Bariatric Surgery: A Cost-effective Treatment of Obesity? · 2018-09-29 · Minimally Invasive...
Transcript of Bariatric Surgery: A Cost-effective Treatment of Obesity? · 2018-09-29 · Minimally Invasive...
Bariatric Surgery: A Cost-effective
Treatment of Obesity?
Shaneeta M. Johnson MD FACS FASMBS2018 NMA Professional Development Seminar
Congressional Black Caucus FoundationAnnual Legislative Conference
Washington, DC
Greater than one-third of U.S. adults are obese
Estimated that one third of all children, one half of all black and Hispanic children born in 2000 will develop diabetes
Linked to type 2 diabetes, heart disease, hypertension, certain types of cancer and more
OBESITY
Prevalence of Childhood and Adult Obesity in the United States, 2011-2012 Cynthia L. Ogden, PhD1; Margaret D. Carroll, MSPH1; Brian K. Kit, MD, MPH1,2; Katherine M. Flegal, PhD JAMA. 2014;311(8):806-814. doi:10.1001/jama.2014.732.
The Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report
Obesity costs
Estimated annual cost of $147 billion in 2008
$1,500 higher medical costs than those of normal weight
Decreased productivity due to ‘absenteeism’
Presenteeism - decreased productivity
Preventive, diagnostic, and treatment services related to obesity
Eric A. Finkelstein, Justin G. Trogdon, Joel W. Cohen and William Dietz Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates Health Affairs 28, no.5 (2009):w822-w831
Obesity as a Disease
American Medical Association - recognized obesity “as a disease state with multiple pathophysiological aspects
requiring a range of interventions to advance obesity treatment and prevention”
June 2013
Bariatric Surgery
“[Bariatric surgery] is the most effective treatment to date, resulting in sustainable and significant weight loss along with resolution of weight-related health conditions in up to 80% [of people].
ASMBS/ASGE white paper, 2011
Recommended by the American Diabetes Association (ADA) as a treatment for diabetes
Bariatric SurgeryEndorsements
Prevalence¶ of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2016
¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011.
*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.
Prevalence of Obesity
Prevalence of Self-Reported Obesity Among Non-Hispanic Black Adults, by State and Territory, BRFSS, 2014-2016
*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.
Prevalence of Obesity in African-Americans
IncreasedMedical Costs
Obesity
PrematureDeath
Comorbid Diseases
Disability
Reduced Quality of Life
The Impact of Obesity
Obesity-related Disease
The Harmful Effects of Obesity
Liver disease
Gallbladderdisease
OsteoarthritisGout
Asthma
Heart disease
Menstrual/Infertility problems
Type 2 diabetes
High blood pressure
Sleep apnea
GERD
Migraines
Urinary Incontinence
Venous diseaseand leg swelling
•Increased chance of developing one of these
and/or additional diseases:
Risks of Obesity
BMI 30-35=
Reduced Median survivalby 2-4 years
Body mass index (BMI)=
Strong predictor ofoverall mortality
BMI > 30 associated with
Risk of Premature death
Office of the Surgeon General – US Department of Health and Human Services. Overweight and Obesity: health consequencesKaplan, L.M. (2003) Body weight regulation and obesity. Journal of Gastrointetinal Surgery. 7(4) pp. 443-51.
Risks of ObesityCancer Risks
Esophageal Cancer
Pancreatic Cancer
Colon and Rectal Cancer
Thyroid Cancer
Breast Cancer
Endometrial Cancer
Kidney Cancer
Women: 50,500Men: 34,000
500,000 new US cases by 2030
(estimate)
Obesity and Cancer Risk – National Cancer Institute
Minimally Invasive Bariatric Surgery
• Surgery altering the gastrointestinal tract to cause weight loss• Effective means of losing substantial weight and maintaining that
weight loss• Affects the numerous comorbidities associated with obesity• Considered Metabolic Surgery• Indicated for severely obese patients
Who is a Surgical Candidate?
• 100 lbs over ideal body weight
• OR BMI equal to or > 40
• OR BMI equal to or > 35 complicated by other medical conditions
• eg. diabetes, high blood pressure
Category BMI % Over IBWUnderweight < 18.5
Normal 18.5 –24.9
Overweight 25.0 –29.9
Obesity (Class 1)
30 – 34.9 > 20%
Severe Obesity (Class 2)
35 – 39.9 > 100%
(Class 3)40 – 49.9
Super obesity > 50 > 250%
Bariatric SurgeryThe numbers
2011 2012 2013 2014 2015 2016 2017
Total 158,000 173,000 179,000 193,000 196,000 216,000 228,000
Sleeve 17.80% 33.00% 42.10% 51.70% 53.61% 58.11% 59.39%
RYGB 36.70% 37.50% 34.20% 26.80% 23.02% 18.69% 17.80%
Band 35.40% 20.20% 14.00% 9.50% 5.68% 3.39% 2.77%
BPD-DS 0.90% 1.00% 1.00% 0.40% 0.60% 0.57% 0.70%
Revision 6.00% 6.00% 6.00% 11.50% 13.55% 13.95% 14.14%
Other 3.20% 2.30% 2.70% 0.10% 3.19% 2.63% 2.46%
Balloons — — — — 0.36% 2.66% 2.75%
Estimate of Bariatric Surgery Numbers, 2011-2017
Published June 2018The ASMBS total bariatric procedure numbers are based on the best estimation from available data (BOLD,ACS/MBSAQIP, National Inpatient Sample Data and outpatient estimations).
Primary Metabolic and Bariatric ProceduresLaparoscopic Gastric Bypass
• Stomach reduced to size of walnut, attached to jejunum, thereby bypassing a portion of small intestine
• Limits consumption and absorption of calories
• Risks: Allergic reactions, pulmonary emboli, deep vein thrombosis, infection, cardiovascular or pulmonary risks, nutritional deficiencies
Primary Metabolic and Bariatric ProceduresSleeve Gastrectomy
• Stomach divided and stapled vertically, removing a portion stomach, creating banana-shaped pouch
• Restricts amount of food and consumed and absorbed
• Risks: GERD, infection, gastritis, pulmonary emboli, nutritional deficiencies
Bariatric Surgery It’s SAFE!
Increased minimally invasive surgery
Advanced surgical techniques
American College of Surgeons (ACS) and American Society of Metabolic and Bariatric Surgeons (ASMBS) accreditation program
Bariatric SurgeryLow Mortality Rate
0.00%
0.10%
0.20%
0.30%
0.40%
0.50%
0.60%
0.70%
0.80%
0.90%
1.00%
Mortality Rate
Mortality Rate
Bariatric Surgery Gallbladder Removal Hip Replacement Surgery
Bariatric Surgery
Gallbladderremoval
Hip replacementsurgery
Agency for Healthcare Research and Quality (AHRQ (2007), Statistical Brief #23. Bariatric Surgery Utilization and Outcomes in 1998 and 2004.
Bariatric Surgery
BMI >30
50% increased risk of premature
death
Bariatric surgery increases lifespan
Gastric bypassreduce risk
of premature death by 40%
Increase life expectancy
by 89%
Risks of morbid obesityoutweigh risks
of surgery
U.S. Department of Health and Human Services Office of the Surgeon General. (2007). Overweight and obesity: health consequencesEffects of bariatric surgery on mortality in Swedish obese subjects. New England Journal of Medicine. 357 pp741-752
Adams, T. D. et al. (2007) Long-term mortality after gastric bypass surgery. New England Journal of Medicine 357pp.753-761
Bariatric SurgeryIt’s Effective!
60%excess weightat 6 months
77%excess weightat 12 months
50%excess weight
at 5 years
Wittgrove, A.C., et al. (2000). Laparosocpic gastric bypass, roux-en-y: 500 patients: technique and results, with 3-60 month follow-up. Obesity Surgery. 10(3) pp.223-239
Bariatric SurgeryImpact on Mortality
Improve or resolve more than 40
obesity-related diseases and
conditions
% Reduction in mortality Disease/Condition
60% reductionCancer
esp. breast and colon cancer
56% reduction Coronary artery disease
92% reduction Type 2 diabetes
40% overall reduction
Overall reduction in gastric bypass
patients
Adams, T.D. et al. (2007). Long-term mortality after gastric bypass surgery. New England Journal of Medicine. 357 pp.753-761Christou, N.V., et al. (2008). Bariatric Surgery reduces cancer risk in morbidly obese patients. Surgery for Obesity and Related Diseases. 4(6) pp. 691-95
Bariatric SurgeryMedical Outcomes
Condition/Disease % Resolved or Improved % Resolved
Type 2 Diabetes 86% 76.8%
Hypertension 78.5% 61.7%
Obstructive Sleep Apnea 85.7% 83.6%
Hyperlipidemia 78.5% 61.7%
Buchwald, H, et al. (2004). Bariatric surgery: a systematic review and meta-analysis. Journal of the American Medical Association 292(12) pp.1724-1737
Health Benefits of Weight Lossafter Bariatric Surgery
• ↑Quality of Life
• ↑ Life expectancy
• Diabetes resolved/improved
• High blood pressure resolved/improved
• Improved/resolved depression
• Decreased heart risks
Bariatric Surgery
33,718 patients,13 comorbidities with
at least 1% prevalencebefore surgery
Diabetes
Hypertension
Economics of Bariatric SurgeryHealth care
costs
29% in 5 years
Payers recover bariatric
surgery costs within
2-4 years
Worker productivity
$2,765/year for employers
Costs =$11,500 - $26,000
Sampalis J.S., et al. (2004). Impact of weight reduction surgery on health care costs in morbidly obese patients. Obesity Surgery. 14(7) pp. 939-47Cremieux et al (2008) A study of economic impact of bariatric surgery. The American Journal of Managed Care. 14(9) pp 589-596
Bariatric Surgeryin African-Americans
• Obesity is highest among African-American populations
• Obese African-American patients have a higher prevalence of obesity-related comorbidities
• Most patients undergoing bariatric surgery are Caucasian
Bariatric surgery outcomes in black patients with super morbid obesity
Significant decrease in weight and BMI
Significant improvement or resolution of hypertension, type 2 diabetes and
hyperlipidemia
Onyewu, Fullum et. Al Bariatric surgery outcomes in black patients with super morbid obesity: a 1-year postoperative review
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300
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400
Preoperative Weight Postoperative Weight
Weight (lbs)
Weight (lbs)
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10
20
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Preoperative BMI Postoperative BMI
BMI kg/m2
BMI kg/m2
STAMPEDE Trial
150 patients underwent either intense medical
therapy,
or
gastric bypass or sleeve
gastrectomy
STAMPEDE TRIAL
HgbA1c of <6.0 at five years
Surgery- 29%Medical – 5%
Weight loss
Surgery -23%Medical – 5%
88% of insulin at 5 years
in surgical arm
Decreased diabetic and cardiac meds
Surgery-35%Medical-13%
Morehouse School of Medicine
• Comprehensive Bariatric Surgery Program
– Nutritional counseling
– Psychological counseling
– Partnerships with Sleep medicine, Endocrinology, Cardiology, Pulmonary, and more
• Optimal Wellness Program
– Stress medicine
– Exercise physiology
– Nutritional counseling
Bariatric Surgery• Effective means for resolution of obesity• Significant effect on obesity-related diseases• Effective treatment for African-Americans with obesity and
comorbidities• Most effective as part of a comprehensive obesity
approach