggests that the major risk factors for obesity are located outside of schools. That helps explain why many school-based initiatives focused on improving the nutritional content of school lunches and promoting physical activity have had little impact on the pediatric obesity epidemic, said Dr. von Hippel of the University of Texas at Austin.
The data suggest it’s time to explore the potential of reshaping out-of-school behaviors by promoting summer school and summer camp, curbing food advertising directed at children, providing parental nutrition education, and other interventions, he added.
The explanation for the observed increase in body mass index during summer vacation is unclear. It’s known from other studies that children sleep less and engage in more screen time during summer, which may be relevant, according to Dr. von Hippel.
Simultaneous with Dr. von Hippel’s presentation at Obesity 2016, the study was published online in the journal Obesity (2016 Nov 2. doi: 10.1002/oby.21613).
He reported having no financial conflicts of interest regarding the study, which was funded by the Russell Sage Foundation.
NEW ORLEANS – All of the growth in the obesity epidemic in young American schoolchildren takes place during their summer vacations, Paul T. von Hippel, PhD, reported at Obesity Week 2016.
He presented an analysis from the Early Childhood Longitudinal Study, Kindergarten Class of 2010-2011 which included a nationally representative study population composed of 18,170 U.S. children in 970 schools who were followed with serial weight and height measurements from the start of kindergarten in 2010 through the end of second grade in 2013.
During the summer, the prevalence of both overweight and obesity increased by roughly 1 percentage point per month. In contrast, during the more than 9 months of each school year, the prevalence of overweight didn’t budge, while the prevalence of obesity decreased modestly, by 0.1 percentage points per month.
These data have far-reaching public health implications. The new evidence suggests that the major risk factors for obesity are located outside of schools. That helps explain why many school-based initiatives focused on improving the nutritional content of school lunches and promoting physical activity have had little impact on the pediatric obesity epidemic, said Dr. von Hippel of the University of Texas at Austin.
The data suggest it’s time to explore the potential of reshaping out-of-school behaviors by promoting summer school and summer camp, curbing food advertising directed at children, providing parental nutrition education, and other interventions, he added.
The explanation for the observed increase in body mass index during summer vacation is unclear. It’s known from other studies that children sleep less and engage in more screen time during summer, which may be relevant, according to Dr. von Hippel.
Simultaneous with Dr. von Hippel’s presentation at Obesity 2016, the study was published online in the journal Obesity (2016 Nov 2. doi: 10.1002/oby.21613).
He reported having no financial conflicts of interest regarding the study, which was funded by the Russell Sage Foundation.
NEW ORLEANS – All of the growth in the obesity epidemic in young American schoolchildren takes place during their summer vacations, Paul T. von Hippel, PhD, reported at Obesity Week 2016.
He presented an analysis from the Early Childhood Longitudinal Study, Kindergarten Class of 2010-2011 which included a nationally representative study population composed of 18,170 U.S. children in 970 schools who were followed with serial weight and height measurements from the start of kindergarten in 2010 through the end of second grade in 2013.
During the summer, the prevalence of both overweight and obesity increased by roughly 1 percentage point per month. In contrast, during the more than 9 months of each school year, the prevalence of overweight didn’t budge, while the prevalence of obesity decreased modestly, by 0.1 percentage points per month.
These data have far-reaching public health implications. The new evidence suggests that the major risk factors for obesity are located outside of schools. That helps explain why many school-based initiatives focused on improving the nutritional content of school lunches and promoting physical activity have had little impact on the pediatric obesity epidemic, said Dr. von Hippel of the University of Texas at Austin.
The data suggest it’s time to explore the potential of reshaping out-of-school behaviors by promoting summer school and summer camp, curbing food advertising directed at children, providing parental nutrition education, and other interventions, he added.
The explanation for the observed increase in body mass index during summer vacation is unclear. It’s known from other studies that children sleep less and engage in more screen time during summer, which may be relevant, according to Dr. von Hippel.
Simultaneous with Dr. von Hippel’s presentation at Obesity 2016, the study was published online in the journal Obesity (2016 Nov 2. doi: 10.1002/oby.21613).
He reported having no financial conflicts of interest regarding the study, which was funded by the Russell Sage Foundation.
AT OBESITY WEEK 2016
Key clinical point:
Major finding: Between the start of kindergarten and the end of second grade, the prevalence of overweight in a large group of U.S. children grew from 23.3% to 28.7%, with all of the increase coming during their two summer vacations.
Data source: The Early Childhood Longitudinal Study, Kindergarten Class of 2010-2011 included a nationally representative study population composed of more than 18,000 children who were followed with multiple weight and height measurements from the start of kindergarten through the end of second grade.
Disclosures: The study was funded by the Russell Sage Foundation. The presenter reported having no financial conflicts of interest.
How to reduce early readmissions after bariatric surgery
NEW ORLEANS – A couple of home nursing visits early after bariatric surgery halved emergency department visits and hospital readmissions within the first 30 days in a case-control study, Linden A. Karas, MD, reported at Obesity Week 2016.
“Home nursing visits during the month following surgery, between doctor’s office visits, are a simple and inexpensive intervention that drastically decreases hospital revisits,” she declared at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
These early revisits to the hospital following bariatric surgery are not only common, they carry a substantial cost. An ED visit for hydration runs about $3,000 and a 2-day inpatient admission about $18,000. In contrast, the price tag for two home nursing visits in this study was $300, noted Dr. Karas, a surgeon at Mercy Catholic Medical Center in Philadelphia.
The triad of dehydration, nausea, and vomiting in addition to abdominal pain account for up to 40% of early readmissions following bariatric surgery. Because most hospital revisits for these reasons entail very little intervention other than IV fluids, Dr. Karas and her coinvestigators decided to investigate whether preemptive structured home visits by nurses prepared to administer IV fluids on the spot would cut down on hospital revisits. They found that indeed this strategy was successful.
Mercy Catholic Medical Center serves a largely low-income Medicare/Medicaid population. Part of the local culture is for many patients to obtain their primary care in the ED, so bariatric surgery patients are generally not reluctant to show up there if they don’t feel well in the first few weeks post surgery. That’s why in the year prior to the study the 30-day readmission rate was 23.6%, she explained.
The study included 193 consecutive prospectively followed adult participants in the home nursing program who underwent Roux-en-Y gastric bypass, laparoscopic adjustable banding, or revision surgery in 2014 and a control group of 267 matched bariatric surgery patients who underwent the same procedures in 2013, before introduction of the home nursing visits.
The first home visit occurred roughly 3 days after hospital discharge. The second one bridged the period between the first scheduled postoperative office visit at 2 weeks and the next office visit at 4 weeks. At discharge, patients were given a checklist concerning the signs and symptoms of dehydration, dietary recommendations, and lifestyle choices. Patients were encouraged to use the checklist to self-evaluate for dehydration and hand it over to the visiting nurses. The same checklist was provided to the home nurses. If the nurses found that patients met three or more criteria on the dehydration checklist, which included dry mucus membranes, heart rate greater than 90 beats/minute, headache, going more than 8 hours without urination, weakness, abdominal pain, and roughly a dozen other well-known criteria, they were instructed to initiate home hydration therapy with a banana bag and 2 L of normal saline.
If 1-2 days of home hydration failed to resolve the symptoms, the home care nurse was supposed to refer the patient to the ED. If the patient improved in response to home hydration therapy, the home nurse informed the surgeon’s office, which then set up a follow-up office visit to take place within the next 24 hours. Also, if the patient’s responses on the nutrition and behavioral health questionnaire raised any red flags regarding inadequate food and fluid intake, nonadherence to the recommended daily minimum of 30 minutes of physical activity, or depressive symptoms, the nurse was supposed to notify the surgeon to schedule a behavioral or nutrition appointment at the patient’s next scheduled visit.
The 30-day rate of all-cause hospital revisits in the home nursing care group was 11.9%, compared with 23.6% in controls. The rate of hospital revisits specifically for dehydration was 6.2% in the home visit group vs. 8.6% in controls, a 28% relative risk reduction in the home treatment group, which didn’t achieve statistical significance. However, in hindsight, it was evident that some of the visiting nurses didn’t fully understand the treatment protocol; they sent patients straight to the ED without first providing home hydration therapy. The visiting nurses were subcontracted out and weren’t part of the hospital’s bariatric surgery program.
Among those patients who did receive the therapy, however, it prevented readmission in 77% of cases. The 23% of patients who didn’t improve were referred to the hospital for further workup and treatment.
Patients with early hospital readmission had an average of 4.38 comorbid conditions, significantly more than the average 3.46 comorbidities in patients who weren’t readmitted. Several specific comorbid conditions were independently associated with significantly increased risk of hospital readmission: asthma, chronic obstructive pulmonary disease, anxiety, heart failure, and gastroesophageal reflux disease.
“Patients with those comorbidities are the ones to watch aggressively in the postop period,” according to Dr. Karas.
Insurers have paid for the home nursing visits without hesitation.
Her presentation met with an enthusiastic audience reception.
“I think it’s important that you’ve shown a return on investment for this initiative,” one surgeon commented.
Session cochair John J. Kelly, MD, chief of general and minimally invasive surgery at the University of Massachusetts in Worcester, declared, “I think this is a very-important paper. We’re obviously all faced with this dilemma in terms of readmission rates. If you can prevent them, it’s to be commended.”
Dr. Karas reported having no financial conflicts of interest regarding her study.
NEW ORLEANS – A couple of home nursing visits early after bariatric surgery halved emergency department visits and hospital readmissions within the first 30 days in a case-control study, Linden A. Karas, MD, reported at Obesity Week 2016.
“Home nursing visits during the month following surgery, between doctor’s office visits, are a simple and inexpensive intervention that drastically decreases hospital revisits,” she declared at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
These early revisits to the hospital following bariatric surgery are not only common, they carry a substantial cost. An ED visit for hydration runs about $3,000 and a 2-day inpatient admission about $18,000. In contrast, the price tag for two home nursing visits in this study was $300, noted Dr. Karas, a surgeon at Mercy Catholic Medical Center in Philadelphia.
The triad of dehydration, nausea, and vomiting in addition to abdominal pain account for up to 40% of early readmissions following bariatric surgery. Because most hospital revisits for these reasons entail very little intervention other than IV fluids, Dr. Karas and her coinvestigators decided to investigate whether preemptive structured home visits by nurses prepared to administer IV fluids on the spot would cut down on hospital revisits. They found that indeed this strategy was successful.
Mercy Catholic Medical Center serves a largely low-income Medicare/Medicaid population. Part of the local culture is for many patients to obtain their primary care in the ED, so bariatric surgery patients are generally not reluctant to show up there if they don’t feel well in the first few weeks post surgery. That’s why in the year prior to the study the 30-day readmission rate was 23.6%, she explained.
The study included 193 consecutive prospectively followed adult participants in the home nursing program who underwent Roux-en-Y gastric bypass, laparoscopic adjustable banding, or revision surgery in 2014 and a control group of 267 matched bariatric surgery patients who underwent the same procedures in 2013, before introduction of the home nursing visits.
The first home visit occurred roughly 3 days after hospital discharge. The second one bridged the period between the first scheduled postoperative office visit at 2 weeks and the next office visit at 4 weeks. At discharge, patients were given a checklist concerning the signs and symptoms of dehydration, dietary recommendations, and lifestyle choices. Patients were encouraged to use the checklist to self-evaluate for dehydration and hand it over to the visiting nurses. The same checklist was provided to the home nurses. If the nurses found that patients met three or more criteria on the dehydration checklist, which included dry mucus membranes, heart rate greater than 90 beats/minute, headache, going more than 8 hours without urination, weakness, abdominal pain, and roughly a dozen other well-known criteria, they were instructed to initiate home hydration therapy with a banana bag and 2 L of normal saline.
If 1-2 days of home hydration failed to resolve the symptoms, the home care nurse was supposed to refer the patient to the ED. If the patient improved in response to home hydration therapy, the home nurse informed the surgeon’s office, which then set up a follow-up office visit to take place within the next 24 hours. Also, if the patient’s responses on the nutrition and behavioral health questionnaire raised any red flags regarding inadequate food and fluid intake, nonadherence to the recommended daily minimum of 30 minutes of physical activity, or depressive symptoms, the nurse was supposed to notify the surgeon to schedule a behavioral or nutrition appointment at the patient’s next scheduled visit.
The 30-day rate of all-cause hospital revisits in the home nursing care group was 11.9%, compared with 23.6% in controls. The rate of hospital revisits specifically for dehydration was 6.2% in the home visit group vs. 8.6% in controls, a 28% relative risk reduction in the home treatment group, which didn’t achieve statistical significance. However, in hindsight, it was evident that some of the visiting nurses didn’t fully understand the treatment protocol; they sent patients straight to the ED without first providing home hydration therapy. The visiting nurses were subcontracted out and weren’t part of the hospital’s bariatric surgery program.
Among those patients who did receive the therapy, however, it prevented readmission in 77% of cases. The 23% of patients who didn’t improve were referred to the hospital for further workup and treatment.
Patients with early hospital readmission had an average of 4.38 comorbid conditions, significantly more than the average 3.46 comorbidities in patients who weren’t readmitted. Several specific comorbid conditions were independently associated with significantly increased risk of hospital readmission: asthma, chronic obstructive pulmonary disease, anxiety, heart failure, and gastroesophageal reflux disease.
“Patients with those comorbidities are the ones to watch aggressively in the postop period,” according to Dr. Karas.
Insurers have paid for the home nursing visits without hesitation.
Her presentation met with an enthusiastic audience reception.
“I think it’s important that you’ve shown a return on investment for this initiative,” one surgeon commented.
Session cochair John J. Kelly, MD, chief of general and minimally invasive surgery at the University of Massachusetts in Worcester, declared, “I think this is a very-important paper. We’re obviously all faced with this dilemma in terms of readmission rates. If you can prevent them, it’s to be commended.”
Dr. Karas reported having no financial conflicts of interest regarding her study.
NEW ORLEANS – A couple of home nursing visits early after bariatric surgery halved emergency department visits and hospital readmissions within the first 30 days in a case-control study, Linden A. Karas, MD, reported at Obesity Week 2016.
“Home nursing visits during the month following surgery, between doctor’s office visits, are a simple and inexpensive intervention that drastically decreases hospital revisits,” she declared at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
These early revisits to the hospital following bariatric surgery are not only common, they carry a substantial cost. An ED visit for hydration runs about $3,000 and a 2-day inpatient admission about $18,000. In contrast, the price tag for two home nursing visits in this study was $300, noted Dr. Karas, a surgeon at Mercy Catholic Medical Center in Philadelphia.
The triad of dehydration, nausea, and vomiting in addition to abdominal pain account for up to 40% of early readmissions following bariatric surgery. Because most hospital revisits for these reasons entail very little intervention other than IV fluids, Dr. Karas and her coinvestigators decided to investigate whether preemptive structured home visits by nurses prepared to administer IV fluids on the spot would cut down on hospital revisits. They found that indeed this strategy was successful.
Mercy Catholic Medical Center serves a largely low-income Medicare/Medicaid population. Part of the local culture is for many patients to obtain their primary care in the ED, so bariatric surgery patients are generally not reluctant to show up there if they don’t feel well in the first few weeks post surgery. That’s why in the year prior to the study the 30-day readmission rate was 23.6%, she explained.
The study included 193 consecutive prospectively followed adult participants in the home nursing program who underwent Roux-en-Y gastric bypass, laparoscopic adjustable banding, or revision surgery in 2014 and a control group of 267 matched bariatric surgery patients who underwent the same procedures in 2013, before introduction of the home nursing visits.
The first home visit occurred roughly 3 days after hospital discharge. The second one bridged the period between the first scheduled postoperative office visit at 2 weeks and the next office visit at 4 weeks. At discharge, patients were given a checklist concerning the signs and symptoms of dehydration, dietary recommendations, and lifestyle choices. Patients were encouraged to use the checklist to self-evaluate for dehydration and hand it over to the visiting nurses. The same checklist was provided to the home nurses. If the nurses found that patients met three or more criteria on the dehydration checklist, which included dry mucus membranes, heart rate greater than 90 beats/minute, headache, going more than 8 hours without urination, weakness, abdominal pain, and roughly a dozen other well-known criteria, they were instructed to initiate home hydration therapy with a banana bag and 2 L of normal saline.
If 1-2 days of home hydration failed to resolve the symptoms, the home care nurse was supposed to refer the patient to the ED. If the patient improved in response to home hydration therapy, the home nurse informed the surgeon’s office, which then set up a follow-up office visit to take place within the next 24 hours. Also, if the patient’s responses on the nutrition and behavioral health questionnaire raised any red flags regarding inadequate food and fluid intake, nonadherence to the recommended daily minimum of 30 minutes of physical activity, or depressive symptoms, the nurse was supposed to notify the surgeon to schedule a behavioral or nutrition appointment at the patient’s next scheduled visit.
The 30-day rate of all-cause hospital revisits in the home nursing care group was 11.9%, compared with 23.6% in controls. The rate of hospital revisits specifically for dehydration was 6.2% in the home visit group vs. 8.6% in controls, a 28% relative risk reduction in the home treatment group, which didn’t achieve statistical significance. However, in hindsight, it was evident that some of the visiting nurses didn’t fully understand the treatment protocol; they sent patients straight to the ED without first providing home hydration therapy. The visiting nurses were subcontracted out and weren’t part of the hospital’s bariatric surgery program.
Among those patients who did receive the therapy, however, it prevented readmission in 77% of cases. The 23% of patients who didn’t improve were referred to the hospital for further workup and treatment.
Patients with early hospital readmission had an average of 4.38 comorbid conditions, significantly more than the average 3.46 comorbidities in patients who weren’t readmitted. Several specific comorbid conditions were independently associated with significantly increased risk of hospital readmission: asthma, chronic obstructive pulmonary disease, anxiety, heart failure, and gastroesophageal reflux disease.
“Patients with those comorbidities are the ones to watch aggressively in the postop period,” according to Dr. Karas.
Insurers have paid for the home nursing visits without hesitation.
Her presentation met with an enthusiastic audience reception.
“I think it’s important that you’ve shown a return on investment for this initiative,” one surgeon commented.
Session cochair John J. Kelly, MD, chief of general and minimally invasive surgery at the University of Massachusetts in Worcester, declared, “I think this is a very-important paper. We’re obviously all faced with this dilemma in terms of readmission rates. If you can prevent them, it’s to be commended.”
Dr. Karas reported having no financial conflicts of interest regarding her study.
AT OBESITY WEEK 2016
Key clinical point:
Major finding: The combined rate of ED visits and hospital readmissions within 30 days post–bariatric surgery was 11.9% in a group of patients who received two home nursing visits that included home hydration therapy as indicated, compared with 23.6% in bariatric surgery patients who weren’t involved in the home visit program.
Data source: This study compared 30-day hospital readmission rates in 193 consecutive prospectively followed bariatric surgery patients who received two structured home nursing visits in the first 4 postoperative weeks to readmissions in 267 matched controls whose surgery occurred prior to implementation of the home nursing program.
Disclosures: The presenter reported having no financial conflicts of interest regarding the study.