NEW ORLEANS, LA (May 2, 2024) – Pay-for-performance
reimbursement models may create unintended financial incentives for
doctors to discriminate against obese patients, measuring a
patient's waist circumference may be more effective in predicting
surgical outcomes than the more traditional body mass index
measure, and childhood obesity doubles the risk of developing colon
cancer, according to data being presented at Digestive Disease
Week® (DDW®) 2010. DDW is the largest international
gathering of physicians and researchers in the field of
gastroenterology, hepatology, endoscopy and gastrointestinal
surgery.
"Doctors have long been aware of the toll that obesity takes on
the body," said Christopher C. Thompson, MD, MSc, FASGE, Brigham
& Women's Hospital. "These studies help us understand the
specific ramifications of childhood and adult obesity and the
increased risk that obesity poses when considering surgical
outcomes."
Pay-for-Obesity? Performance Metrics Ignore Differences in
Complication Rates and Cost for Obese Patients Undergoing Two
Common General Surgical Procedures (Abstract #290)
New Medicare and Medicaid payment policies are intended to
reward physicians for positive patient outcomes while cutting
costs, but according to new research from the Johns Hopkins
University School of Medicine, Baltimore, MD, such policies may
actually provide financial incentives for doctors to discriminate
against patients.
Pay-for-performance policies have grown in popularity over the
last few years and are increasingly used to measure the quality of
medical care. The premise behind the mechanism is to financially
reward hospitals and doctors for good outcomes and punish for poor
patient outcomes by adjusting reimbursement by one percent to two
percent if an infection occurs within 30 days of surgery.
According
to Martin Makary, MD, MPH, surgeon and associate professor of
public health at the Johns Hopkins School of Medicine, such payment
structures fail to account for patient factors that are out of the
control of doctors yet influence outcomes, the most common being
obesity, which can double a patient's chance of infection.
Studying national insurance claims of 36,483 patients who had
undergone one of two common general surgical procedures, Dr.
Makary, senior author of the study, found that obese patients
undergoing appendectomy were 25 percent more likely to experience
complications, and patients undergoing cholecystetomy were 7
percent more likely to have complications. In addition, Makary
found that the cost of providing such care was higher for obese
patients: the median total inpatient costs for obese patients after
a basic gallbladder removal were $2,978 higher and $1,600 higher
for appendectomy.
Because obesity rates are higher in minority populations —
black women have a 50 percent incidence of being overweight
compared to 18 percent for white men — Dr. Makary expressed
concern for the discrimination implications under such payment
structures. "What sounds good in theory turns out in reality to
punish doctors who take care of more high-risk patients, and
actually financially incentivizes discrimination," said Dr.
Makary.
Dr. Makary points out that standardized outcomes accounting for
patient factors would eliminate the unintended incentives to
discriminate. The National Surgical Quality Improvement Program
(NSQIP) is a doctor-initiated program that has developed such
outcome measures.
Dr. Makary and Dr. Hirose will present these data on Monday, May
3 at 9 a.m. CT in 244-245, Ernest N. Morial Convention Center.
Waist Circumference Predicts Complications in Rectal Cancer
Surgery (Abstract # 431)
A patient's waist circumference can serve as a predictor as to
whether the patient will experience complications in recovering
from rectal cancer surgery, according to researchers at the Michael
E. DeBakey VA Medical Center (MEDVAMC) and Baylor College of
Medicine (BCM).
"Being overweight or obese is known to impact a patient's
ability to recover from surgery," said David H. Berger, MD, MHCM,
co-author of the paper, MEDVAMC operative care line executive, and
professor of surgery at BCM. "However, our study indicates
abdominal fat is particularly relevant to abdominal surgical
outcomes."
Dr. Berger and Courtney Balentine, MD, co-author of the paper
and a fellow in surgical research at BCM, sought to find out if a
patient's waist circumference could serve as a better indicator
than body mass index (BMI) in determining whether a patient would
have difficulty recovering from surgery. BMI is a common
measurement that uses a person's height and weight to formulate a
measure of overweight or obesity.
"It is our contention that BMI misses the nuances of obesity
because it is unable to demonstrate where the fat is distributed on
the patient," said Dr. Balentine.
The study of 150 patients who underwent rectal cancer surgery
found heavier patients were twice as likely to experience
complications than patients with a smaller waist circumference.
Patients with a waist of 45 inches or more were three times more
likely to experience surgical site infections and twice as likely
to require reoperation after their initial surgery.
"This study provides important insight for surgeons planning to
operate on a patient with heavy midline fat distribution," said Dr.
Berger. "Necessary surgical procedures cannot be avoided, but
surgeons may want to consider altering antibiotic dosages in order
to better fight infection."
Past studies of BMI and surgical infections have had
inconsistent findings. This study is the first using waist
circumference as a predictor of short-term surgical
complications.
Dr. Balentine will present these data on Monday, May 3 at 4:15
p.m. CT in 243, Ernest N. Morial Convention Center.
The Effect of Early-Onset Obesity on Adult-Onset Colon
Neoplasia (Abstract #314g)
Obese adults who were overweight or obese in childhood and early
adulthood are at twice the risk for developing colon cancer
compared to adults with consistently normal weight, according to
investigators from New York University (NYU). Findings could lead
to more targeted colon cancer screening recommendations and
preventative interventions.
Fritz Francois, MD, MS, assistant dean for academic affairs and
diversity and assistant professor of medicine at NYU's Langone
Medical Center, and colleagues studied the current and past body
mass index (BMI) and waist circumference of 1,865 patients referred
for a screening colonoscopy. Past BMIs were estimated from patient
recall of body type and clothing size at ages 10 and 20. Each
patient's level of obesity at specific age points were compared
with the information from the screening colonoscopy, including the
number, size and location of each polyp found.
From their analysis, investigators found a significant
prevalence of polyps in patients who had been consistently
overweight or obese (27 percent), especially compared to patients
with consistently normal BMI (13 percent) and overweight BMIs at
present (19 percent). This study also observed that specific racial
and ethnic group participants were more likely to be obese at
present and throughout their life, increasing their risk of
polyps.
"Our findings suggest that the chronicity of obesity is a
significant risk factor for developing colon cancer," said Dr.
Francois. "Given the continued rise in early-onset obesity,
especially in minority populations, there is a need for
interventions and lifestyle modifications earlier in life to help
lessen this serious health risk later in life."
Dr. Francois also noted that these findings might help
clinicians better target individuals for screening
colonoscopies.
While this study shows that obesity is an additional factor that
predisposes individuals to colon cancer, individuals with normal
weight are also at risk of developing colon cancer and should be
screened.
Dr. Ian Fagan will present this data on Monday, May 3, at 8:30
a.m. CT in 280-282, Ernest N. Morial Convention Center.
Efficacy and Safety of Intragastric Balloon for Obesity and
Pre-Obese Patients: A Brazilian Experience (Abstract
#M1515)
New research from Gastroendo Medical Group in Brazil has found
intragastric saline-filled balloons to be a safe, effective and
minimally invasive weight-loss treatment for pre-obese and obese
patients, and may offer an alternative weight-loss treatment option
for patients who may not be eligible for gastric bypass to reduce
the morbidity and mortality associated with obesity.
Since the initial designs in the 1980s, the intragastric balloon
procedure designs have progressed to eliminate many of the
complications initially associated with the procedure, namely a
smooth, seamless balloon constructed from a long-lasting material
with a low ulcerogenic (tending to develop into ulcers) and
obstruction potential, as well as the ability to adjust the balloon
size and to fill the balloon with fluid instead of air. While this
procedure has been employed internationally and in the U.S. for
some time, this study may help establish expanded indications for
intragastric balloon procedures including pre-obese patients.
Over a 15 month period, 81 patients completed the study using
the intragastric balloon. Patients were divided along BMIs in four
grades: pre-obese (BMI < 30), obesity grade 1 (BMI 30-34.9),
obesity grade 2 (BMI 35-39.9) and obesity grade 3 (BMI ≥ 40).
Prior to the procedure, each patient had failed to respond to
previous clinical treatment for weight loss including, a
calorie-restricted diet, physical activity, behavior modification
and pharmacotherapy.
Researchers, led by Paula Elia, MD, at Gastroendo, performed the
placement and subsequent removal of the balloon under propofol
sedation. Balloons were smoothly inserted into the stomach by
traction under direct endoscopy vision and were positioned in the
upper stomach position. The balloon was filled with a saline
solution and methylene blue, to help in locating and removal of the
balloon. Patients were followed for five to seven months in a
multidisciplinary clinical setting, including a gastroenterologist,
endocrinologist, nutritionist, psychologist and psychiatrist. The
balloon was removed after the five to seven month observation.
Participants across all obesity grades experienced significant
weight loss, losing an average of 9.18 percent of initial weight.
Patients with an obesity grade 3 experienced a more significant
average weight loss of 12.2 percent of initial weight.
"This study reinforces the concept, efficacy and safety of
intragastric balloon procedures for treatment of overweight and
obesity," said Dr. Elia. "This is a reversible procedure that can
be considered as an alternative weight-loss treatment option,
particularly in pre-obese patients with a history of failure in
other clinical treatments."
Dr. Elia cautioned that the intragastric balloon and
intragastric balloon procedures are not a miracle weight loss
method; after the balloon is extracted, weight loss maintenance
depends exclusively on a combination of a calorie-restricted diet,
physical activity and behavior modification.
Dr. Elia will present these data on Monday, May 3 at 8 a.m. CT
in Hall F, Ernest N. Morial Convention Center.
Intragastric Air-Filled Balloon with New Features for Obesity
(Bioflex): Preliminary Results (Abstract #W1582)
A new study from the Hospital Sírio Libanês in Sao
Paolo, Brazil, suggests that a new endoscopic method using an
air-filled balloon could help obese patients maintain weight
loss.
Researchers led by Kiyoshi Hashiba, MD, associate professor of
the surgical department at Sao Paolo University, sought to develop
a balloon treatment to capture images in the stomach and small
intestine using newer features to improve the safety of placement
and removal of the balloon. Theirs contained a device wall with two
covering sheets, one made of silicon and the other with
polyurethane. It also has a valve connected to a plastic tube for
inflation, along with another tube containing a needle, which is
used for reinflation, deflation and retrieval.
Investigators used a Bioflex balloon (BioB), an air balloon, and
inserted it with 600 ml of air over a guide wire on six patients
with an average BMI of 35.8 (obese). The guide wire is necessary
because unlike other balloons, it does not require manual maneuvers
inside the mouth during insertion. Balloon placement and removal
were conducted under general anesthesia and endotracheall
intubation and removal was planned for six months, or earlier in
the event of intolerance, complications or desinsuflation of the
balloon.
The balloon was completely deflated at the second month in two
patients for whom it had to be replaced. Investigators did not find
complications in any patients such as gastric perforation,
ulceration, bleeding or acid reflux. The average weight loss was a
loss of BMI of minus four.
Another important feature is the connection to a tube with a
needle that allows deflation easy retrieval, which permits
reinflation, allowing a longer and therefore more productive scan.
Since the BioB is an air balloon and the patient does not need to
be an inpatient, the costs will decrease. It also allows the use of
BioB for long enough to change the habits of the patient.
The study showed that BioB presents an interesting, non-invasive
option for obese patients. The balloon is an aid to the obese
patient to help them change their behavior, since BioB causes the
initial satiety, but that eventually decreases. Satiety can be
reestablished with reinflation or overinflation.
Although the treatment is not recommended for morbidly obese
patients because of complications with imagery, the fact that 45
percent of obese patients are not morbidly obese means there are
still many patients who could benefit from this treatment.
Dr. Hashiba will present these data on Wednesday, May 5 at 8
a.m. CT in Hall F, Ernest N. Morial Convention Center.
SOURCE