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.
Padwal 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