Editorial Message: The decision to discharge patients should be the physician’s, not insurance carriers

| October 20, 2010

Dear Friends:
I am writing to you on my flight back from Washington, DC, where I attended the 96th Annual Clinical Congress of the American College of Surgeons (ACS). Although I have plenty to share with you, I will try to concentrate on what I believe are the most important issues.
First, I would like to announce that the American Society for Metabolic and Bariatric Surgery (ASMBS) will be issuing the “International Fellow of the ASMBS” title to surgeons from around the globe that, aside from being active bariatric surgeons, are contributing their cases to the national Surgical Review Corporation (SRC)-administered database Bariatric Outcomes Longitudinal Database or “BOLD.” I encourage all international bariatric surgeons not to wait—apply for ASMBS membership and start entering your data to help us show our governments and insurance carriers the safety and outcomes of bariatric surgery.

At the ACS, I was privileged to participate in a discussion about a rumor that is very concerning to me. The rumor is that some insurance carriers are planning to implement new guidelines that will mandate surgeons to discharge patients 24 hours after bariatric surgery regardless of whether the procedure was a band, a bypass, or a sleeve. More importantly, it appears that age, body mass index (BMI), and/or comorbid conditions will not be taken into account as well. If this rumor proves to be true, I have to ask what is going on in our country? I trained in a school of surgery in Germany where it was our practice to keep patients in house for three days after an inguinal hernia repair. This rumored mandate of discharge is frightening to me. Who will take responsibility for this action? Who will prepare and sign the documents stating that a patient has been cleared to go home 24 hours after major surgery—the insurance carriers or the surgeons? Regardless of who will take the responsibility, I am certain that in the end patients will get hurt.

Why are insurance companies allowed to regulate healthcare delivery without us physicians being consulted first? Who is consulting them? I understand that the economy in our country is recovering from a recession and that we are facing an upcoming healthcare reform, but while the economy is critical, patient safety is, in my opinion, paramount. If patients are discharged 24 hours after surgery, we are disregarding patient safety completely. Being discharged 24 hours after a procedure like a bypass or band means patients would be facing most of the deadly complications of surgery (e.g., pulmonary embolisms and leaks) at home. We would see the morbidity and mortality rates of bariatric surgery increase significantly. Malpractice lawyers must be licking their fingers in anticipation if this rumored regulation comes into effect. For the sake of our patients’ lives and safety, I urge you all not to ignore this rumor and become verbal in supporting our leaders in fighting back.

Another event of interest is the recent decision made by the United States Food and Drug Administration (FDA) to withdraw the drug Meridia (sirbutamine) (Abbott Laboratories, Abbott Park, Illinois) from the market. A study performed in England showed that patients being treated with Meridia had a higher incidence of nonfatal strokes and heart attacks when compared to control. So what will be the next step to treat obesity and metabolic syndrome in the lower-class BMI? Are you thinking what I am thinking?

In this issue of Bariatric Times, we present several interesting articles, including a difficult case scenario of proximal gastrogastric fistula due to staple line dehiscence presented to Dr. Alfons Pomp for his expert opinion. I cannot agree more with Dr. Pomp’s recommendation to stay out of the operating room in these cases whenever you can.

And don’t miss Alëna Balasanova’s excellent review article on binge eating and bariatric surgery outcomes. The author examines the literature and discovers discrepancies in current research on not only the definition of binge eating but the measures used for its diagnosis. The bariatric community should exercise caution, as Ms. Balasanova recommends, when interpreting research results surrounding binge eating and bariatric surgery outcomes.

Finally, I enjoyed the interview with Dr. Evan Nadler on bariatric surgery, adolescents, and obesity research in this issue of Bariatric Times. I liked his insightful answer when questioned about the potential role of genetics and obesity. He said, “Why is obesity considered a hereditary condition and weight loss is not?” My response to Dr. Nadler’s question is a simple one—Obesity is a hereditary condition and weight loss is not because of the history of human kind and its adaptation to starvation and survival. Because of the thousands of years during which our ancestors fought famine and disease, our bodies developed into “energy-storing machines.” We are constantly getting ready for the next episode of starvation. Our genome has not woken up yet to realize that food is now widely available to us living in developed countries. We have restaurants, super markets, and refrigerators, making it possible to expend very little energy getting our food. That creates an even worse imbalance between energy intake and expenditure. Genotype is important but phenotype does play a critical role in today’s obesity disease.

I hope you will enjoy reading this month’s issue of Bariatric Times as much as I have.

Sincerely,

Raul J. Rosenthal, MD, FACS
Editor, Bariatric Times

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