Posts Tagged ‘Surgical Review Corporation’

The Exciting Recent History of Bariatric Surgery

November 8th, 2011

David Flum’s Bariatric Obesity Outcome Modeling Collaborative at the University of Washington School of Medicine (funded by the Department of Defense and the National Institute of Diabetes, Digestive Diseases and Kidney) recently published a study on the use, safety and cost of bariatric surgery before and after Medicare’s National Coverage Decision (NCD) expanding bariatric surgery in 2006.

The Medicare NCD expanded Medicare coverage of new surgeries, particularly laparoscopic gastric banding and laparoscopic gastric bypass when done in centers of excellence approved by either the American College of Surgeons (ACS) or the American Society for Metabolic and Bariatric Surgery (ASMBS). The standards of the two societies differed somewhat but both certified both hospitals and surgeons and both were based on having large volumes of cases. In addition, the ASMBS system, implemented by the Surgical Review Corporation, requires participation in a robust database, called BOLD, and a five-year follow-up of patients. 

The number of surgeries dropped after the NCD but soon regained their pre-NCD levels. There was a significant shift to the laparoscopic gastric band after the NCD was issued. The mean age and mean comorbidity index increased slightly. The study found that outcomes improved after the NCD. The 90-day mortality rate dropped from 1.5% to 0.7% after the NCD. There was a significant reduction in the number of sites and surgeons performing the surgery. The improvement in patient safety seems mainly due to the shift to the laparoscopic gastric band rather than centers of excellence themselves. Overall, costs appear to have gone down across all procedures. The authors note that the durability of weight loss due to surgery is still an issue as the bands are showing a disturbing rate of removal in several European studies. The Use, Safety and Cost of Bariatric Surgery Befor… [Ann Surg. 2011] – PubMed – NCBI

 The paper brought me back to a particular point in time in my professional career which I would like to share with you. In the early years of the new century, there was an intersection of two threads in obesity and public policy. On the one hand, bariatric surgery was reeling from bad publicity of terrible stories of botched operations. Insurers were dropping coverage of bariatric surgery all across the country. Malpractice insurers were upping their rates. The surgeons were in a crisis.

On a totally separate track, as director of the American Obesity Association, I had persuaded the Internal Revenue Service to recognize obesity as a disease in April of 2002. Subsequently, I took the same arguments to the Centers for Medicare and Medicaid Services (CMS) which had a policy statement that obesity was not a disease. On July 15, 2004, Medicare withdrew that statement, recognizing obesity as a disease. Soon thereafter, I met with Steve Phurrough, the head of the CMS center for coverage and analysis, and asked him what was CMS going to do next. “Bariatric Surgery,” he replied. CMS scheduled a Medicare Coverage Advisory Committee (MCAC) hearing for November 4, 2004 to look at bariatric surgery.

I contacted ASMBS (or ASBS as it was then called) as well as five companies involved in bariatric surgery. A couple of the companies did not have products on the market but were in developmental phase. I felt it was important they were at the table. I read them all the riot act. If everyone went off on their own, bariatric surgery was not going to fare well at the MCAC hearing. If we focused on what was best for the patients, who the patients were and what they needed, we would do ok. I want to say it was an easy sell. Some got it, some did not.

So the two threads crossed: crisis for bariatric surgery and an emerging consensus to treat obesity as a disease. At this point, the presentation for bariatric surgery at the MCAC was in the hands of a few veterans: Walter Poires, Henry Buchwald, Harvey Sugerman, and Neil Hutcher, stand out in my mind. As they were putting the presentation to MCAC together, they were also working within ASBS to create the Centers of Excellence movement. The stakes of such a move should not be understated. Such an effort means saying to loyal, dues-paying, members that their colleagues felt they are not good enough to keep doing what they have been doing for years. The emotional and professional price could be high. Participating in the MCAC hearing were the next generation of leaders, Bruce Wolf, Robin Blackstone, Christopher Still, to name a few.

At the end of the day, CMS expanded coverage for bariatric surgery, much to the dismay of some. ASBS created its centers of excellence of program, implemented by the Surgical Review Corporation. (I went on its board of directors for a few years.)

Now, we see from Flum’s report what we had hoped for: patients have access to a safer, cheaper procedure. I am not aware of any medical specialty which has overcome its quality problems so aggressively in such a short period of time. When people talk about how hard it is to achieve change, I think of what ASMBS did in a few short years.

Subsequent research may challenge this but subsequent technological improvements may enhance surgery as well. It isn’t always that one gets to see whether an earlier effort has played out as you hoped. As my son would say, “Sweet.”

Time for Obesity in Health Care Reform

September 27th, 2009

January 30, 2009 :: By Morgan Downey

These are exciting times for health care reformers. We seem to have a President who is truly committed to reform of the health care system with the political strength to get his program enacted, at least a good part of it. What is the President’s program and how does or can, obesity be part of it?

First, some parts have already been enacted in the American Recovery and Reinvestment Act (ARRA), aka the Stimulus Bill. Millions of federal dollars are starting to flow into (a) expanded Health Care Information Technology, (b) comparative-effectiveness research and (c) expanded research at the National Institutes of Health. In addition, President Obama and several of his key aides, such as Melody Barnes, Director of Domestic Policy Council, and Peter Orszag, director of Office of Management and Budget have both addressed obesity and its important role in reducing health care costs and increasing the nation’s health.

Second, a major component to be worked on this summer is providing health insurance to millions of Americans without health insurance.

How might these plans affect obesity?

Healthcare Information Technology (HIT) may provide some interesting opportunities. In a few places, extensive clinical databases are already in use which track patients receiving bariatric surgery. The Surgical Review Corporation, for one, has 100,000 surgical patients which are being tracked for long-term outcomes. The Geisinger Medical Center in central Pennsylvania also has extensive database on patients in surgical and medical treatment. Such clinical registries can provide a vast improvement in understanding obesity and its co-morbidities as well as tracking long-term improvements. Doing this in real time with real-world patients can add tremendous information to clinical trials, which, by their nature, have more restrictive populations and end-points. Last year, the National Committee on Quality Assurance (NCQA) expanded the widely used HEDIS system which measures quality in managed care plans to capture Body Mass Index (BMI) for adults and children. The Administration’s emphasis on electronic medical records (EMR) in primary care practice, by requiring capture of BMIs, along with other clinical indicators, such as blood pressure, cholesterol levels and lipids, can provide a tremendous database for researchers and has the potential to greatly improve patient care. But there is a third level as well. Private entities, such as Google and Microsoft, are developing Personal Health Records (PHR) for individuals to track their own information, which might include nutritional and exercise patterns. One can almost envision a system whereby food and exercise diaries, clinical indicators, pharmaceutical and surgical information is available for patients, health care professionals and researchers.

Of course, such systems take a lot of effort. Common terminology must be agreed to. Data has to be able to be verified. Systems have to interface and patient privacy has to be protected. Who owns this information is a critical issue.

Comparative effectiveness research has already received a great deal of funding under ARRA. The Institute of Medicine has a panel recommending research priorities and, given the discussion at a public meeting on March 20, 2009, there is good reason to anticipate that obesity will be one of the priorities. But the question should not be just what is the best way to lose weight. The research should look at weight loss by various interventions against standard treatments for a number of the co-morbid conditions associated with obesity. And, while there is good data on the efficacy of weight loss for resolution of type 2 diabetes and cardiovascular disease, less is know about its efficacy in mobility problems, such as knee and hip replacements, asthma or breast cancer.

Finally, the Obama Administration has an enormous opportunity in the coverage of the uninsured to make a real change for persons with obesity. First, the Administration should oppose using overweight or obesity as a pre-existing exclusion. While we do not know what percent of the uninsured population is overweight or obese, it is unlikely that the rate is any lower than the national averages. To exclude 30-60% of the uninsured population because of their weight would be poor policy indeed. Next, the Administration should provide a full range of interventions from counseling on nutrition and physical activity to pharmaceutical and surgical interventions. Not only would this directly address the source of many of the uninsured population’s health care problems, it could break the logjam of resistance to coverage of obesity prevention and treatment. While these two steps will be costly, we have seen the rising rates of health care costs and obesity go hand-in-hand. Economists today see obesity as a major contributor to chronic illness and its costs. Finally, coverage should be tied into electronic records which can track long term outcomes.

In the April 15, 2009 issue of the Journal of the American Medical Association, Johathan Q. Purnell and David R. Flum estimate that gastric bypass surgery could save 14, 310 diabetes-related deaths over five years. The evidence on the power of weight loss to prevent and improve chronic disease is there, if not yet perfect. The Administration has an opportunity to make a major leap forward in addressing obesity. It should not miss this chance.

Bariatric Surgery

September 27th, 2009

Centers of Excellence Programs Surgical Review Corporation

NIH: WIN – Publication – Bariatric Surgery for Severe Obesity

An unique, new study found that maternal weight loss from bariatric surgery may improve cardiometabolic  risks in infants which is sustained into adulthood.Effects of Maternal Surgical Weight Loss in Mother…[J Clin Endocrinol Metab. 2009] – PubMed Result

 

Health Outcomes of Gastric Bypass Patients Compare…[Obesity (Silver Spring). 2009] – PubMed Result

Two-year changes in health-related quality of life…[Surg Obes Relat Dis. 2009 Mar-Apr] – PubMed Result

Health and health-related quality of life: differe…[Surg Obes Relat Dis. 2008 Sep-Oct] – PubMed Result

Review of meta-analytic comparisons of bariatric s…[Surg Obes Relat Dis. 2008 May-Jun] – PubMed Result

Change in predicted 10-year cardiovascular risk fo…[Obes Surg. 2009] – PubMed Result

Complications and Costs for Obesity Surgery Declining

Bariatric surgery and reduction in morbidity and m…[Int J Obes (Lond). 2008] – PubMed Result

Bariatric Surgery in Adolescents

An update on 73 US obese pediatric patients treate…[J Pediatr Surg. 2008] – PubMed Result

Bariatric surgery for severely obese adolescents. [J Gastrointest Surg. 2003] – PubMed Result

Best practice updates for pediatric/adolescent wei…[Obesity (Silver Spring). 2009] – PubMed Result