Facility Certification Debate…Bariatric Surgery Explained…1 in 5 Die From Obesity, Study Finds…Moms With Obesity Cause Health Problems for Kids…Bariatric Surgery Shown to Alter Liver DNA…
ASMBS president Dr. Jaime Ponce was featured in two stories last week commenting on the potential consequences of CMS dropping its bariatric surgery facility certification requirement. Dr. Ponce explained, "Without the accreditation, Medicare patients are going to struggle... Medicare patients are the higher-risk patients. They tend to have more medical problems, more issues, and more complications. If they go to places that don't have experience, there will be more mortality… The ability to rescue patients from a complication is less optimal." Dr. Birkmeyer, who triggered the review by CMS countered, "The accreditation standards, as they've been formulated and implemented, have done zero to steer patients to hospitals with better outcomes. If anything, they've given both patients and hospitals a sense of complacency."
The article notes that the ASMBS and American College of Surgeons sent a letter to CMS, which was also signed by representatives of the Obesity Society, the Society of American Gastrointestinal Endoscopic Surgeons and the American Society of Bariatric Physicians -- arguing that some of the studies put forth by the CMS (including the Birkmeyer study) to support removal of the requirement have limitations, and it cites different research that it says supports the continuing need for accreditation of centers performing bariatric surgery. This includes a paper published in the August edition of Surgical Endoscopy that examines 2006–2010 bariatric-surgery data from the Nationwide Inpatient Sample. Of a total 277,760 cases, 85 percent were performed at "high-volume" centers (more than 50 cases per year). Inpatient mortality was 0.17 percent at low-volume centers, vs 0.07 percent at the high-volume centers. When only the high-volume centers are examined, in-hospital mortality at non-accredited centers was 0.22 percent compared with 0.06 percent at accredited centers, a highly significant difference, with an odds ratio of 3.6 (P < .01). Serious morbidity was also significantly lower at the accredited centers (odds ratio, 0.8; P < .01).
Quoting from the letter, "Accredited high-volume centers have significantly lowered in-patient mortality while nonaccredited high-volume centers have worse mortality outcomes, indicating that accreditation provides a benefit beyond volume." In addition, according to Dr. Ponce, the studies that show no difference in outcomes before vs. after the policy change can be explained in part by the fact that the ASMBS/ACS standards were already in place in many centers as early as two years prior to the CMS policy, and those policies helped accelerate the overall improvements in outcomes.
The MedPage Today article points out that accreditation’s supporters have “focused on two studies showing virtually identical disparities in perioperative mortality between accredited and non-accredited facilities," both by Dr. Ninh Nguyen and colleagues. A study co-authored by ASMBS President-elect Dr. Nguyen showed perioperative mortality of 0.21 percent and 0.06 percent for non-accredited and accredited facilities, respectively, in association with 35,284 bariatric procedures performed from 2007 to 2009, 89 percent of which were performed at accredited facilities. Additionally, Dr. Nguyen and colleagues have another study in press showing perioperative mortality of 0.22 percent and 0.06 percent in non-accredited versus accredited centers for 277,760 bariatric operations performed during 2006 to 2010. "We think that lowering the requirement to 50 stapling procedures a year is more representative of what is going on," Dr. Nguyen told MedPage Today. "Stapling procedures are the more complicated procedures, such as Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy. Gastric banding has a very low complication rate, no matter where it is being done."
Dr. Dimick argued, "There are definitely two points of view on the issue. There is the professional association point of view, representing the people who perform accreditation, and obviously they support keeping the requirement, which is certainly understandable. Doctors Birkmeyer and I represent the scientific perspective, which is about what the evidence shows, and we think the evidence does not support the need for mandatory accreditation." ACS' Dr. Hoyt, who favors accreditation, commented, "We think many of those centers, which number about 750, will choose to continue with the verification process. A verification visit is really fulfilling our contract with the public that we are doing what we say we're doing. By allowing yourself to undergo peer review, you're giving the public a level of confidence that we think they should have."
Weight Loss Surgery (Native America Calling)
ASMBS past president, Dr. Robin Blackstone was featured on Native America Calling, a one-hour talk show broadcast on 52 stations across the country and Canada. Dr. Blackstone discussed and answered listener questions on the methods of bariatric surgery, disease improvement or resolution after bariatric surgery, the importance of accreditation in supporting patients and minimizing risk, metabolic disease and the long-term effectiveness of bariatric surgery.
About 18 percent of deaths among whites and African-Americans in the United States ages 40 to 85, are associated with people being overweight or obese, according to a study that will be published in American Journal of Public Health. Previously, the CDC has calculated the yearly number of U.S. deaths from obesity to be about 5 percent, but in this case, researchers applied new statistical models to data from a national interview survey, to determine that between 1986 and 2006, 27 percent of deaths among black women; 22 percent of deaths among white women; 5 percent of deaths among black men; and 16 percent of deaths among white men could be attributed to being overweight or obese. Researchers said there were too few individuals from other ethnic groups to include them in the analysis. They added the percentage of deaths attributed to obesity in this study is higher than previous estimates because it accounted for serious health complications of obesity among older adults, as well as higher rates of obesity among younger generations of Americans. However, several experts, including Ken Thorpe, professor of health policy at Emory University, who commented to USA Today, think the new statistic may be an overestimate. Thorpe said the researchers of the new study didn't take into account factors such as alcohol use, smoking and health insurance so obesity "is getting credit" for deaths caused by those factors too.
Children born to mothers with obesity were 35 percent more likely to experience premature death than those born to mothers of healthy weight, according to a British Medical Journal study. The researchers, who examined the birth and death records of nearly 38,000 people born in Scotland after 1950, found the leading cause of death was cardiac events – attributed to 24 percent of male and 13 percent of female mortality. Having a mother with obesity also led to a 29 percent higher risk of hospital admission for a cardiovascular event. Children born to mothers who were overweight also were at a higher risk – the study showed they were 11 percent more likely to die prematurely, and individuals born to mothers with a BMI of 24 to 28 had the lowest chance of premature death. Researchers believe intrauterine metabolic programming and postnatal environment play a role in risk.
Small Intestine Explains Diabetes ‘Cure’ After Gastric Bypass (Medscape)
A new study in rats published in Science reports “reprogrammed” glucose uptake in the small intestine may explain why gastric-bypass surgery can sometimes result in the early resolution of type 2 diabetes. The report, by Nima Saeidi, PhD, and colleagues, at Boston Children’s Hospital in Massachusetts, was published July 26 in Science. The study revealed that in rat models of this surgery, the small intestine appeared to play a role that was unrecognized until now: it altered the way it processed glucose after the bypass surgery. “Previously, we had not considered the intestine as a major glucose-utilizing organ, [but] we have found this process is exactly what happens after surgery,” senior author Dr. Nicholas Stylopoulos, said in a statement. If confirmed in other studies, the authors suggest, “future drugs might let patients ‘Bypass the Bypass.’"
Bariatric Surgery Changes Liver DNA (MedPage Today)
Bariatric surgery alters gene expressions in the liver of patients with nonalcoholic fatty liver disease (NAFLD), according to a study published in Cell Metabolism. To review liver changes associated with surgery, the researchers examined organ biopsies from both normal and obese patients with and without NAFLD to assess alterations in DNA methylation and mRNA expression profiling. Nine genes associated with metabolism and insulin signaling were expressed at different levels in surgery patients those in healthy non-obese patients. The researchers found that NAFLD-associated methylation changes were partially reversible, which "may represent a key mechanism in the restitution of hepatic insulin sensitivity during weight loss." The researchers added that while the study is relatively small it shows the "dynamic change induced by the weight loss after bariatric surgery in humans," and that some of the candidate epigenetic driver genes identified here "may one day represent targets for mechanistic studies and therapeutic interventions."