Thursday, February 6, 2014

Patients’ Acceptance of Prioritization for Bariatric Surgery

sharma-obesity-waiting-timeAs regular readers are well aware, bariatric surgery is still rather hard to come by in most Canadian provinces.

This prompted us to examine patients’ perspectives on wait-list prioritization and willingness to pay for bariatric surgery amongst patients waiting for surgery in our program.

The paper by Richdeep Gill and colleagues, published in the Canadian Journal of Surgery, examines the responses of wait-listed patients to nine hypothetical scenarios describing patients waiting for surgery.

Respondents were asked to rank the priority of these hypothetical patients on the wait list relative to their own.

Scenarios examined variations in age, clinical severity, functional impairment, social dependence and socioeconomic status. We also assessed willingness to pay for faster access using a 5-point ordinal scale.

Overall respondents assigned similar priority to hypothetical patients with characteristics similar to their own but higher priority (greater urgency) to those exhibiting greater clinical severity and functional impairment.

On the other hand, they assigned lower priorities to patients at the extremes of age, on social assistance, or of of higher socioeconomic status.

Most (85%) respondents disagreed with payment to expedite access, although participants earning more than $80 000/year were less likely to disagree.

These findings show that most patients waiting for bariatric surgery are OK with prioritization of patients with greater clinical severity and functional impairments but generally disagree with paying for faster access.

Thus, these findings certainly suggest that there would be general acceptance of giving priority to patients with higher Edmonton Obesity Stages, even if this would mean longer waits for themselves.

How Canadian is that?

@DrSharma
Edmonton, AB

ResearchBlogging.orgGill RS, Majumdar SR, Wang X, Tuepah R, Klarenbach SW, Birch DW, Karmali S, Sharma AM, & Padwal RS (2014). Prioritization and willingness to pay for bariatric surgery: the patient perspective. Canadian journal of surgery. Journal canadien de chirurgie, 57 (1), 33-9 PMID: 24461224

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Monday, November 12, 2012

Fixing the Canadian Health Care System

Readers may recall that last week I spoke on obesity at the Conference Board of Canada’s Summit on Sustainable Health Care.

The key learnings from this Conference are now elegantly summarized by Glen Hodgson, Senior VP and Chief Economist at the Conference Board on his blog

Five key priorities for reform emerged from the Summit.

  • Fix the gateway to the health care system. Primary care is the first contact point with the health care system. There was a strong consensus that interdisciplinary family care teams should be the standard model for primary care, and these teams should be expanded and strengthened in all provinces and territories.
  • Invest in and use technology more intensively in the health care system, particularly information technology. More intensive and standardized use of information technology would allow patient information to be collected and shared seamlessly, making treatment much more efficient and thereby boost productivity in the health care system.
  • Change health professional compensation. The compensation model for physicians and other health professionals should be linked to more patient outcomes, not to activities like treatment or consultation, within a clear accountability structure.
  • Build an appropriate support system to care for the elderly. Few older Canadians want to be hospitalized for chronic conditions. They want to be cared for and healed where they live: in their homes and communities.
  • Improve the state of Canadians’ overall health and wellness. A healthier population would slow the growth in chronic diseases and in health care demand—so Canada needs a “wellness system” as well as a health care system. Employers have an important role to play in supporting the wellness of their employees and their families.

One aspect that is missing in this discussion, is the realisation that the obesity epidemic will lead to an unprecedented epidemic of ‘chronic disease of the young’. This will require taking chronic disease management directly to the workplace, an effort that goes well beyond current workplace ‘wellness’ activities.

Rather, we should be looking at creating an infrastructure which (in collaboration with the primary care provider) takes chronic disease management directly to the workplace.

The rationale for this is the simple fact, that contrary to the problem of chronic diseases in the elderly, younger people, who are likely to bear the brunt of the obesity epidemic, can ill afford to sit around in doctor’s waiting rooms during normal office hours.

Even expecting them to show up in doctor’s offices or community clinics after a busy work day may prove an important deterrent.

Thus, I believe that we will need to explore ways in which to bring chronic disease management resources and expertise into the workplace in a fashion that goes well beyond simply providing a treadmill for employees or changing food options in the cafeteria.

AMS
Edmonton, Alberta

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Tuesday, July 31, 2012

Medication (Over?) Use in Overweight Canadian Kids

Excess weight is often (but not always) associated with health problems, and the latter can certainly often contribute to weight gain – even in kids!

A study by Stefan Kuhle and colleagues from the University of Alberta, published in the Archives of Diseases of Childhood, shows that overweight and obese Canadian kids use more medications than do normal weight kids.

The authors compare medication use between normal weight and overweight children (n=2,087) in a nationally representative sample from the Canadian Health Measures Survey 2007/2009, a cross-sectional survey assessing indicators of health and wellness in Canadian.

While there was no difference in the frequency of prescription, over-the-counter and natural health product (NHP) medication use between normal weight and overweight/obese 6-11 year olds, overweight/obese 12-19 year olds reported the use of prescription medication about 60% more often than their normal weight peers, especially for nervous system and respiratory problems. On the other hand, they were about 50% less likely to report the use of NHP medications.

As the authors note,

“With an overweight/obesity prevalence of 28% in the sample and 59% higher medication costs, approximately 14% of drug expenditures in this age group may be attributed to overweight and obesity.”

Less concerning than the cost associated with this increased use of medications is the question of why these kids develop obesity and related health problems in the first place.

It is particularly noteworthy that the use of drugs for the treatment of obstructive respiratory disorders was almost twice as high in the overweight/obese kids than in their normal weight peers.

Given that asthma is notoriously overdiagnosed in obese adults, I wonder how much of these drugs may be overprescribed in these kids.

In my own experience in adults, many admit that symptoms of ‘asthma’ were often a convenient way of getting out of gym class (as were ‘menstrual’ cramps). Anecdotally, I have the impression that this was more commonly reported in my female patients, who often recall gym class during their peri-pubertal years as particularly unpleasant (the fact that they often had to wear bras before any of the other girls in their class did not exactly help).

Nevertheless, the numbers are concerning and certainly an indicator that overweight and obese kids may have more health problems than their peers.

I wonder how many of my readers can remember having to take asthma or other meds as kids and how these problems may have contributed to their current health status.

AMS
Edmonton, Alberta

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ResearchBlogging.orgKuhle S, Fung C, & Veugelers PJ (2012). Medication use in normal weight and overweight children in a nationally representative sample of Canadian children. Archives of disease in childhood PMID: 22833408

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Thursday, May 3, 2012

Impact of Severe Obesity on Post-Acute Rehabilitation Costs

Glenrose Rehabilitation Hospital, Edmonton, AB

Glenrose Rehabilitation Hospital, Edmonton, AB

Some of the greatest advances in modern medicine are in the field of rehabilitation – from accident victims to individuals with strokes and heart attacks, diligently working with patients to restore their health and function can be time consuming, resource intensive, but also immensely rewarding to patients, their families, and society.

Unfortunately, when patients are also severely obese, costs and duration of rehabilitation dramatically increase. Thus, in a paper we recently published in the Journal of Obesity, we looked at the impact of severe obesity on post-acute rehabilitation efficiency, length of stay, and hospital costs.

We retrospectively looked at these parameters in 42 severely obese subjects (mean age 53 y; mean BMI 50.9) and compared them to 42 nonobese controls (mean age 59 y; mean BMI 23.0) matched by sex and admitting diagnosis.

Although in the end the severely obese subjects achieved the same functional independence measure as the lean controls (0.58 vs. 0.67), they experienced longer total length-of-stay (98.4 vs. 37.4 days), rehabilitation length-of-stay (55.8 vs. 37.4 days), and waiting for transfer (42.6 vs. 0 days).

This resulted in almost a three-fold increase in hospital costs ($115,822 vs. $43,969).

It is apparent from these findings that the most significant determinant of higher costs in severely obese rehab patients is not the cost for their treatment but their considerably longer length-of-stay after achieving their rehabilitation goals.

As discussed in our paper,

“We suspect that the increased waiting-for-transfer-of-service length-of-stay in the severely obese is a consequence of the patient’s inability to gain independence following rehabilitation. In our experience, these subjects cannot return home and due to a lack of suitable alternative discharge destinations, often wait in hospital for transfer to a nursing home.”

This speaks to the lack of appropriate bariatric care facilities in nursing homes and the difficulties that severely obese patients may often face in their usual home and familial settings with even modest additional limitations that remain after the completion of in-patient rehabilitation. Indeed, few homes and personnel delivering home care are equipped or trained to deal with the special needs to individuals with severe obesity.

We also discuss at length some of the considerable challenges that severely obese patients face whilst within the rehabilitation setting:

“However there are very limited published data on bariatric-specific PAR interventions and this deficiency was recently recognized at a multidisciplinary consensus conference [hosted by the Canadian Obesity Network]. Many potential barriers to developing effective rehabilitation strategies in bariatric patients were identified by this expert panel, including the lack of bariatric-specific rehabilitation programs in both acute and post-acute rehabilitation, a paucity of standards of care specific to obese patients, weight bias on the part of health care staff, and a lack of training programs and research consortia specializing in bariatric rehabilitation. The higher prevalence of medical complexity, mental health impairment, and psychosocial dysfunction in the severely obese were also recognized as potential barriers to effective rehabilitation and factors that may increase the likelihood of acute illness relapse during post-actue rehabilitation.”

Despite these limitations, it is clear that much of the excess cost is simply due to increased length-of-stay of patients waiting for transfer either back home or to a long-term care facility. While it is important to consider the “bed blocking” effect (preventing use of these beds for other patients requiring rehabilitation) and to reductions in cost-efficient health care delivery, it is as important to recognize the need for creating structures and resources that will better allow these patients to be reintegrated into the community – at home or in a long-term care facility.

We should remain conscious of how weight bias may play a role in our reluctancy to adequately meet these challenges of this special population.

AMS
Leipzig, Germany

ResearchBlogging.orgPadwal RS, Wang X, Sharma AM, & Dyer D (2012). The impact of severe obesity on post-acute rehabilitation efficiency, length of stay, and hospital costs. Journal of obesity, 2012 PMID: 22523669

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Friday, March 30, 2012

ISORAM Day 4: Dollars and Sense, Obesity Stages, Community Programs, and Nutritional Finesing

On day 4 of the 2nd International School on Obesity Research and Management (ISORAM), the presentations focussed on the nuts and bolts of bariatric care.

The day was kicked off with a presentation by David Urbach (Toronto) presenting an overview of economic considerations in providing appropriate bariatric care. As he pointed out, despite the fact that such analyses, necessarily, are based on a number of assumptions and may turn out different depending on the perspective (e.g. patients, health care systems, societies), most analyses strongly favour the cost-effectiveness of bariatric surgery – especially for patients with obesity related health problems like diabetes.

However, as pointed out by Scott Gmora (McMaster), the ‘elephant’ in the room, often ignored or glossed over, is the issue of the many unintended clinical outcomes that can occur following bariatric surgery. His talk focused especially on the issue of post-surgical inadequate weight loss and/or weight regain, which may occur in over 20% of all surgical patients. As he pointed out, even this number may be a gross underestimate of ‘failure’ rates, as there is very little data on long-term outcomes, as the vast majority of surgical studies routinely losing 30-40% of patients to follow-up even after just a couple of years. Thus, no one really know how high these ‘failure’ rates may be. On the other hand, there is also no clear definition of ‘failure’ – thus, for e.g. a patient with diabetes, who after surgery loses only 5% of his body weight but experiences a marked improvement in his diabetes, may be considered a ‘failure’ if the focus is on weight loss but would clearly be a ‘success’ if the outcome measure is diabetes control. Given this lack of standardisation in defining outcomes and the general lack of follow-up of surgical patients, Gmora presented a framework for systematically assessing factors related to weight recidivism (pre-operative, intra-operative and post-operative).

Raj Padwal (University of Alberta) discussed the evidence for and possible utility of the Edmonton Obesity Staging System (EOSS) and why it is high time that obesity staging be incorporated into the overall estimation of obesity-related risk and eligibility for treatments.

Sean Wharton (Burlington, ON), described his experience with a model of a publicly funded bariatric service in the community, which can provide significant weight management interventions to a high volume of patients by making adequate use of a multidisciplinary team including dieticians, bariatric educators, exercise specialists, psychologists and physicians.

Bonnie MacKinnon (Sudbury, Ontario), described the challenges of setting up a bariatric regional assessment and treatment centre as part of the Ontario Bariatric Network. Patients are referred to the centre through a central process. Setting up this centre to serve North Eastern Ontario, which covers 400,000 sq km and has a culturally diverse population of 570,000, including 25% of Francophone and 10% Aboriginal, provided significant learnings. Building relationships with the community, media, host hospital and community hospitals were instrumental in establishing a successful clinic. Futures goals for the Sudbury RATC include continued outreach to clinicians and patients in the region offering support and education in bariatric surgical care and implementation of a non-surgical obesity program.

Additional talks included a presentation by Daniel Birch (University of Alberta) on surgical outcomes in a publicly funded health care system, a talk by Keith Brewster (Kelowna, BC) on the establishing a LABG program in a community setting, a review of nutritional aspects of bariatric management by Jacqueline Jaques (Irvine, FL), and my take on the importance of exploring the whys of obesity rather than just the whats.

AMS
Lake Louise, Alberta

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In The News

Diabetics in most need of bariatric surgery, university study finds

Oct. 18, 2013 – Ottawa Citizen: "Encouraging more men to consider bariatric surgery is also important, since it's the best treatment and can stop diabetic patients from needing insulin, said Dr. Arya Sharma, chair in obesity research and management at the University of Alberta." Read article

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