Behavioral and Psychological Factors in the Assessment and Treatment of Obesity Surgery Patients

Objective: To provide evidence‐based guidelines on the psychological and behavioral screening of weight loss surgery (WLS) candidates and the impact of psychosocial factors on behavior change after gastric bypass surgery. Research Methods and Procedures: The members of the Behavioral and Psychological subgroup of the Multidisciplinary Care Task Group conducted searches of MEDLINE and PubMed for articles related to WLS, behavior changes, and mental health, including quality of life (QOL) and behavior modification. Pertinent abstracts and literature were reviewed for references. A total of 198 abstracts were identified; 17 papers were reviewed in detail. Search periods were from 1980 to 2004. Results: We found a high incidence of depression, negative body image, eating disorders, and low QOL in severely obese patients. Our task subgroup recommended that all WLS candidates be evaluated by a licensed mental health care provider (i.e., psychiatrist, psychologist, or social worker), experienced in the treatment of severely obese patients and working within the context of a multidisciplinary care team. We also recommended development of pre‐ and postsurgical treatment plans that address psychosocial contraindications for WLS and potential barriers to postoperative success. Discussion: The psychological consequences of obesity can range from lowered self‐esteem to clinical depression. Rates of anxiety and depression are three to four times higher among obese individuals than among their leaner peers. A comprehensive multidisciplinary program that incorporates psychological and behavior change services can be of critical benefit in enhancing compliance, outcome, and QOL in WLS patients.     

Best Practices in Policy and Access (Coding and Reimbursement) for Weight Loss Surgery

To update evidence‐based best practice guidelines for coding and reimbursement and establish policy and access standards for weight loss surgery (WLS). Systematic search of English‐language literature on WLS and health‐care policy, access, insurance reimbursement, coding, private payers, public policy, and mandated benefits published between April 2004 and May 2007 in MEDLINE, EMBASE, and the Cochrane Library. Use of key words to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence‐based models. We identified 51 publications in our literature search; the 20 most relevant were examined in detail. These included reviews, cost‐benefit analyses, and trend and cost studies from administrative databases. Literature on policy issues surrounding WLS are very sparse and largely focused on economic analyses. Reports on policy initiatives in the public and private arenas are primarily limited to narrative reviews of nonsurgical efforts to fight obesity. A substantial body of work shows that WLS improves or reverses most obesity‐related comorbidities. Mounting evidence also indicates that WLS confers a significant survival advantage for those who undergo it. WLS is a viable and cost‐effective treatment for an increasingly common disease, and policy decisions are more frequently being linked to incentives for national health‐care goals. However, access to WLS often varies by payer and region. Currently, there are no uniform criteria for determining patient appropriateness for surgery.     

Best Practice Recommendations for Surgical Care in Weight Loss Surgery

Objective: To establish evidence‐based guidelines for best practices for surgical care in weight loss surgery (WLS). Research Methods and Procedures: We carried out a systematic search of English‐language literature on WLS in MEDLINE and the Cochrane Library. Key words were used to narrow the field for a selective review of abstracts. Data extraction was performed, and evidence categories were assigned according to a grading system based on established evidence‐based models. Results: We assessed types of WLS, recommended guidelines for appropriateness, developed strategies for medical error reduction, established criteria for credentialing of systems and practitioners, and specified research needed for the future. Discussion: Surgeon training, credentialing, and type of surgery performed were identified as key factors in patient safety. Other important issues in the delivery of best practice care included appropriate patient selection; use of a multidisciplinary treatment team; facility staffing, equipment, and administrative support; and early recognition and proper management of complications.     

Best Practice Guidelines in Pediatric/Adolescent Weight Loss Surgery

Objective: To establish evidence‐based guidelines for best practices in pediatric/adolescent weight loss surgery (WLS). Research Methods and Procedures: We carried out a systematic search of English‐language literature in MEDLINE on WLS performed on children and adolescents. Key words were used to narrow the field for a selective review of abstracts. Data were extracted, and evidence categories were assigned according to a grading system based on established evidence‐based models. Eight pertinent case series, published between 1980 and 2004, were identified and reviewed. These data were supplemented with expert opinions and literature on WLS in adults. Results: Recommendations focused on patient safety, reduction of medical errors, systems improvements, credentialing, and future research. We developed evidence‐based criteria for eligibility, assessment, treatment, and follow‐up; recommended surgical procedures based on the best available evidence; and established minimum guideline requirements for data collection. Discussion: Lack of adequate data and gaps in knowledge were cited as important reasons for caution. Physiological status, comprehensive screening of patients and their families, and required education and counseling were identified as key factors in assessing eligibility for surgery. Data collection and peer review were also identified as important issues in the delivery of best practice care.     

Population‐based Study of Trends,Costs, and Complications of Weight Loss Surgeries from 1990 to 2002

Objective: To describe the trends, costs, and complications associated with weight loss surgery (WLS). Research Methods and Procedures: Wisconsin inpatient hospital discharge data from 1990 to 2003 were used for analysis. A WLS case was defined as anyone with a WLS‐related procedure code and a primary diagnosis of morbid obesity. Charges were inflation‐adjusted to 2001 constant dollars; complications were defined on the basis of readmission, extended length of stay, repeat surgical procedures, or death. Results: The number of WLSs increased from 269 in 1990 to 1992 to 1884 in 2000 to 2002 (rate ratio = 4.6). Increases in WLSs were greatest among those 50 to 59 years of age (rate ratio = 6.4), women (rate ratio = 6.8), and blacks (rate ratio = 20.0). Between the two periods, inflation‐adjusted WLS charges increased 12‐fold, and the inflation‐adjusted charge per procedure doubled, despite a decreased length of stay. For 2000 to 2002, 23.3% of WLS patients had either an extended length of stay or readmission within 30 days, 7.4% required a repeat surgical procedure, and 0.7% died. Discussion: In Wisconsin, the rate and costs of WLSs have increased dramatically, and the incidence of postoperative complications was high. The epidemic of obesity in the United States makes it imperative to better assess the cost‐effectiveness of WLS and to improve its safety.     

Criteria for Patient Selection and Multidisciplinary Evaluation and Treatment of the Weight Loss Surgery Patient

Objective: To provide evidence‐based guidelines for patient selection and to recommend the medical and nutritional aspects of multidisciplinary care required to minimize perioperative and postoperative risks in patients with severe obesity who undergo weight loss surgery (WLS). Research Methods and Procedures: Members of the Multidisciplinary Care Task Group conducted searches of MEDLINE and PubMed for articles related to WLS in general and medical and nutritional care in particular. Pertinent abstracts and literature were reviewed for references. Multiple searches were carried out for various aspects of multidisciplinary care published between 1980 and 2004. A total of 3000 abstracts were identified; 242 were reviewed in detail. Results: We recommended multidisciplinary screening of WLS patients to ensure appropriate selection; preoperative assessment for cardiovascular, pulmonary, gastrointestinal, endocrine, and other obesity‐related diseases associated with increased risk for complications or mortality; preoperative weight loss and cessation of smoking; perioperative prophylaxis for deep vein thrombosis and pulmonary embolism (PE); preoperative and postoperative education and counseling by a registered dietitian; and a well‐defined postsurgical diet progression. Discussion: Obesity‐related diseases are often undiagnosed before WLS, putting patients at increased risk for complications and/or early mortality. Multidisciplinary assessment and care to minimize short‐ and long‐term risks include: comprehensive medical screening; appropriate pre‐, peri‐, and postoperative preparation; collaboration with multiple patient care disciplines (e.g., anesthesiology, pulmonary medicine, cardiology, and psychology); and long‐term nutrition education/counseling.     

Data Collection Systems for Weight Loss Surgery: An Evidence‐Based Assessment

Objective: To evaluate the existence and efficacy of data collection systems for weight loss surgery (WLS) and establish evidence‐based guidelines for the development of a statewide WLS registry in Massachusetts. Research Methods and Procedures: We conducted two systematic searches of English language literature in MEDLINE. The first was on data collection registries related to WLS; the second was an expanded search encompassing other surgical fields (e.g., cardiac and thoracic surgery) and registries (i.e., cancer). Fourteen articles were found to be pertinent. Data were extracted, and evidence categories were assigned according to a grading system based on established evidence‐based models. Recommendations were derived from these literature reviews and expert opinion. Results: This task group found that there are no standardized data collection systems for WLS in Massachusetts (or any other states) and no mandated reporting of WLS‐specific outcomes. We described existing WLS databases and systems in other surgical fields. Recommendations focused on the importance and feasibility of data collection for WLS and the need to conduct a pilot study and explore options for creating a statewide WLS database. Discussion: A statewide WLS data collection system would optimize patient care by enabling the collection, analysis, and dissemination of best practice data. A broad‐based effort is needed to meet challenges involved in defining and implementing such a system.     

Best Practice Guidelines on Informed Consent for Weight Loss Surgery Patients

Objective: To provide evidence‐based guidelines on informed consent and the education that underlies it for legally competent, severely obese weight loss surgery (WLS) patients. Research Methods and Procedures: We conducted a systematic review of the scientific literature published on MEDLINE between 1984 and 2004. Three articles focused on informed consent for WLS; none was based on empirical studies. We summarized each paper and assigned evidence categories according to a grading system derived from established evidence‐based models. We also relied on informed consent and educational materials from six WLS programs in Massachusetts. All evidence is Category D. Recommendations were based on a review of the available literature, informed consent materials from WLS programs, and expert opinion. Results: This Task Group found that the informed consent process contributes to long‐term outcome in multiple ways but is governed by limited legal requirements. We focused our report on the legal and ethical issues related to informed consent, i.e., disclosure vs. comprehension. Recommendations centered on the importance of assessing patient comprehension of informed consent materials, the content of those materials, and the use of active teaching/learning techniques to promote understanding. Discussion: Although demonstrated comprehension is not a legal requirement for informed consent in Massachusetts or other states, the members of this Task Group found that the best interests of WLS patients, providers, and facilities are served when clinicians engage patients in active learning and collaborative decision making.     

Effects of a reimbursement incentive on enrollment in a weight control program

Objective: The objective was to examine the effect of offering a reimbursement incentive on the percentage of inquirers who enrolled in a weight control program and on weight loss and program attendance among enrollees. Research Methods and Procedures: We used a sequential control‐intervention design to observe how inquirers of the University of Alabama at Birmingham EatRight Lifestyle Program responded to an enrollment incentive for potential 50% ($150) reimbursement of the total program fee if they attended 10 of 12 classes and lost at least 6% of their current body weight. Inquirers had to be adults with a BMI ≥30 kg/m², seeking information about a weight control program, and informed of the program cost. Outcomes included proportion of inquirers enrolled, overall number of classes attended, and weight loss. Results: Of the 401 people who inquired during the study periods, 24.5% and 25.0% enrolled in the intervention and control periods, respectively. There was a trend toward higher attendance in the intervention group, compared with the control group; there were no differences in percentage of weight loss. The odds of attending ≥10 classes were 2.4 times as high, and both losing >6% body weight and attending ≥10 classes were three times as high in the intervention subjects compared with controls, although non‐significant. Discussion: The potential of earning a performance‐based reimbursement incentive did not affect enrollment in the EatRight Lifestyle Program. Performance‐based incentives may be an ideal mechanism for extending coverage of weight‐loss interventions by insurers because of limited financial risk and improved adherence.     

基于老年人口卫生服务分析的医保效果评价

目的 通过对某省老年人口卫生服务需求、利用、就医流向及费用负担等卫生服务指标进行测算,了解现行医保制度的实施效果。方法 通过抽取某省第五次卫生服务调查的老年人群数据,对社会人口学特征、卫生服务需求与利用、医疗卫生费用负担及住院流向等指标进行测算与分析。结果 不同医保制度下,老年人口卫生服务需求与利用存在差异性,且在住院就医服务的选择上尚未形成合理格局,卫生费用负担较重。结论 某省现行医保制度对老年人口的经济保护力度仍有待提高,应调整医保制度卫生福利包的覆盖范围并提高补偿水平,通过政策倾斜构建合理就医格局,进而减轻老年人口的疾病经济负担。     

Ethnicity,Insurance Type,and Follow‐up in a Pediatric Weight Management Program

Objective: To assess the characteristics of children and adolescents who drop out of a clinical weight management program. Research Methods and Procedures: A retrospective survey of children and adolescents attending a pediatric weight management program [n = 518; mean ± SEM: age 10.4 ± 0.2 years, BMI z‐score 4.9 ± 0.1, 62% female, 41% African American and 57% white] was undertaken. Characteristics of children (age, relative weight, gender, and ethnicity) who dropped out of the program were compared with characteristics of those who continued beyond the initial assessment as a function of type of insurance. Results: The children who dropped out of the program after the initial assessment differed by ethnicity from those who continued in the program: 63% of white children returned for more than one visit, whereas only 35% of the African‐American children continued in the program. Indemnity insurance coverage was associated with more clinic visits, as compared with managed care insurance. The association between insurance type and clinic visit number was of borderline significance (p = 0.06), when ethnic group was added to this analysis. Discussion: Ethnicity is associated with attendance in a Pediatric Weight Management Program. Given the epidemic of obesity in children and adolescents, issues related to program compliance must be assessed to improve overall outcome. This is especially important given the high rate of obesity among African Americans and the low rate of ongoing attendance observed among African Americans in the Weight Management Program.     

Best Practice Recommendations for Anesthetic Perioperative Care and Pain Management in Weight Loss Surgery

Objective: To develop evidence‐based recommendations that optimize the safety and efficacy of perioperative anesthetic care and pain management in weight loss surgery (WLS) patients. Research Methods and Procedures: This Task Group examined the scientific literature on anesthetic perioperative care and pain management published in MEDLINE from January 1994 to March 2004. We also reviewed additional data from other sources (e.g., book chapters). The search yielded 195 abstracts, of which 35 references were reviewed in detail. Task Group consensus was used to provide recommendations when evidence in the literature was insufficient. Results: We developed anesthesia practice and patient safety advisory recommendations for preoperative evaluation, intraoperative management, and postoperative care and pain management of WLS patients. We also provided suggestions related to medical error reduction and systems improvements, credentialing, and future research. Discussion: Obesity‐related comorbidities including obstructive sleep apnea place WLS patients at increased risk for complications perioperatively. Regarding perioperative safety and outcomes, conclusive evidence beyond the accepted standard of care in the reviewed literature is limited. Few reports specifically address the perioperative needs of severely obese patients. In this advisory, we synthesize current knowledge and make best practice recommendations for perioperative care and pain management in WLS patients. These recommendations require periodic review as further medical knowledge and evidence evolve.     

The economics of clinical genetics services. II. A time analysis of a medical genetics clinic.

In a time-and-reimbursement analysis of our clinical genetics service, we documented (1) the time spent by professionals and staff in serving families before, during, and after the clinic visit; (2) the charges and reimbursement for the services provided; and (3) the relationship between income from clinical practice and the personnel costs of the clinic. We found that newly referred and returning families required 7.1 and 4.0 h, respectively. Average collections for professional services were +135 (+19/h) for new families and +49 (+12/h) for returning families. Income from clinical practice covered 37% of the clinical portion of personnel costs. These results indicate that cognitive clinical genetics services are labor intensive, yield low payments per service hour, and are not financially self-supporting. To improve the economic status of genetics clinics, administrators might consider rendering services more efficiently; increasing charges for services; billing for all services provided to all family members; billing for all genetics professionals, including counselors and social workers; and requesting payment at the time of service.     

Impact of Free Delivery Care on Health Facility Delivery and Insurance Coverage in Ghana’s Brong Ahafo Region

Background

Many sub-Saharan countries, including Ghana, have introduced policies to provide free medical care to pregnant women. The impact of these policies, particularly on access to health services among the poor, has not been evaluated using rigorous methods, and so the empirical basis for defending these policies is weak. In Ghana, a recent report also cast doubt on the current mechanism of delivering free care – the National Health Insurance Scheme. Longitudinal surveillance data from two randomized controlled trials conducted in the Brong Ahafo Region provided a unique opportunity to assess the impact of Ghana’s policies.

Methods

We used time-series methods to assess the impact of Ghana’s 2005 policy on free delivery care and its 2008 policy on free national health insurance for pregnant women. We estimated their impacts on facility delivery and insurance coverage, and on socioeconomic differentials in these outcomes after controlling for temporal trends and seasonality.

Results

Facility delivery has been increasing significantly over time. The 2005 and 2008 policies were associated with significant jumps in coverage of 2.3% (p = 0.015) and 7.5% (p<0.001), respectively after the policies were introduced. Health insurance coverage also jumped significantly (17.5%, p<0.001) after the 2008 policy. The increases in facility delivery and insurance were greatest among the poorest, leading to a decline in socioeconomic inequality in both outcomes.

Conclusion

Providing free care, particularly through free health insurance, has been effective in increasing facility delivery overall in the Brong Ahafo Region, and especially among the poor. This finding should be considered when evaluating the impact of the National Health Insurance Scheme and in supporting the continuation and expansion of free delivery care.     

The Australian joint inquiry into the Protection of Human Genetic Information

The Australian Law Reform Commission (ALRC) and the Australian Health Ethics Committee are currently engaged in an inquiry into the Protection of Human Genetic Information. In particular, the Attorney-General and the Minister for Health and Ageing have asked us to focus, in relation to human genetic information and tissue samples, on how best to ensure world's best practice in relation to: privacy protection; protection against unlawful discrimination; and the maintenance of high ethical standards in medical research and clinical practice. While initial concerns and controversies have related mainly to aspects of medical research (e.g. consent; re-use of samples) and access to private insurance coverage, relevant issues arise in a wide variety of contexts, including: employment; medical practice; tissue banks and genetic databases; health administration; superannuation; access to government services (e.g. schools, nursing homes); law enforcement; and use by government authorities (e.g. for immigration purposes) or other bodies (e.g. by sports associations). Under the Australian federal system, it is also the case that laws and practices may vary across states and territories. For example, neonatal genetic testing is standard, but storage and retention policies for the resulting 'Guthrie cards' differ markedly. Similarly, some states have developed highly linked health information systems (e.g. incorporating hospitals, doctors' offices and public records), while others discourage such linkages owing to concerns about privacy. The challenge for Australia is to develop policies, standards and practices that promote the intelligent use of genetic information, while providing a level of security with which the community feels comfortable. The inquiry is presently reviewing the adequacy of existing laws and regulatory mechanisms, but recognizes that it will be even more important to develop a broad mix of strategies, such as community and professional education, and the development of official standards and industry codes that reflect emerging international best practice in the area.     

National Health Insurance Development in China from 2004 to 2011: Coverage versus Benefits

BackgroundThe simultaneous improvement of the security capability of China Health Insurance System and its development in the last decade remains uncertain. This study measures the status and trends of reimbursement levels of the China Health Insurance System, as well as to offer policy advice to subsequent insurance reforms.MethodsThe National Reimbursement Ratio was created to determine the reimbursement level of the national health insurance system based on total health expenditure and the covered population. Chinese total health expenditure data from 2004 to 2011 were extracted from China’s Health Statistics according to the standards of the International Classification for Health Accounts by Healthcare Financing.ResultsIn 2011, the medical expenditure per capita in China was USD 130.95 and the National Reimbursement Ratio was 26.39%. The National Reimbursement Ratio showed an intense transition from 2004 to 2011, with a sharp decrease from 98.51% in 2004 to 22.44% in 2009, and then a small increase to 26.39% in 2011.ConclusionThe National Reimbursement Ratio was effective in revealing the reimbursement level of the national health insurance system and in predicting its trends. The challenge to China’s healthcare reform is to switch from increasing insurance coverage to guaranteeing a steady increase in government input and building a powerful supervision mechanism.     

Weight Loss Surgery Eligibility According to Various BMI Criteria Among Adolescents

A BMI cutoff point at the 99th percentile for age and gender or at 40 kg/m² has been suggested for more aggressive treatment of adolescent obesity. The main objective of this study was to determine the proportion of adolescents eligible for weight loss surgery (WLS) based on various BMI cutoff points. Data was extracted from the electronic medical record database of an urban pediatric ambulatory care center over 4 years. National data were used to calculate BMI percentiles (Centers for Disease Control and Prevention (CDC), 2000). Eligibility for WLS was based on a BMI percentile criterion (≥99th percentile) or the adult WLS cutoff point (≥40 kg/m²). The sample consisted of 3,220 adolescents aged 12–17.9 years, of which 53% were female, 55% were of black race, and 17% of Hispanic ethnicity. Overall, 88 (3%) adolescents had a BMI ≥40 kg/m² and 236 (7%) had a BMI ≥99th percentile (P < 0.001). All adolescents with BMI ≥40 kg/m² had a BMI ≥99th percentile. A total of 159/2,007 (8%) of 12–14.9‐year olds had a BMI ≥99th percentile compared with 77/1,213 (6%) 15–17.9‐year olds (P = 0.10), whereas 43/2,007 (2%) of 12–14.9‐year olds had a BMI ≥40 kg/m² compared with 45/1,213 (4%) 15–17.9‐year olds (P = 0.003). In summary, a relatively large proportion of adolescents from a diverse urban population would qualify for WLS based on the percentile criterion. Fewer adolescents would be eligible based on the adult WLS criterion, and younger adolescents would be less likely to be eligible for WLS than older adolescents.     

Need, Enabling, Predisposing, and Behavioral Determinants of Access to Preventative Care in Argentina: Analysis of the National Survey of Risk Factors

Introduction

Health care utilization is an important step to disease management, providing opportunities for prevention and treatment. Anderson’s Health Behavior Model has defined utilization by need, predisposing, and enabling determinants. We hypothesize that need, predisposing, and enabling, highlighting behavioral factors are associated with utilization in Argentina.

Methods

We performed a logistic regression analysis of the 2005 and 2009 Argentinean Survey of Risk Factors, a cohort of 41,392 and 34,732 individuals, to explore the association between need, enabling, predisposing, and behavioral factors to blood pressure measurement in the last year.

Results

In the 2005 cohort, blood pressure measurement was associated with perception of health, insurance coverage, basic needs met, and income. Additionally, female sex, civil state, household type, older age groups, education, and alcohol use were associated with utilization. The 2009 cohort showed similar associations with only minor differences between the models.

Conclusions

We explored the association between utilization of clinical preventive services with need, enabling, predisposing, and behavioral factors. While predisposing and need determinants are associated with utilization, enabling factors such as insurance coverage provides an area for public intervention. These are important findings where policies should be focused to improve utilization of preventive services in Argentina.     

Binge Eating and Eating‐Related Cognitions and Behavior in Ethnically Diverse Obese Women

Objective: To examine binge eating and eating‐related cognitions and behavior in a sample of ethnically diverse women who are severely obese and seeking bariatric surgery. Research Methods and Procedures: Female bariatric surgery candidates (62 African Americans, 18 Latinas, 130 whites) completed questionnaires on binge eating and eating‐related cognitions and behavior and completed a structured clinical interview to confirm binge‐eating disorder diagnosis. Results: Ethnic minorities and whites did not differ in rates of binge‐eating disorder (26.3%), binges per week (M = 0.95), or dietary restraint. Ethnic minorities reported less disinhibition, and there was a trend to report less hunger awareness than whites. After controlling for BMI and education, ethnicity accounted for significant variance in disinhibition (4%; p < 0.01). Ethnic minorities were younger, became overweight at a later age, and were overweight for fewer years than whites. Discussion: Results suggest that ethnicity exerts an important influence on disinhibition and that ethnic differences are not caused by BMI or education. Findings point to the need to continue to investigate the role of ethnicity, binge eating, and disinhibition in severely obese women, so that culturally appropriate services can be provided.