Dr. Sharma's Obesity Notes

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

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

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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

No doubt obesity is associated with a wide range of health problems affecting almost every organ system.

But acute earache is perhaps not a health problem that immediately comes to mind when we consider the health risks of excess weight.

According to a paper by Stefan Kuhle and colleagues from University of Alberta, School of Public Health, published in the latest issue of Pediatric Obesity, acute middle ear infections (otitis media) may be far more common in obese than in normal weight kids.

This prospective cohort study, linked data from a population-based survey of Grade 5 students (aged 10-11 years) in the Canadian province of Nova Scotia in 2003 with Nova Scotia administrative health data via Health Card numbers.

Relative to normal weight children, obese children had twice as many healthcare provider contacts for severe purative otitis media (ICD9: 382; ICD10: H65-66), incurred more costs per otitis media-related visit ($47 vs. $24) and were two-and-a-half times more likely to have repeated otitis media infections.

There was a significant dose-risk effect with overweight kids fitting nicely between normal weight and obese kids in terms of increased risk.

This risk was independent of a range of socioeconomic factors, history of breastfeeding, presence of an allergic disorder or chronic adenoid/tonsil disorders.

Although, association does not prove causality, it is worth noting that this finding has considerable biological face value.

Thus, the authors provide the following possible explanation for this relationship:

“…obesity has been linked with low-grade systemic inflammation, which may produce a milieu that increases the risk of otitis media or lead to chronic otitis media. Alternatively, gastroesophageal reflux, which is seen more frequently in individuals with higher BMI may enter the middle ear through the Eustachian tube and cause otitis media. Finally, in obese individuals fatty tissue may accumulate around the Eustachian tube thereby compromising ventilation of the middle ear.”

As the authors also point out, this finding may have considerable public health implications:

“Acute otitis media is the second most common reason for visits to a family physician, accounting for 10– 15% of all childhood visits. Recurrent otitis media may result in long-term sequelae such as learning disability, impaired linguistic development or hearing disorder, or sleep apnoea because of the development of chronic adenoid/tonsil disorder.”

But the cost implications are also worth noting:

“We were able to show that the per capita physician costs for otitis media between 2001 and 2006 were 92% higher ($47 vs. $24) in obese children compared with normal weight children. This cost differential is second only to that of chronic adenoid/tonsil disorder (230%) out of the 10 childhood disorders examined”

While the study does not provide any insights into whether reducing childhood obesity would reduce ear infections or whether or not obese kids need to adopt any other precautions to avoid earaches, it certainly points to an under appreciated risk factor for this common and excruciatingly painful condition.

AMS
Edmonton, Alberta

Kuhle S, Kirk SF, Ohinmaa A, Urschitz MS, & Veugelers PJ (2012). The association between childhood overweight and obesity and otitis media. Pediatric obesity, 7 (2), 151-7 PMID: 22434755

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As someone working in a public health care system, I am particularly interested in what exactly patients ‘value’ in health care.

In other words, what is it that patients really want from health care?

This, is the topic of a commentary by Allan Detsky from the University of Toronto, published in a recent issue of JAMA.

According to his analysis (and experience), here are some of the things that patients value and want most:

• Most patients want a health care system that responds (quickly) when care is needed. Although patients generally understand the concept of preventive medicine, they are really far more interested in quickly receiving help that relieves illness and symptoms when they have the problem (or in other words, “while prevention is nice - what I really want is quick help when I am sick!”)

• Patients want hope and certainty (even if there is no hope and things are uncertain). They also prefer doing ’something’ to doing nothing. When in doubt, many would prefer the extra test or two even if it is unlikely that the test will be useful - ‘just to be sure’. Many are also open to ‘trying’ something, even if the likelihood that the treatment will actually work is small.

• Patients want continuity, build relationships with their providers, and want their providers to communicate effectively with each other.

• Patients prefer treatments that require little effort (medications, surgery) to treatments that require a lot of effort (behavioural change).

Not quite as high on the priority list are:

• Efficiency, whereby, patients define efficiency in terms of ‘their own time not being wasted’. This is different from how decision makers define efficiency, namely delivering the best value with the least resources. The latter is something patients don’t really worry about too much.

• Statistics, whereby, most patients don’t really care about the ‘average’ patient. Most care mainly about themselves. They are also not impressed by ’statistical’ findings of what works and what doesn’t - “so what if the treatment doesn’t work for most people, as long as it works for me”. (also, I would add, “if it works for me, it should be covered!”).

• Conflicts of interest, whereby, most patients are less concerned about whether or not their doctors are making extra money, as long as the service they receive makes them feel better.

Interestingly enough, according to Detsky, things that have the lowest priority for patients are

• The real cost of the care they receive (as long as they are not paying directly ‘out of pocket’)

• How much of the total GNP the government spends on health or how their health care compares to other provinces or countries.

As Detsky states:

“Preferences for immediate care and elimination of uncertainty make excess capacity and waste tolerable to the public. It may be more rational to spend resources on interventions that are of more value, like efforts to combat obesity, but most of the public cares more about treating illness”.

He also points out, that although these consumer preferences may appear irrational or unrealistic,

“What people want when they are healthy may be different from what they want when they are sick”.

Perhaps politicians and decision makers are indeed smarter than we think, when it comes to knowing what people really want, namely much talk about prevention for those who are healthy but real action and quick help (with all diagnostic and treatment options - whether necessary or not) for those who are sick.

AMS
Edmonton, Alberta

Detsky AS (2011). What patients really want from health care. JAMA : the journal of the American Medical Association, 306 (22), 2500-1 PMID: 22166610

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Last week the Conference Board of Canada released a not too flattering report on the status of chronic disease and obesity management in Canada.

According to the press release that accompanied this Health Report Card, which Canada receives “A” grades on self-reported health status, mortality due to circulatory diseases (primarily heart disease and stroke), and premature mortality, it receives “B” grades on mortality due to mental disorders and mortality due to respiratory diseases (which include asthma, tuberculosis, bronchiolitis, emphysema, cystic fibrosis, influenza, and pneumonia).

But, when it comes to the prevention management of three major chronic diseases, Canada’s performance is dismal compared to its 17 peers:

- Mortality due to musculoskeletal diseases—“C” grade, 11th-place ranking

- Mortality due to cancer—“C” grade, 13th-place ranking

- Mortality due to diabetes—“C” grade, 15th-place ranking (out of 17?!?)

It does not take a genius to recognize that all three of these conditions are tightly linked to obesity, which is why Gabriela Prada, the Conference Board’s Director, Health, Innovation, Policy and Evaluation is quoted as saying:

“Canada is facing a growing burden from chronic diseases such as diabetes and cancer. This burden is expected to increase due to an aging population and rising rates of obesity”.

Indeed, as the report points out:

“Obesity has taken centre stage as a major risk factor for chronic diseases. Obesity is one of the most significant contributing factors to many chronic conditions, including heart disease, hypertension, and type 2 diabetes—type 2 diabetes accounts for 85 to 95 per cent of all diabetes cases in high-income countries. The share of overweight or obese Canadians continues to increase. According to calculations based on measured data, almost two-thirds of Canadians were considered to be either overweight or obese in 2008, and 24 per cent were considered to be obese. Particularly troubling is the growing share of children who are overweight. More than one in four Canadian children are considered overweight—a share that is higher than the OECD average.”

So while decision makers in Canada’s health care system may well feel that other issues are perhaps more important (or have stronger lobbies), the future of Canada’s health care system very much depends on whether or not these decision makers will eventually recognize that without significant attention to chronic diseases and obesity Canadians’ health will be unlikely to become ‘world class’.

Importantly, none of this is simply a matter of pouring more money into Canada’s health care systems. Indeed, as the report points out,

“…countries with considerably older populations than Canada’s—like Japan and Sweden—do not have more expensive health systems. In fact, Japan, which has the lowest health care spending per capita, boasts the highest life expectancy and the lowest infant mortality rate. Japan also has one of the lowest premature mortality rates, the second-lowest mortality rate due to cancer, and the lowest rates of mortality due to circulatory diseases, diabetes, and mental illness.”

The report concludes that,

“Canada has no choice but to adopt a model that focuses on sound primary care practices and population health approaches—particularly preventing and managing chronic diseases—and recognizes and rewards high-quality health care services.”

As I have said before, no health care system can afford NOT to address and manage obesity.

AMS
Edmonton, Alberta