Patients Who Undergo Weight-Loss Operations at Accredited Bariatric Surgical Centers Have Fewer Postoperative Complications
Findings reveal that some patients are frustrated and discontinued medication because they were not reaching their individualized A1C target quick enough
Chicago, Illinois—Patients who have weight-loss operations at nonaccredited bariatric surgical facilities in the United States are up to 1.4 times likelier to experience serious complications and more than twice as likely to die after the operation compared with patients who undergo these procedures at accredited bariatric surgical centers, researchers conclude. These results from a systematic review of published medical studies that included more than 1 million patients appear online as an “article in press” on the Journal of the American College of Surgeons website in advance of print publication.
These findings have potential implications for the increasing number of people who choose surgical treatment for obesity—widely considered the most effective long-term weight-loss therapy. An estimated 179,000 people underwent gastric bypass, gastric banding, and other bariatric operations in 2013 versus 158,000 two years earlier, according to the American Society for Metabolic and Bariatric Surgery (ASMBS).
The researchers called their new analysis the first comprehensive review of the best available evidence comparing bariatric surgical results in accredited versus nonaccredited U.S. centers.
“A preponderance of scientific evidence demonstrates that bariatric surgery becomes safer with accreditation of the surgical center,” said principal investigator John Morton, MD, MPH, FACS, FASMBS, chief of bariatric and minimally invasive surgery, Stanford (Calif.) University School of Medicine. “Accreditation makes a big difference.”
Despite the published evidence, the Centers for Medicare & Medicaid Services (CMS) no longer requires Medicare patients to undergo covered bariatric surgical procedures at an accredited bariatric center. The agency’s decision in 2013 reversed a 2006 CMS policy to limit coverage for bariatric operations to only those performed at accredited bariatric surgical facilities.
Facility accreditation has been available in the bariatric surgery field for more than a decade. The American College of Surgeons (ACS) and the ASMBS merged their similar accreditation programs in 2012 to create the unified Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). Currently more than 700 centers in the country now hold this accreditation, according to the MBSAQIP. This credential designates that a surgical facility has met rigorous standards for high-quality surgical care.
According to the ASMBS, most bariatric surgical procedures performed in recent years were minimally invasive laparoscopic procedures.
Dr. Morton, MBSAQIP Co-Chair and immediate past president of the ASMBS, said his prior research found that laparoscopic bariatric operations have fewer postoperative complications than do traditional “open” surgical procedures.
“Even though we use little incisions, it’s still a big operation,” he said. “Accreditation indicates that a bariatric surgical center has the resources and experience in place to take care of any complications that may potentially occur.”
In their review article, Dr. Morton and first author Dan Azagury, MD, also from Stanford, included 13 studies published between 2009 and 2014 and totaling more than 1.5 million patients. Dr. Morton acknowledged that a number of patients might be duplicates because some studies used the same national database, and therefore he could estimate a total in excess of 1 million patients.
Eight of 11 studies that evaluated postoperative complications found that undergoing a bariatric operation in an accredited facility reduced the odds of having a serious complication by 9 to 39 percent (odds ratios of 1.09 to 1.39), the researchers reported.
The difference was reportedly even more pronounced for the risk of death occurring in the hospital or up to 90 days postoperatively. Six of eight studies that reported mortality showed that the odds of dying after a bariatric procedure, while low at an accredited center, was 2.26 to 3.57 times higher at a nonaccredited facility.
Nearly all the studies used risk adjustment, which compensates for different levels of patient risk and which experts believe makes results more accurate.
Only three studies (23 percent) failed to show a significant benefit of accreditation, and those studies had limitations, according to Dr. Morton. For instance, in one study most patients underwent their operations in a bariatric surgical collaborative, whose standards at even nonaccredited centers were very similar to those of accredited centers, he said.
When analyzing studies that reported average hospital charges, Drs. Morton and Azagury found lower costs at accredited centers.
“Accredited bariatric surgical centers provide not only safer care but also less expensive care,” Dr. Morton said.
Patients often choose a bariatric surgical facility by its distance from home, he noted, but added, “It’s worth it for patients to drive a few minutes longer to an accredited center, although the drive typically is short, with more than 700 accredited centers nationwide.”
A systematic review was the best way to study this issue, according to Dr. Morton. He said most insurers today will not cover surgical care at nonaccredited bariatric centers, thus making it difficult to perform a randomized controlled clinical trial, which is considered the gold standard in medical research. Many private insurers, he explained, began to require accreditation after CMS initially required it for reimbursement 10 years ago, before later reversing the policy.
“These results provide important information that can be used to guide future policy decisions. Perhaps CMS should revisit this policy again,” Dr. Morton suggested.
Patients can find an accredited bariatric surgical center on the MBSAQIP website: https://www.facs.org/quality-programs/mbsaqip.
“FACS” designates that a surgeon is a Fellow of the American College of Surgeons. “FASMBS” designates a Fellow of the American Society for Metabolic and Bariatric Surgery.
To read the abstract, visit http://www.journalacs.org/article/S1072-7515(16)30267-8/abstract
1. Colquitt JL, Pickett K, Loveman E, Frampton GK. Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014;(8):CD003641. Madura JA II, DiBaise JK. Quick fix or long-term cure? Pros and cons of bariatric surgery. F1000 Med Rep. Published online October 2, 2012.
2. New procedure estimates for bariatric surgery: what the numbers reveal. Connect. May 2014. Available at: http://connect.asmbs.org/may-2014-bariatric-surgery-growth.html. Accessed July 5, 2016.
3. Banka G, Woodard G, Hernandez-Boussard T, Morton JM. Laparoscopic vs open gastric bypass surgery: differences in patient demographics, safety, and outcomes. Arch Surg. 2012;147(6):550–556.
4. References 5 to 17 in the Journal article. Table 1 describes the studies in detail.
5. Birkmeyer NJ, Dimick JB, Share D, et al; Michigan Bariatric Surgery Collaborative. Hospital complication rates with bariatric surgery in Michigan. JAMA. 2010;304(4):435–442.
News from the obesity society
New research shows keeping the weight off is a lot more than willpower
SILVER SPRING, Maryland—A front-page article in The New York Times in May spotlighted a National Institutes of Health study in Obesity that studied 14 former contestants of the reality TV show The Biggest Loser who regained an average of 90 pounds—nearly 70% of what they had lost—six years after the show because of complex factors that affected their metabolism and caused their bodies to regain the weight. Researchers explained that a lowered resting metabolic rate (RMR) was partly to blame. RMR is the rate at which calories are burned at rest, which contributes to total daily energy expenditure (TDEE). This study, which was discussed widely on the Internet following The New York Times story, is now published in the August print edition of Obesity, the scientific journal of The Obesity Society, along with a second, new paper also examining metabolic rates after weight loss. In a special mini-series in the journal, leading obesity experts weigh in on the two papers through two additional commentaries and an editorial, all of which explain the phenomenon of metabolic adaptation, or the process where weight loss is accompanied by a decline in energy (caloric) expenditure as weight is lost. These studies were conducted on different populations, but reached the same conclusion: weight regain results from complex biological forces. The common accusation that individuals who don’t keep the weight off just lack willpower is incorrect.
“Obesity is a serious disease that cannot be ‘cured’ with weight loss,” says Donna Ryan, MD, FTOS, Associate Editor in Chief of Obesity and spokesperson for The Obesity Society. “Research is showing that once people lose weight and their metabolism slows, they experience an increase in appetite and a decrease in energy expenditure. These studies demonstrate that keeping the weight off long term requires constant vigilance and lifestyle changes to combat the biologic factors that are fighting to regain the weight.”
In the second paper released July 27, 2016, researchers Michael Rosenbaum, MD, and Rudolph L. Leibel, MD, examined 17 individuals with obesity first at their usual weight, again during maintenance of a 10% reduced weight, and a final time during maintenance of a 20% reduced weight. Their goal was to determine whether the reduction in energy expenditure was directly proportional to the amount of weight lost, if it was proportional up to a certain point, or if it was increasingly—or even exponentially—proportional. They found that all three models were effective.
While these authors found that energy expenditure is explained by a combination of the three models, Fothergill et al’s research on The Biggest Loser contestants seems to fall in line with the proportional model, where the more weight is lost the more the energy expenditure will decrease.
“This study reinforces the complexities of obesity, illustrating that dramatic weight loss, such as that experienced by contestants from The Biggest Loser, may not be the best approach for keeping weight off long term,” continued Dr. Ryan. “Efforts to maintain weight loss should focus on establishing sustainable diet and physical activity routines. While they may not lead to the dramatic weight loss experienced by contestant on The Biggest Loser, they can improve overall health and well-being.”
To read the full press release, which contains full links to the articles mentioned, please visit http://www.obesity.org/obesity/news/press-releases/new-research-shows-keeping-the-weight-off-is-a-lot-more-than-willpower
OBESITYWEEK 2016: MAJOR OBESITY SCIENTIFIC & MEDICAL CONFERENCE IN NEW ORLEANS, LA, OCT. 31 – NOV. 4
SILVER SPRING, Maryland—Get a glimpse into the future of obesity research and treatment when more than 1,000 research abstracts are presented on new and emerging obesity treatments, the science of weight loss, new prevention strategies, metabolic surgery, the genetics of obesity and public policy at the largest international conference on obesity. Thousands of leading researchers, policymakers and healthcare professionals will gather for the fourth annual ObesityWeek conference at the New Orleans Ernest N. Morial Convention Center in Louisiana from Oct. 31 – Nov. 4, 2016.
The weeklong conference will feature the largest exhibit hall of its kind, showcasing the latest innovative products, services and technologies from obesity-focused companies and organizations worldwide.
Keynote Speakers Offer Unique Perspectives
Opening Keynote Speaker Addresses Neural and Physiological Mechanisms Involved in Human Energy Balance, Nov. 2
Genetics of obesity expert, Professor Sadaf Farooqi PhD, FRCP, FMedSci, Wellcome Trust Senior Clinical Fellow and Professor of Metabolism and Medicine at the University of Cambridge Metabolic Research Laboratories offers the ObesityWeek 2016 opening keynote address. In her work, Dr. Farooqi is applying a genetic approach to help patients with early onset obesity. She identified the first single gene defect to cause human obesity in patients with a mutation in the leptin gene, published in Nature in 1997, where she described the dramatic response of these patients to leptin therapy. American Society for Metabolic and Bariatric Surgery (ASMBS) Integrated Health Keynote Speaker, Nov. 2
A leader in nutrition and public policy, Kelly Brownell, PhD, is Vice President of Community Health at Kaiser Permanente. Dr. Brownell is Dean of the Sanford School of Public Policy at Duke University, where he is also Robert L. Flowers Professor of Public Policy and Professor of Psychology and Neuroscience. In 2006, Time included Kelly Brownell among “The World’s 100 Most Influential People” in its special Time 100 issue featuring those “whose power, talent or moral example is transforming the world.”
Top Research to Answer Key Questions in Obesity
This year, top research presentations answer key questions confronting the obesity research and treatment community. Look forward to the discussion of the latest research by both renowned and emerging obesity experts that provide insight into:
• Do our bones have an impact on our metabolism?
• From warning labels to portion reduction, what policy solutions for obesity prevention have been effective?
• Could the love hormone, oxytocin, be used to treat obesity?
• How can electronic health records be used to improve obesity care?
• What do our gut bugs have to do with obesity treatment?
Leading Organizations Host ObesityWeek 2016
The Obesity Society (TOS), the leading professional society dedicated to better understanding, preventing and treating obesity, and the American Society for Metabolic and Bariatric Surgery (ASMBS), the nation’s leading organization for bariatric and metabolic surgeons and integrated health professionals, together host ObesityWeek 2016.
TOS and ASMBS will be joined by nearly 30 partner organizations, some of which will contribute to the educational agenda with symposia covering the spectrum of obesity and its impact on health: • Academy for Nutrition and Dietetics – Weight Management Dietetic Practice Group
• American Heart Association
• American Society of Nutrition
• IEEE Engineering in Medicine
• International Federation for the Surgery of Obesity and Metabolic Disorders
• International Society for the Perioperative Care of the Obese Patient
• Obesity Action Coalition
• Obesity Medicine Association
• Osteoarthritis Action Alliance
• Society for the Study of Ingestive Behavior
• World Obesity Federation
Unmatched Education for Health Professionals and Clinicians
At ObesityWeek 2016, attendees can learn from the great minds of unique, seasoned obesity professionals who will unveil the future of obesity treatment and prevention. Conference sessions will touch on topics like obesity surgery, clinical intervention, prevention, research, public policy and more. ObesityWeek is expected to attract more than 5,000 international obesity clinical and research professionals, as well as those working in related fields such as fitness, nutrition, nursing and primary care.
Register now for ObesityWeek 2016, which is expected to be the greatest year yet for the conference now in its fourth year. Attendees can save by registering before August 21, 2016. For more information, visit www.ObesityWeek.com. Be sure to also follow ObesityWeek on Twitter and Facebook, and search #OW2016 for the latest updates.
About ObesityWeek. ObesityWeek is the premier, international event focused on the basic science, clinical application, prevention and treatment of obesity. The Obesity Society (TOS) and the American Society for Metabolic and Bariatric Surgery (ASMBS) host the world’s preeminent conference on obesity, ObesityWeek 2016, Oct. 31–Nov. 4, at the Ernest N. Morial Convention Center in New Orleans, Louisiana. For the fourth year, both organizations hold their respective annual scientific meetings under one roof to unveil exciting new research, discuss emerging treatment and prevention options, network and present.
About The Obesity Society. The Obesity Society (TOS) is the leading professional society dedicated to better understanding, preventing and treating obesity. Through research, education and advocacy, TOS is committed to improving the lives of those affected by the disease. For more information visit: www.Obesity.org.
NEWS FROM THE AMERICAN COLLEGE OF SURGEONS
Non-technical skills matter too: Nation’s doctors, payers and surgical stakeholders recommend teamwork, communication training and standardized processes to improve safety
Each member of the surgical team should be empowered to speak up and take responsibility for patient care
ROSEMONT, Illinois—Patient safety before, during, and after surgery requires an appropriately educated, committed and empowered health care team, according to recommendations being presented at the inaugural National Surgical Patient Safety Summit (NSPSS). The two-day event, which includes more than 100 representatives from medical professional associations, insurers, health care systems, payers and government agencies, is sponsored by the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Surgeons (ACS), with the goals of developing surgical care and surgical education curricula standards, and prioritizing safety research efforts.
Technical and non-technical skills are both important to successfully and safely perform surgery. The surgeon, anesthesiologist, nurses, and all supporting staff must ensure consistent use of surgical safety strategies and tools throughout surgical care, including patient-centered shared-decision making and timely informed consent, standardized surgical site marking procedures, accurate surgical information transfer, integrated electronic medical records, and effective team communication and coordination.
“Surgical safety improves when non-technical strategies, tools and behaviors are combined with proficient surgical skills,” said William Robb, MD, co-chair of NSPSS and past-chair of the AAOS Patient Safety Committee.“Each member of the surgical team needs to know how to effectively communicate and appropriately adapt during an adverse situation. An empowered, well-trained surgical team improves surgeon performance and patient outcomes.”
“As patient safety has always been our highest priority, there is tremendous value in bringing together surgical organizations and other groups concerned about this important issue to collaboratively work on prioritizing surgical patient safety standards,” said David B. Hoyt, MD, FACS, NSPSS co-chair and ACS Executive Director. “This Summit and its resulting recommendations are innovative, and will have a very positive impact on the quality of surgical patient care.”
Workgroups, including surgeons, anesthesiologists and nurses, convened prior to the summit to prepare draft recommendations for all surgical team members, surgical institutions, medical and nursing schools, surgical residency and fellowship programs, and surgical credentialing organizations. The recommendations include the creation and adoption of standardized:
• Surgical safety education programs with assessment of competence for surgeons, residents, medical students, perioperative team members, and surgical institutions on effective communication, resilience, leadership and teamwork.
• Safety training modules (simulation-based) for the entire surgical team—doctors, nurses, anesthesiologists, surgical technicians and physician assistants.
• Training on teamwork, and other essential non-technical skills, beginning during undergraduate medical education, and continuing through surgical residency and postgraduate training, as a requirement of ongoing Maintenance of Certification (MOC).
• “Shared-decision making” practices and procedures to ensure an informed and prepared surgical patient.
• Patient-centered, timely and accurate surgical consent processes.
• Communication tools and procedures to improve the accuracy and efficiency of transferring patient information before, during and following surgical care.
• Surgical site marking and identification policies (with local modifications as appropriate) for all surgical procedures and surgical facilities, and utilizing a pre-surgical team “Brief,” a pre-surgical team “Time-out” and a postsurgical team “De-Brief.”
• A common data collection system to measure and improve patient safety outcomes. The system should include uniform definitions, a consistent reporting structure, and accessibility and usability by all stakeholders—hospitals, care providers and medical society databases.
These recommendations will be used to finalize National Surgical Patient Safety Standards, develop surgical safety education curriculum proposals, and to identify surgical safety knowledge gaps and research priorities. “We believe that the implementation of these standards will guide surgical teams and members to achieve the ultimate goal of ensuring safe and optimal surgical patient outcomes,” said David D. Teuscher, MD, AAOS past president.
About the American College of Surgeons. The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 80,000 members and is the largest organization of surgeons in the world. For more information, visit www.facs.org.
About the American Academy of Orthopaedic Surgeons. With more than 39,000 members, the American Academy of Orthopaedic Surgeons (AAOS) is the world’s largest association of musculoskeletal specialists. The AAOS provides education programs for orthopaedic surgeons and allied health professionals, champions and advances the highest musculoskeletal care for patients, and is the authoritative source of information on bone and joint conditions, treatments, and related issues. For more information, visit www.aaos.org.
Surveys Find Adults With Type 2 Diabetes Are More Willing to Take Action to Achieve A1C Targets Quicker than Physicians and Other Medical Professionals Perceive
Findings reveal that some patients are frustrated and discontinued medication because they were not reaching their individualized A1C target quick enough
Jacksonville, Florida—The American Association of Clinical Endocrinologists (AACE) announced results of two online surveys that identified differences in perceptions among adults living with type 2 diabetes as well as endocrinologists, primary care physicians and other medical professionals including nurse practitioners, physician assistants and pharmacists. The Perspectives in Diabetes Care surveys revealed that patients are more willing to take action to reach their individualized average blood glucose, or A1C, targets quicker than physicians and other medical professionals believe. More than half of adults living with type 2 diabetes polled are very willing to visit their physicians and other medical professionals more often and make multiple medication changes in order to achieve their A1C targets quicker, while less than one in five physicians and other medical professionals believe that patients would be very willing to take these actions.
Specifically, these findings reveal:
• While 57 percent of adults living with type 2 diabetes would be very willing to visit their physicians and other medical professionals more often, only 19 percent of physicians and other medical professionals polled believe they would be willing to do so.
• In addition, 52 percent of adults living with type 2 diabetes would be very willing to make multiple medication changes, though only 16 percent of physicians and other medical professionals think they would be very willing to make these changes.
These differing perceptions could play a role in the length of time it takes some patients to achieve their individualized A1C targets. The implications could be significant as more than 42 percent of patients surveyed have yet to achieve their A1C target and 77 percent of these respondents want to achieve it more quickly.
Read the full press release at http://media.aace.com/press-release/surveys-find-adults-type-2-diabetes-are-more-willing-take-action-achieve-a1c-targets-q