News and Trends—April 2015

| April 1, 2015

Bariatric surgery prior to joint replacement improves outcomes in obese patients
NEW YORK, New York—Obesity is not only a risk factor for developing knee and hip arthritis, it is also linked to less favorable outcomes after joint replacement surgery. Two new studies at Hospital for Special Surgery (HSS) in New York City find that bariatric surgery prior to joint replacement is a cost-effective option to improve outcomes after hip or knee replacement.

The research was presented at the annual meeting of the American Academy of Orthopaedic Surgeons in Las Vegas, Nevada. One HSS study looks at the costs and benefits of weight-loss surgery prior to knee replacement, and the other analyzes the costs and benefits before hip replacement.

“Up to 50 percent of hip replacements are performed in obese patients at some institutions,” said Emily Dodwell, MD, an orthopedic surgeon at HSS and lead investigator. “Obesity is associated with longer hospital stays, higher overall costs, and higher failure rates, necessitating costly revision surgery.”

It is well known that obesity takes a toll on one’s health. Bariatric surgery and subsequent weight loss reduces the risk of heart disease, diabetes, and even some forms of cancer. But the effect of bariatric surgery on joint replacement outcomes was not known, and this is what HSS investigators set out to determine.

“We know that bariatric surgery is a cost-effective intervention for morbid obesity,” said Alexander McLawhorn, MD, a chief orthopedic surgery resident at HSS and study author. “Yet, the cost-effectiveness of bariatric surgery to achieve weight loss prior to joint replacement and thus decrease the associated complications and costs in morbidly obese patients was unknown.”

Investigators used a sophisticated computer software program to compare the cost utility of two treatment protocols for patients who were considered morbidly obese and had advanced knee or hip osteoarthritis. One group had joint replacement immediately, without losing weight. The other group had bariatric surgery, followed by hip or knee replacement two years later. Patients typically lose weight during this time period. “For the study, we chose a decision analysis design because we could use a mathematical model to simulate the outcomes and costs of each treatment path based on results and costs that have already been published in the literature,” Dr. Dodwell explained.
Study patients had a body mass index (BMI) of at least 40kg/m2, or a BMI of 35kg/m2 or higher and at least one other serious obesity-related health problem.

For study purposes, researchers assumed that at least one-third of patients having bariatric surgery lost their excess weight prior to undergoing joint replacement.
“Our findings indicate that surgical weight loss prior to joint replacement is likely a cost-effective option from a public payer standpoint in order to improve outcomes in obese patients who are candidates for joint replacement,” Dr. Dodwell said. “Some healthcare systems do not include weight loss surgery as a covered benefit, and it is possible that studies such as this will be helpful in re-evaluating whether weight loss surgery may be a reasonable covered benefit.”

Dr. McLawhorn noted that for some patients experiencing severe knee or hip pain, it may be impractical to hold off on joint replacement. He adds that many times, an orthopedic surgeon is the first doctor such a patient sees for arthritis pain.
“Ideally, a team approach would be used to treat morbidly obese patients with hip and knee arthritis in which various healthcare professionals are in place to help a patient lose weight, improve his or her health, and optimize nutrition before joint replacement to maximize its benefits,” he said.

Bariatric surgery cuts asthma-related hospital visits
Boston, Massachusetts (HealthDay News)—A recent study published in the Journal of Allergy and Clinical Immunology suggest that in patients with obesity, bariatric surgery cuts the risk of an emergency department visit or hospitalization for asthma.
“Research on nonsurgical weight loss interventions has failed to demonstrate consistent efficacy on asthma control, although these interventions resulted in only modest weight reductions,” wrote Kohei Hasegawa, MD, MPH, of Massachusetts General Hospital in Boston, and colleagues.

To examine if bariatric surgery is associated with a rapid and sustained decrease in risk of asthma exacerbation, the investigators culled data from a population-based emergency department and inpatient sample in three states (California, Florida, and Nebraska). The participants (n=2,261) were aged 18 to 54 years and underwent bariatric surgery.

The patients’ risk of asthma exacerbation was followed during sequential 12-month periods using presurgery months 13 to 24 as the reference period.
During the reference period, 22 percent of patients had an emergency department visit or hospitalization for asthma exacerbation, whereas significantly fewer emergency department visits or hospitalizations for asthma exacerbation occurred within 12 months after bariatric surgery (10.9%; odds ratio, 0.42). The risk remained significantly lower in the subsequent period of 13 to 24 months after bariatric surgery (10.9%; odds ratio, 0.42).

To read the article abstract, visit http://www.ncbi.nlm.nih.gov/pubmed/25670012

Disconnect Between Bariatric Surgery Practice, Training
Sacramento and Carmichael, California—Though a large portion of surgical practice is dedicated to bariatric surgery, an article published in JAMA Surgery claimed training for the technique and subsequent patient care has not followed suit.

Assessing the Faculty Practice Solution Center (FPSC) database—a tool comprised of the revenue data of 90,000 physicians working at 95 United States institutions—researchers from the University of California, Davis (UCD), and Mercy San Juan Medical Center determined the annual mean procedure frequency per surgeon (PFS) for every year from from 2006 to 2011. To gauge physicians’ effort and skill, they used associated work relative value units (wRVUs).

“For example, the wRVUs for the laparoscopic Roux-en-Y gastric bypass (RYGB) and Whipple procedures are 3.7 and 6.6 times greater than the repair of the inguinal hernia, respectively,” the investigators explained.

The authors then analyzed the 100 most common surgical procedures, which consisted of RYGB (PFS, 18.–224.6)—frequently a top 10 procedure—and other commonly practiced procedures including laparoscopic cholecystectomy (PFS, 30.3–43.5), upper gastrointestinal tract endoscopy (PFS, 26.5–34.3), mastectomy (PFS, 16.5–35.0), inguinal hernia repair (PFS, 15.5–22.1), and abdominal wall hernia repair (PFS, 21.6–26.1). In doing so, they also reported RYGB yielded the highest wRVUs (wRVUs, 491.0–618.2) every year, with laparoscopic cholecystectomy (wRVUs, 335.8–498.7) often being second on the list.

In light of their findings, the researchers warned that the training provided to physicians performing bariatric surgery is insufficient; and with general surgery growing, academic exposure to this procedure will be even more essential.

“We believe that resident surgical training should continue to re-evaluate its core curriculum to ensure that surgical graduates have received appropriate training,” the authors concluded. “Bariatric surgery would provide ample opportunity for surgeons to improve laparoscopic technical expertise and become familiar with this increasing population of patients.”

New research reveals effects of physician advice on weight loss
ATHENS, Georgia—Patients advised to lose weight by their physicians dropped more pounds on average than those who didn’t receive a recommendation, according to new research from the University of Georgia published in the journal Economics & Human Biology.

Using a national data set from the Centers for Disease Control and Prevention, study author Joshua Berning found that physician advice was associated with a reported 10-pound loss for women and a 12-pound loss for men over a one-year period, after controlling the data for numerous covariates. The diet and exercise habits of participants were also associated with weight loss.

“The data set also measures the number of people who were advised to lose weight, regardless of whether or not they wanted to hear it,” said Berning, an assistant professor of agricultural and applied economics in the College of Agricultural and Environmental Sciences. “That measure, of whether they were recommended to lose weight, makes this data unique.”

The data also shows that physician advice may have different effects on weight gain and weight loss.

“People often gain weight as they age,” Berning said. “The recommendation of weight loss mitigated weight gain more than it facilitated weight loss.”

The impact direct communication can have on obesity is powerful, he said, and the solution sounds easy enough. The problem Berning found is that many “physicians often don’t take the time to consult patients about being overweight. They need to take the opportunity to interact with their patients. Through an open dialogue, patients can find solutions to their health issues, especially in terms of obesity.”

Berning explained that the success of physician recommendation comes from getting a tailored opinion. Physicians are able to put a person’s health into context by looking at factors beyond just weight or body mass index. Healthcare providers can assess multiple components, such as the diet, exercise, and medical history, to determine if a patient is at risk for obesity.

“If I talk to a physician, he or she can tell me about my current health and my health trajectory,” Berning said. “Oftentimes we have a sense of complacency with our own health. A good physician can help us understand what kind of health trajectory we are on and how we can improve it.”

Because of the personalized medical advice, physician visits have a distinct advantage over other weight-loss methods, like commercial weight-loss programs.

“Since commercial weight-loss programs are for profit, they can be prohibitively expensive,” Berning said. “Healthcare provider advice is more affordable and achievable for a wider population. Doctors can identify obesity problems earlier on and build long-term relationships with their patients.”

BariatricPal Gains Its Quarter-Millionth Member
NEW YORK, New York—BariatricPal, a leading online weight loss surgery community, reached a membership of 250,000 members. The BariatricPal forums offer a welcoming environment where members can discuss topics related to weight loss surgery, including pre-surgery concerns, pre and postoperative diets, complications, and surgeons.
“We are thrilled to reach this milestone,” says Alex Brecher, founder and CEO of BariatricPal. “We are very excited to keep growing and to continue to serve the weight loss surgery community. BariatricPal is proud to support efforts to fight obesity.”
BariatricPal is an online social network for the weight loss surgery community. Brecher initially founded WLSBoards, which included LapBandTalk.com, VerticalSleeveTalk.com, RNYTalk.com, and SleevePlicationTalk.com. The four communities merged into a single site and app, BariatricPal, in 2013.

Since its inception, members have posted nearly four million messages. BariatricPal is available online as well as apps for Apple and Android users. BariatricPal has also published the four “Big Books” on weight loss surgery. Three of the books are dedicated to the adjustable gastric band, vertical sleeve gastrectomy (gastric sleeve), and gastric bypass, respectively, while the fourth offers guidance for healthy living after bariatric surgery.

BariatricPal members include pre- and postoperatuve bariatric surgery patients who come for information and peer-to-peer support. Surgeons and other bariatric professionals are also active in the community, which offers opportunities for growing their patient base. With a member base of over a quarter-million, BariatricPal is an ideal platform to reach the bariatric community.

Membership is free, and everyone is welcome to join. Members are encouraged to spread the word about BariatricPal to their friends and others who may be interested in learning more about weight loss surgery or getting support for themselves or a loved one who is a bariatric surgery patient or candidate.

Any inquiries can be sent to Alex Brecher, alex@BariatricPal.com; Phone: (917) 807-3241.

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