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ASMBS Milestones in 2016
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Published in December Issue             

First National Quality Improvement Program for Bariatric Surgery

Results from the Decreasing Readmissions through Opportunities Provided (DROP), the first initiative focused on hospital readmissions developed through Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) were announced at ObesityWeek 2016.

In the study, while the average hospital saw 30-day readmission rates for weight-loss surgery patients drop by about 14 percent, some hospitals had reductions as much as 32 percent after implementing the new quality improvement program. The program takes on added importance as national payers, including Centers for Medicare and Medicaid Services (CMS), continue to emphasize readmissions as an opportunity for improvement in healthcare.

“Weight-loss surgery has already become one of the safest operations in America, comparable to gallbladder and joint replacement surgery, but we saw readmissions as an area we could improve even further,” said lead study author John M. Morton, MD, Director of Bariatric Surgery at Stanford Hospital & Clinics and ASMBS immediate past-president. “Through a true collaboration among hospitals and centers, we bundled best pre-operative and post-operative programs and practices that focused on key triggers for readmissions, taking advantage of a bariatric program’s multi-disciplinary approach.”

DROP was implemented by 128 MBSAQIP Comprehensive Centers between March 2015 and March 2016 for patients undergoing primary laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy, or laparoscopic Roux-en-Y gastric bypass.

In the year prior to the program, centers had a 30-day readmission rate of 4.79 percent with 1,446 readmissions from 30,204 cases. Six months after starting the DROP program, the readmission rate had fallen by an average of 14 percent. The reduction in readmissions was more than three times that (32%) for hospitals in the top quartile of readmissions before the start of the program.

DROP components spanned preoperative to postoperative services including educational videos, inpatient nutritional consults, prescription medication management, postop surgeon and nutritionist visits, and discharge checklists. Of the eight interventions, the post-operative visit with the nutritionist had the most impact.

ASMBS/NORC Poll on Obesity in America

The ASMBS commissioned its first national survey on Obesity in America and that that while the understanding of the risks of obesity has improved, major misperceptions about its causes and treatments persist.

The ASMBS/NORC poll found Americans consider obesity as serious a health threat as cancer, and an even bigger health concern than heart disease and diabetes, yet most do not go beyond traditional diets or involve doctors in their largely unsuccessful personal struggles against the disease.

  • 81 percent of Americans consider obesity to be the most serious health problem facing the nation, tying cancer as the top issue, ahead of diabetes (72 percent), heart disease (72 percent), mental illness (65 percent), and HIV/AIDS (46 percent).

Nearly everyone (94 percent) agrees that obesity itself increases the risk for an early death, even if no other health problems are present. Yet, despite the seriousness with which they take the threat, the vast majority of Americans incorrectly perceive diet and exercise alone to be the most effective long-term weight loss method, and 1 in 3 struggling with obesity report that they have never spoken with a doctor or health professional about their weight.

Only 12 percent of those with severe obesity, for whom weight-loss surgery may be an option, say a doctor has ever suggested they consider surgery.

“This survey reveals that Americans understand the risks of obesity better than ever, but hold major misperceptions about the causes of the disease, the effectiveness of the different treatments and the importance of involving the medical community in their care,” Raul J. Rosenthal, MD, commented. “I think obesity may be the only life- threatening disease where more than a third of the patients do not consult a doctor for treatment, and where the majority do not explore other treatment options beyond diet and exercise that may yield better long-term success rates.”

The ASMBS/NORC Obesity Poll finds about 60 percent of Americans are currently trying to lose weight, although most everyone with obesity has tried before (94 percent). More than half of those with obesity have tried at least five previous times, and 1 in 5 have made more than 20 attempts to lose weight over their lifetimes. Only 22 percent of obese Americans rate their health positively, and half report being diagnosed with two or more chronic conditions.

Most Americans consider diet and exercise on one’s own to be the most effective method (78 percent) for long-term weight loss, saying it’s even more effective than weight-loss surgery (60 percent) and prescription obesity drugs (25 percent).

“Diet and exercise alone is simply not the most effective long-term treatment. It’s an important component, but on its own, it’s probably the least effective option for most people with obesity,” said John M. Morton, MD, MPH, ASMBS immediate past president. “We have to get people, and even the medical community, to go beyond ‘eat less and exercise more.’ That’s too simple an answer for a complex disease like obesity. We have an expanding spectrum of treatments and many are underutilized because they are misperceived or
poorly understood.”

Key Findings

  • When it comes to safety, 88 percent of Americans say losing weight through diet and exercise, especially with the help of a doctor, is the safest way to go, while prescription medications (15 percent) and dietary supplements (16 percent) are perceived to be the least safe. As for weight-loss surgery, Americans are divided, with about one-third of each who believe it to be safe (31 percent), unsafe (37 percent), or neither safe nor unsafe (31 percent). Despite the mixed feelings, a 68 percent think living with obesity is still riskier than having weight-loss surgery.

  • Using self-reported height and weight to calculate body mass index, the ASMBS/NORC Obesity Poll assessed a person’s perceptions of their own weight status, and 57 percent of obese respondents underestimated where they were. Almost half (47 percent) said they were overweight or about the right weight (10 percent). Men were more likely to underestimate their weight than women (66 percent vs 50 percent).

“Obesity in America is a constant struggle for many adults, one filled with worry, denial, conflicted thinking and significant health concerns,” said Trevor Tompson, Vice President at NORC at the University of Chicago. “The survey shows there’s a significant need for education so that Americans can better match the health risks and impact of obesity on their lives with the actions they take and the treatments they choose.”

Part of the issue may be that the public thinks about obesity differently than the medical community. While health professionals have generally reached consensus that obesity is a disease (the American Medical Association and other medical groups declared it so in 2013), little more than one-third (38 percent) of Americans agree, with most considering it simply a risk factor for other diseases. Additionally, health experts say obesity is caused by a combination of genetic, environmental, and social factors, yet many Americans (48 percent) believe it is caused primarily by a person’s lifestyle choices and that the biggest barrier to weight loss is a lack of willpower (75 percent).

Guidelines Call for Metabolic Surgery as Treatment for Diabetes

For the first time, metabolic surgery is included as a standard treatment option in clinical practice guidelines for people with diabetes, even for those who have mild obesity. The evidence-based guidelines were published in the June 2016 issue of Diabetes Care, and carry the endorsement of 45 international professional organizations including the American Diabetes Association (ADA), the International Diabetes Federation (IDF), and the American Society for Metabolic and Bariatric Surgery (ASMBS).

The guidelines emerged from the 2nd Diabetes Surgery Summit (DSS-II), an international consensus conference held last last fall in London and jointly organized with the ADA, IDF, Diabetes UK (DUK), Chinese Diabetes Society (CDS), and Diabetes India (DI). According to the authors, “the report from DSS-II in Diabetes Care reflects the most comprehensive and rigorous assessment of the available evidence on the subject to date, provides a thorough analysis of current knowledge gaps in the field, and identifies priorities for research designed to further refine the role of surgery in the diabetes management algorithm.”

Dr. David Cummings, an endocrinologist at the University of Washington and senior author of the guidelines told the Associated Press, “We do not claim that surgery should be the first-line therapy,” but as standard care often isn’t enough, “it’s time for something new.”

According to the new guidelines, metabolic surgery should be recommended to treat type 2 diabetes in patients with Class III obesity (BMI greater than or equal to 40), as well as in those with Class II obesity (BMI between 35 and 39.9) if hyperglycemia is
inadequately controlled.

The new guidelines and recommendations are based on a large body of evidence including 11 randomized clinical trials showing that in most cases, surgery can either reduce blood sugar levels below diabetic thresholds (“diabetes remission”) or maintain adequate glycemic control despite major reduction in medication usage. The guidelines state that while relapse of hyperglycemia may occur in up to 50 percent of patients with initial remission, most patients maintain substantial improvement of A1c over the long term.

Dr. Samer Mattar commented, “This global statement represents a major advancement in the recognition of the efficacy, safety and durability of bariatric surgery in both the treatment and prevention of this disease.”

Karen Flanders, the new president of Integrated Health for the ASMBS added, “The consensus statement demonstrates the importance to re-examine and revise the NIH Consensus Statement from 1991 regarding the criteria for metabolic and bariatric surgery.”

Third Annual National Obesity Collaborative Care Summit

The ASMBS convened its “Third Annual National Obesity Collaborative Care Summit” bringing together more than 30 leading healthcare groups including The National Lipid Association, American Academy of Orthopedic Surgeons and American Society of Clinical Oncology. The group discussed the continuum of care for patients with obesity and began the process of developing a consensus statement for best practices in obesity care, which should appear some time in 2017.

ObesityWeek 2016: Three Times a Charm

ObesityWeek 2016 in The Big Easy was a major success with over 5,000 attending the conference, now in its third year. Major studies, a national survey and courses covered the spectrum of obesity treatment. Studies getting media coverage included those about reducing readmissions after bariatric surgery through a quality initiative, gender differences after bariatric surgery when it comes to heart disease and new and positive long-term mortality data around gastric bypass.

In addition, the exhibit hall featured more than 265 booths showcasing the latest products, services and technologies in obesity. Keynote speakers included Sadf Farooqi, PhD from the University of Cambridge and Kelley Brownell, PhD, Dean of the Sanford School of Public Policy at Duke University.

New App Gives the “Essentials” of Metabolic/Bariatric Surgery

Everything a healthcare professional needs to know about the fundamentals of bariatric and metabolic surgery became available for the first time in 2016, via a free app, developed by the ASMBS Essentials of Bariatric & Metabolic Surgery Taskforce.

The Essentials App covers the entire continuum of care for the bariatric surgery patient before, during and after surgery. It provides the option for CME and CEU credits (for a nominal fee) for general surgeons, anesthesiologists, nurses, emergency physicians and primary care physicians.

“The idea is to make it easy and free for everyone to learn the fundamentals of bariatric and metabolic surgery and gets everybody on the same page,” said Daniel B. Jones, MD, Chair, ASMBS Essentials of Bariatric & Metabolic Surgery Task Force. “We introduce best practices and the importance of the multidisciplinary team, informed consent and
good communication.”

Through compelling visuals and audio, optimized digital layouts and easy-to read language, the Essentials App shows how to recognize common surgical complications early, provides the latest information and data about surgical methods including sleeve gastrectomy and intragastric balloons, and outlines risk management strategies.

The Essentials App is also a comprehensive resource for MBSAQIP credentialing, personnel, and facilities, top articles from SOARD, ASMBS Guidelines, case studies, best practice recommendations, and diet recommendations.

The Essentials App is available via iTunes and the ASMBS website. The ASMBS Essentials of Bariatric & Metabolic Surgery Task Force will update the app throughout the year based on feedback and changes from users or new data or guidelines about metabolic and
bariatric surgery.