Louis F. Martin

Cost-benefit analysis for the treatment of severe obesity

Abstract. Cost-benefit and cost-effectiveness analyses (CEAs) are only now beginning to be used by business, government, and policymakers to evaluate various medical treatments. The evolution of why CEAs are being demanded is reviewed. To date, a formal CEA of obesity treatments has not been published. This article outlines how a CEA is performed, reviews data relevant to setting up a formal CEA of medical and surgical obesity treatments, and lists published reports that demonstrate the effectiveness of surgical obesity treatments. The general level of discrimination that society allows the obese to suffer also allows medical insurance companies, businesses, and government to not provide many obese Americans with obesity treatments that have established a level of effectiveness far surpassing many other forms of medical therapy. CEAs of obesity treatments, by themselves, cannot be expected to reverse this discrimination. This type of data, however, provides individual obese patients and their physicians with evidence to challenge policymakers’ decisions, especially when cost-effective obesity treatments are excluded or placed at a lower priority than treatments with less proven effectiveness.

Safety and effectiveness of Realize adjustable gastric band: 3-year prospective study in the United States

BACKGROUND The effectiveness and safety of bariatric surgery using laparoscopic adjustable gastric bands have been demonstrated in numerous published studies. We present the results of the first U.S. multicenter trial of the Realize adjustable gastric band, a laparoscopic adjustable gastric band previously available only outside the United States as the Swedish adjustable gastric band. METHODS A total of 405 morbidly obese patients were screened at 12 different centers from May to November 2003 to participate in a prospective, single-arm study of the safety and effectiveness of the laparoscopically implanted Realize band. Changes in excess body weight, the parameters of diabetes and dyslipidemia, and the incidence of complications were assessed at 3 years of follow-up. RESULTS Of the 405 patients, 276 (78.3% women and 61.2% white) qualified for the study. The average age was 38.6 + or - 9.4 years (range 18-61), and the preoperative body mass index was 44.5 + or - 4.7 kg/m(2). The mean hospital stay was 1.2 + or - 1.3 days. At 3 years, the average excess weight loss was 41.1% + or - 25.1% or a decrease in the body mass index of 8.2 kg/m(2) (18.6%) (P < .001). In diabetic patients with a baseline elevated hemoglobin A(1)c level, the level decreased by 1% (P < .001). The total cholesterol, low-density lipoprotein cholesterol, and triglycerides decreased by 9%, 16%, and 50%, respectively (P < .001), and the high-density lipoprotein cholesterol increased by 25% (P < .001) in patients with abnormal baseline values. One patient required conversion to an open surgical technique. No 30-day mortality occurred. The complication frequencies were generally low and included esophageal dysmotility in 0.4%, late balloon failure in 0.4%, band erosion in 0.4%, slippage in 3.3%, esophageal dilation in 3.3%, pouch dilation in 3.6%, catheter kinking in 1.1%, port displacement in 2.5%, and port disconnection in 4.3%. Reoperations were required in 15.2% of the patients and involved 2 band replacements, 9 band revisions, 5 port replacements, 22 port revisions, and 4 explants. CONCLUSION The results of our study have shown that the Realize adjustable gastric band is safe and effective in a diverse U.S. population of morbidly obese patients. Significant weight loss was achieved throughout the 3 years of follow-up, with corresponding improvements in the indicators of diabetes and dyslipidemia.

Socioeconomic Issues Affecting the Treatment of Obesity in the New Millennium

The prevalence of obesity among the populations of most developed countries has increased to such an extent that the healthcare and social security/disability system will accumulate direct and indirect costs related to obesity that will be more substantial than those for any other primary disease within this generation. For the past decade, the Healthcare Financing Agency, which oversees the Medicare and Medicaid programmes, has required all physicians and healthcare agencies serving beneficiaries of these programmes to include diagnoses using codes established by the ninth revision of the World Health Organization’s International Classification of Diseases. This coding system actually distorts data collection and undermines appropriate medical insurance reimbursement for the treatment of obesity.Societal prejudices, inability of governmental agencies to address future concerns and the business community’s attempts to control healthcare costs without addressing the underlying issues contributing to these costs have led to confusion on how to confront this emerging epidemic. How will we develop the scientific knowledge and the political willpower to confront this epidemic? First, we need more accurate methods for classifying obesity and for measuring the cost of treatment. We can then determine if it is more cost effective to prevent or treat obesity early in its evolution or pay for its consequences in the form of treatment costs associated with its multiple comorbid diseases, such as hypertension, other cardiovascular disorders, diabetes mellitus, osteoarthritis and cancers, plus the lost productivity from absenteeism, premature retirement and death.

The Biopsychosocial Characteristics of People Seeking Treatment for Obesity

Background: To determine prospectively the characteristics of obese patients allowed to select either a medically supervised weight-reduction treatment program or a surgical treatment program, both offered at the same location. Methods: This was a cohort study at a university medical center where patients, who self-referred themselves for weight loss treatments, were introduced to two different programs before they were allowed to start either program. Four hundred forty-three patients with a mean body mass index (BMI) of 45.6 ± 0.5 (85 men, 358 women) self-selected either a combined supplemented fast with behavior modification (DIET, n = 208) or gastric bypass surgery (SURG, n = 235). Three hundred forty of these patients had private insurance (PI,) and 103 were receiving Medicaid/Medicare (publicly funded, PF). Each patient completed a semistructured psychiatric interview, obesity questionnaire, Profile of Mood Status (POMS), Beck Depression Inventory (BDI), Minnesota Multiphasic Personality Inventory (MMPI), and Hollingshead Index. Results: Three distinct groups of patients emerged on the basis of their insurance reimbursement patterns (employed versus disabled or indigent) and biopsychosocial factors. The disabled and/or indigent group receiving PF usually chose SURG (n = 89) because their insurance program covered it, but 14 disabled patients receiving Medicare chose DIET (together labeled the PF:DS group). The PI patients were divided into two groups: SURG (PI:S), n = 146, and DIET (PI: D), n = 194, respectively, based on their program selection. These three groups differed significantly in their biopsychosocial patterns. The PF:DS subjects appeared to have the strongest degree of biologic influence, followed by the PI:S and PI:D subjects. The pattern of social influences was consistent with the pattern of biologic influences and the selection bias created in forming the PF and PI groups. The pattern of psychologic influences, however, did not appear to follow the pattern of biologic and social influences. PF:DS had the strongest psychologic loading, but PI:D had a stronger degree of psychopathologic impairment than PI:S. Conclusions: The significant differences in the biopsychosocial characteristics of these three groups of obese patients need to be considered by policy-makers when they design and review treatment studies and decide what treatment programs should be offered in medical insurance programs.

What We Know and Don't Know about Deep Venous Thrombosis and Pulmonary Embolism!

The US Institute of Medicine recommends that clinical care be based on evidence-based medicine, primarily randomized controlled trials (RCT). Yet, the vast majority of medical treatments, especially surgical treatments, are not based on RCTs (i.e., appendectomy for appendicitis). When there is a serious, life-threatening complication associated with an elective bariatric operation, however, it behooves all of us to demand RCTs before we make recommendations based on our unproven hypotheses. Most experienced bariatric surgeons, who are well past their learning curves for the technical aspects of our procedures, have discovered that they have more people die in the 30-day postoperative period from pulmonary emboli (PE) than from any other cause 1 (this is when your mortality rate is less than the 2% documented by Flum and Dellinger 2 in their population-based study). This remains true even when we use heparin or low molecular weight heparin, compression pumps, early ambulation and other techniques 3 to prevent deep venous thrombosis (DVT) and PE.

The Medical Malpractice Risk Associated with Bariatric Surgery

Background: Bariatric surgery has been classified as high risk by the medical malpractice industry, but it is unclear what data support this classification. When a small group of physicians is separated from their peers and asked to support their malpractice claims, their premiums will often rise unfairly in relation to the outcome of the claims. This report outlines the results of a survey sent to the members of the American Society for Bariatric Surgery (ASBS) asking for information on malpractice claims. Methods: Surveys were mailed to the 285 ASBS members requesting which bariatric operations were performed, how many procedures were completed each year, details of any suits filed against the member including final outcome, and information on whether the members also performed gastric surgery for ulcer disease. Results: Surveys were returned by 165 members (58%) from surgeons in 33 states and Washington, D.C. Malpractice claims had been made after 107 bariatric procedures and three ulcer procedures with the risk of a suit being filed for a bariatric procedure being approximately 1.6/1,000 cases. The average monetary award was

The Evolving Role of the Psychologist

88,667. Of the suits that resulted in a jury trial, 14% agreed with the plaintiff. Over half the cases that had been resolved were either dropped or dismissed before trial. Conclusions: The incidence of suit being brought against ASBS members performing bariatric procedures is low. Once filed, most cases do not reach a jury trial. Settlements are usually under

Pregnancy after adjustable gastric banding

100,000. These data suggest that this group of bariatric surgeons do not represent a disproportionately large risk pool for medical malpractice insurance companies.

Treating morbid obesity with laparoscopic adjustable gastric banding

In the past decade the widespread expansion of the American waistline has driven the increased demand for bariatric surgery. Although obesity surgery has been extant for over 30 years, recent improvements in surgical techniques and the dramatic rise in public awareness have accelerated the pace of both its development and utilization. The changing role of the psychologist in the university-based weight management center has been part of this evolution. The major sources of the change in the psychologist’s role are the following: problems with patient adherence to medical and surgical treatments, developments in the areas of health psychology and behavioral medicine, psychology billing code expansion by the American Medical Association’s Current Procedural Terminology (CPT) Editorial Panel, recommendations from published guidelines for bariatric surgery practice and research, clinical implications of obesity surgery outcome research, and the recent developments in our understanding of the change process.