Medical Tourism: A Cost or Benefit to the NHS?

‘Medical Tourism’ – the phenomenon of people travelling abroad to access medical treatment - has received increasing attention in academic and popular media. This paper reports findings from a study examining effect of inbound and outbound medical tourism on the UK NHS, by estimating volume of medical tourism and associated costs and benefits. A mixed methods study it includes analysis of the UK International Passenger Survey (IPS); interviews with 77 returning UK medical tourists, 63 policymakers, NHS managers and medical tourism industry actors policymakers, and a review of published literature. These informed costing of three types of treatments for which patients commonly travel abroad: fertility treatment, cosmetic and bariatric surgery. Costing of inbound tourism relied on data obtained through 28 Freedom-of-Information requests to NHS Foundation Trusts. Findings demonstrate that contrary to some popular media reports, far from being a net importer of patients, the UK is now a clear net exporter of medical travellers. In 2010, an estimated 63,000 UK residents travelled for treatment, while around 52,000 patients sought treatment in the UK. Inbound medical tourists treated as private patients within NHS facilities may be especially profitable when compared to UK private patients, yielding close to a quarter of revenue from only 7% of volume in the data examined. Costs arise where patients travel abroad and return with complications. Analysis also indicates possible savings especially in future health care and social costs averted. These are likely to be specific to procedures and conditions treated. UK medical tourism is a growing phenomenon that presents risks and opportunities to the NHS. To fully understand its implications and guide policy on issues such as NHS global activities and patient safety will require investment in further research and monitoring. Results point to likely impact of medical tourism in other universal public health systems.     

Safety and efficacy in an accredited outpatient plastic surgery facility: a review of 5316 consecutive cases

Advances in medicine have improved the delivery of health care, making it more technologically superior than ever and, at the same time, more complex. Nowhere is this more evident than in the surgical arena. Plastic surgeons are able to perform procedures safely in office-based facilities that were once reserved only for hospital operating rooms or ambulatory surgery centers. Performing procedures in the office is a convenience to both the surgeon and the patient. Some groups have challenged that performing plastic surgery procedures in an office-based facility compromises patient safety. Our study was done to determine whether outcomes are adversely affected by performing plastic surgery procedures in an accredited outpatient surgical center. A retrospective review was performed on 5316 consecutive cases completed between 1995 and 2000 at Dallas Day Surgical Center, Dallas, Texas, an outpatient surgical facility. Most cases were cosmetic procedures. All cases were analyzed for any potential morbidity or mortality. Complications requiring a return to the operating room were determined, as were infection rates. Events leading to inpatient hospitalization were also included. During this 6-year period, 35 complications (0.7 percent) and no deaths were reported. Most complications were secondary to hematoma formation (77 percent). The postoperative infection rate for patients requiring a return to the operating room was 0.11 percent. Seven patients required inpatient hospitalization following their procedure secondary to arrhythmias, angina, and pulmonary emboli. Patient safety must take precedence over cost and convenience. Any monetary savings or time gained is quickly lost if safety is compromised and complications are incurred. The safety profile of the outpatient facility must meet and even exceed that of the traditional hospital-based or ambulatory care facility. After reviewing our experience over the last 6 years that indicated few complications and no deaths, we continue to support the judicious use of accredited outpatient surgical facilities by board-certified plastic surgeons in the management of plastic surgery patients.     

Bariatric Surgery Patients’ Views of Their Physicians’ Weight‐Related Attitudes and Practices

Objective: A prior study found that nearly 80% of bariatric surgery patients felt that they were treated disrespectfully by members of the medical profession. This study assessed patient‐physician interactions in a group of bariatric surgery patients and in a group of less obese patients who sought weight loss by other means. Research Methods and Procedures: A total of 105 bariatric surgery candidates (mean BMI, 54.8 kg/m²) and 214 applicants to a randomized controlled trial of the effects of behavior modification and sibutramine (mean BMI, 37.8 kg/m²) completed a questionnaire that assessed patient‐physician interactions concerning weight. Results: Only 13% of bariatric surgery patients reported that they were usually or always treated disrespectfully by members of the medical profession, a percentage substantially lower than that found in the previous study. Surprisingly, surgery patients were significantly more satisfied than nonsurgery patients with the care they received for their obesity. Surgery patients also reported significantly more interactions with physicians concerning obesity and weight loss compared with nonsurgery patients. A substantial percentage of both groups, however, reported that their physician did not discuss weight control with them. Discussion: These and other findings suggest that doctor‐patient interactions concerning weight may have improved in the past decade; however, there is still much room for improvement. Increased efforts are needed to help physicians discuss, assess, and potentially treat obesity in primary care practice.     

Effect of weight loss on predicted cardiovascular risk: change in cardiac risk after bariatric surgery

Objective: Our goal was to assess the effect of bariatric surgery on cardiovascular risk estimations of preventable, long‐term adverse outcomes. Research Methods and Procedures: We performed a population‐based, historical cohort study between 1990 and 2003 of 197 consecutive patients from Olmsted County, MN, with Class II to III obesity (defined as BMI ≥35 kg/m²) treated with Roux‐en‐Y gastric bypass and 163 non‐operative patients assessed in a weight‐reduction program. We used the observed change in cardiovascular risk factors and risk models derived from data from the National Health and Nutrition Examination Survey (NHANES) I and the NHANES I Epidemiological Follow‐up Study (NHEFS) to calculate the predicted impact on cardiovascular events and mortality for the operative and non‐operative groups. Results: Mean follow‐up was 3.3 years. Hypertension, diabetes, and dyslipidemia all improved after bariatric surgery. The estimated 10‐year risk for cardiovascular events for the operative group decreased from 37% at baseline to 18% at follow‐up, while the estimated risk for the non‐operative group did not change from 30% at baseline to 30% at follow‐up. Risk modeling to predict 10‐year outcomes estimated 4 overall deaths and 16 cardiovascular events prevented by bariatric surgery per 100 patients compared with the non‐operative group. Conclusions: Bariatric surgery induces an improvement in cardiovascular risk factors in patients with Class II to III obesity. Weight loss predicts a major, 10‐year reduction in cardiovascular events and deaths. Bariatric surgery should be considered as an alternative approach to reduce cardiovascular risk in patients with Class II to III obesity.     

Analysis of outpatient surgery center safety using an internet-based quality improvement and peer review program

Assessing the quality of care delivered in office-based outpatient surgery centers is difficult because formerly there was no central data collection system. The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), in its ongoing effort to assess and improve patient care, has developed an Internet-based quality improvement and peer review program to analyze outcomes for surgery centers it accredits. Reporting is mandatory for all surgeons operating in AAAASF-accredited facilities. Each surgeon must report all unanticipated sequelae and at least six random cases reviewed by an accepted peer review group biannually. A total of 411,670 procedures were analyzed during a 2-year period (from 2001 to 2002). There were 2597 sequelae reported during this period. The most common sequela was hematoma formation following breast augmentation. Infection occurred in 388 cases. Deep vein thrombosis, pulmonary embolism, and intraoperative cardiac arrhythmias were found to occur in a frequency consistent with previous reports. Significant complications (hematoma, hypertensive episode, wound infection, sepsis, and hypotension) were infrequent. A total of 1378 significant sequelae were reported for 411,670 procedures. This calculates to one unanticipated sequela in 299 procedures (an incidence of 0.33 percent). Seven deaths were reported. A death occurred in one in 58,810 procedures (0.0017 percent). The overall risk of death was comparable whether the procedure was performed in an AAAASF-accredited office surgery facility or a hospital surgery facility.This study documents an excellent safety record for surgical procedures performed in accredited office surgery facilities by board-certified surgeons.     

“Metabolic” Surgery For Treatment Of Type 2 Diabetes Mellitus

ObjectiveTo discuss the potential contribution of “metabolic” surgery in providing optimal management of patients with type 2 diabetes mellitus (T2DM).MethodsA literature search was performed with use of PubMed, and the clinical experience of the authors was also considered.ResultsBariatric—or, more appropriately, metabolic—surgical procedures have been shown to provide dramatic improvement in blood glucose levels, blood pressure, and lipid control in obese patients with T2DM. In these patients, metabolic surgery involves a low risk of short-term mortality and a significant long-term survival advantage, whereas the diagnosis of diabetes is associated with significant long-term mortality. Experimental studies in animals and clinical trials suggest that gastrointestinal bypass procedures can control diabetes and associated metabolic alterations by mechanisms independent of weight loss. As a result, the use of bariatric surgery and experimental gastrointestinal manipulations to treat T2DM is increasing, even among less obese patients. Although body mass index (BMI) currently is the most important factor for identifying candidates for bariatric surgery, evidence shows that a specific cutoff BMI value cannot accurately predict successful surgical outcomes. Furthermore, BMI appears limited in defining the risk profile for patients with T2DM.ConclusionCurrent BMI-based criteria for performance of bariatric surgery are not adequate for determining eligibility for operative treatment in patients with diabetes. Large clinical trials, comparing bariatric surgery versus optimal medical care of patients with T2DM, should be given priority in order to define the role of surgery in the management of diabetes. Recognizing the need to work as a multidisciplinary team that includes endocrinologists and surgeons is an initial step in addressing the issues and opportunities that surgery offers to diabetes care and research. (Endocr Pract. 2009;15:624-631)     

The Controversy Over Pediatric Bariatric Surgery

Despite the reported limited success of conventional treatments and growing evidence of the effectiveness of adult bariatric surgery, weight loss operations for (morbidly) obese children and adolescents are still considered to be controversial by health care professionals and lay people alike. This paper describes an explorative, qualitative study involving obesity specialists, morbidly obese adolescents, and parents and identifies attitudes and normative beliefs regarding pediatric bariatric surgery. Views on the etiology of obesity—whether it should be considered primarily a medical condition or more a psychosocial problem—seem to affect the specialists’ normative opinions concerning the acceptability of bariatric procedures as a treatment option, the parents’ feelings regarding both being able to influence their child’s health and their child being able to control their own condition, and the adolescents’ sense of competence and motivation for treatment. Moreover, parents and adolescents who saw obesity as something that they could influence themselves were more in favor of non-surgical treatment and vice versa. Conflicting attitudes and normative views—e.g., with regard to concepts of disease, personal influence on health, motivation, and the possibility of a careful informed consent procedure—play an important role in the acceptability of bariatric surgery for childhood obesity.     

Economic Impact of the Clinical Benefits of Bariatric Surgery in Diabetes Patients With BMI ≥35 kg/m2

The medical costs for a type 2 diabetes patient are two to four times greater than the costs for a patient without diabetes. Bariatric surgery is the most effective weight‐loss therapy and has marked therapeutic effects on diabetes. We estimate the economic effect of the clinical benefits of bariatric surgery for diabetes patients with BMI ≥35 kg/m². Using an administrative claims database of privately insured patients covering 8.5 million lives 1999–2007, we identify obese patients with diabetes, aged 18–65 years, who were treated with bariatric surgery identified using Healthcare Common Procedure Coding System codes. These patients were matched with nonsurgery control patients on demographic factors, comorbidities, and health‐care costs. The overall return on investment (RoI) associated with bariatric surgery was calculated using multivariate analysis. Surgery and control patients were compared postindex with respect to diagnostic claims for diabetes, diabetes medication claims, and adjusted diabetes medication and supply costs. Surgery costs were fully recovered after 26 months for laparoscopic surgery. At month 6, 28% of surgery patients had a diabetes diagnosis, compared to 74% of control patients (P < 0.001). Among preindex insulin users, insulin use dropped to 43% by month 3 for surgery patients, vs. 84% for controls (P < 0.001). By month 1, medication and supply costs were significantly lower for surgery patients (P < 0.001). The therapeutic benefits of bariatric surgery on diabetes translate into considerable economic benefits. These data suggest that surgical therapy is clinically more effective and ultimately less expensive than standard therapy for diabetes patients with BMI ≥35 kg/m².     

Bariatric surgery for patients with type 2 diabetes mellitus requiring insulin: Clinical outcome and cost-effectiveness analyses

BackgroundAlthough bariatric surgery is well established as an effective treatment for patients with obesity and type 2 diabetes mellitus (T2DM), there exists reluctance to increase its availability for patients with severe T2DM. The aims of this study were to examine the impact of bariatric surgery on T2DM resolution in patients with obesity and T2DM requiring insulin (T2DM-Ins) using data from a national database and to develop a health economic model to evaluate the cost-effectiveness of surgery in this cohort when compared to best medical treatment (BMT).Methods and findingsClinical data from the National Bariatric Surgical Registry (NBSR), a comprehensive database of bariatric surgery in the United Kingdom, were extracted to analyse outcomes of patients with obesity and T2DM-Ins who underwent primary bariatric surgery between 2009 and 2017. Outcomes for this group were combined with data sourced from a comprehensive literature review in order to develop a state-transition microsimulation model to evaluate cost-effectiveness of bariatric surgery versus BMT for patients over a 5-year time horizon. The main outcome measure for the clinical study was insulin cessation at 1-year post-surgery: relative risks (RR) summarising predictive factors were determined, unadjusted, and after adjusting for variables including age, initial body mass index (BMI), duration of T2DM, and weight loss. Main outcome measures for the economic evaluation were total costs, total quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) at willingness-to-pay threshold of GBP£20,000.A total of 2,484 patients were eligible for inclusion, of which 1,847 had 1-year follow-up data (mean age of 51 years, mean initial BMI 47.2 kg/m², and 64% female). 67% of patients no longer required insulin at 1-year postoperatively: these rates persisted for 4 years. Roux-en-Y gastric bypass (RYGB) was associated with a higher rate of insulin cessation (71.7%) than sleeve gastrectomy (SG; 64.5%; RR 0.92, confidence interval (CI) 0.86–0.99) and adjustable gastric band (AGB; 33.6%; RR 0.45, CI 0.34–0.60; p < 0.001). When adjusted for percentage total weight loss and demographic variables, insulin cessation following surgery was comparable for RYGB and SG (RR 0.97, CI 0.90–1.04), with AGB having the lowest cessation rates (RR 0.55, CI 0.40–0.74; p < 0.001). Over 5 years, bariatric surgery was cost saving compared to BMT (total cost GBP£22,057 versus GBP£26,286 respectively, incremental difference GBP£4,229). This was due to lower treatment costs as well as reduced diabetes-related complications costs and increased health benefits. Limitations of this study include loss to follow-up of patients within the NBSR dataset and that the time horizon for the economic analysis is limited to 5 years. In addition, the study reflects current medical and surgical treatment regimens for this cohort of patients, which may change.ConclusionsIn this study, we observed that in patients with obesity and T2DM-Ins, bariatric surgery was associated with high rates of postoperative cessation of insulin therapy, which is, in turn, a major driver of overall reductions in direct healthcare cost. Our findings suggest that a strategy utilising bariatric surgery for patients with obesity and T2DM-Ins is cost saving to the national healthcare provider (National Health Service (NHS)) over a 5-year time horizon.

Emma Rose McGlone and colleagues report the clinical and cost- effectiveness of bariatric surgery for patients with Type 2 diabetes.     

Bariatric Surgery and the Role of the Clinical Endocrinologist: 2011 Update

ObjectiveTo discuss the emerging roles of bariatric surgery and clinical endocrinology within the context of obesity and diabetes mellitus comprehensive care plans and cost-effective strategies.MethodsRelevant literature is reviewed and clinical cases are presented.ResultsThe global obesity epidemic poses many challenges to clinical endocrinologists and has fomented a coordinated effort among specialists to revolutionize management paradigms. Technologic innovation drives the need for accelerated learning and research efforts in bariatric surgery. The national shortage of physicians with expertise in nutritional medicine compounds the management problems for this expanding patient population. Certain issues merit continued attention and research, such as gastric banding for mild obesity, surgery for treatment of diabetes, sleeve gastrectomy, and nutritional and metabolic consequences.ConclusionClinical endocrinologists should have a central role in the perioperative decision-making for patients undergoing bariatric surgery. (Endocr Pract. 2011;17:788-797)     

Measuring outcomes in aesthetic surgery: a comprehensive review of the literature

Outcomes research examines the end results of medical interventions, taking into account patients' experiences, preferences, and values. The purpose of assessing outcomes is to provide evidence on which to base clinical decisions. The assessment of outcomes in aesthetic surgery is especially pertinent because patient satisfaction is the predominant factor in determining success. In cosmetic surgery, various scales have been used to assess outcomes. Unfortunately, none of these methods has achieved widespread use. The adoption of broadly accepted, relevant scales to measure outcomes would be advantageous, because this would allow the comparison of techniques, quantification of positive effects, and identification of patients unlikely to benefit from surgery. The purpose of this study was to critically review the present literature to identify the appropriate instruments to assess outcomes in aesthetic surgery. After a comprehensive review of aesthetic surgery outcome instruments, the authors identified body-image and quality-of-life measures to be of the greatest value in determining aesthetic surgery outcomes. These conclusions were based on a critical evaluation of the feasibility, validity, reliability, and sensitivity to change of these measures. The Multidimensional Body-States Relations Questionnaire (MBSRQ), a psychological assessment of body image, was selected as a potential candidate for further study. Two additional body-image assessment instruments, the Facial Appearance Sorting Test (FAST) and the Breast Chest Ratings Scale (BCRS), may be useful in the assessment of rhinoplasty and breast surgery, respectively. The Derriford Scale (DAS59), an instrument that assesses appearance-related quality of life, was also selected. In addition, the authors recommend the use of a generic, utility-based quality-of-life instrument, such as the Health Utilities Index (HUI) or the EuroQol (EQ-5D).     

Establishing a multidisciplinary academic cosmetic center

The demand for cosmetic services has risen rapidly in recent years, but has slowed down with the current economic downturn. Managed care organizations and Medicare have been steadily reducing their reimbursements for physician services. The payment for reconstructive surgical procedures has been decreasing and is likely to worsen with healthcare reform, and many plastic surgery residency programs are facing fiscal challenges. An adequate volume of patients needing cosmetic services is necessary to recruit and train the best candidates to the residency programs. Self-pay patients will help ensure the fiscal viability of plastic surgery residency programs. Attracting patients to an academic healthcare center will become more difficult in a recession without the appropriate facilities, programs, and pricing strategies. Setting up a modern cosmetic services program at an academic center has some unique challenges, including funding, academic politics, and turf. The authors opened a free-standing academic multidisciplinary center at their medical school 3 years ago. The center is an off-site, 13,000-sq ft facility that includes faculty from plastic surgery, ear, nose, and throat, dermatology, and vascular surgery. In this article, the authors discuss the process of developing and executing a plan for starting an aesthetic services center in an academic setting. The financing of the center and factors in pricing services are discussed. The authors show the impact of the center on their cosmetic surgery patient volumes, resident education, and finances. They expect that their experience will be helpful to other plastic surgery programs at academic medical centers.     

Preoperative lifestyle intervention in bariatric surgery: Initial results from a randomized,controlled trial

Objective:

To document preoperative outcomes of a behavioral lifestyle intervention delivered to patients prior to bariatric surgery in comparison to treatment as usual (insurance‐mandated physician supervised diet).

Design and Methods:

After completing a baseline assessment, candidates for surgery were randomized to a 6‐month, evidence‐informed, manualized lifestyle intervention (LIFESTYLE, n = 121) or to preoperative care as usual (USUAL CARE, n = 119). At 6 months, 187 participants remained candidates for bariatric surgery and were included in the analyses.

Results:

LIFESTYLE participants lost significantly more weight than those receiving USUAL CARE [8.3 ± 7.8 kg vs. 3.3 ± 5.5 kg, F(1,183) = 23.6, P < 0.0001], with an effect size of 0.72. Additionally, logistic regression modeling indicated that LIFESTYLE patients were significantly more likely to lose at least 5% of initial body weight than those in USUAL CARE [OR (95% CI) = 2.94 (1.253, 6.903)], as were participants who were heavier [OR (95% CI) = 1.07 (1.001‐1.14) for each unit increase in BMI] or with larger improvements in eating behaviors [OR (95% CI) = 1.1 (1.049, 1.145) for each unit increase on the Eating Behavior Inventory).

Conclusions:

A behavioral lifestyle intervention for severely overweight individuals leads to clinically significant weight loss prior to bariatric surgery. Post‐surgery follow‐up will allow us to examine the impact of the preoperative intervention on postoperative outcomes.     

Metabolic surgery: Quo Vadis?

The impact of bariatric surgery beyond its effect on weight loss has entailed a change in the way of regarding it. The term metabolic surgery has become more popular to designate those interventions that aim at resolving diseases that have been traditionally considered as of exclusive medical management, such as type 2 diabetes mellitus (T2D). Recommendations for metabolic surgery have been largely addressed and discussed in worldwide meetings, but no definitive consensus has been reached yet. Rates of diabetes remission after metabolic surgery have been one of the most debated hot topics, with heterogeneity being a current concern. This review aims to identify and clarify controversies regarding metabolic surgery, by focusing on a critical analysis of T2D remission rates achieved with different bariatric procedures, and using different criteria for its definition. Indications for metabolic surgery for patients with T2D who are not morbidly obese are also discussed.     

A review of psychosocial outcomes for patients seeking cosmetic surgery

The authors reviewed the literature on psychological and psychosocial outcomes for individuals undergoing cosmetic surgery, to address whether elective cosmetic procedures improve psychological well-being and psychosocial functioning and whether there are identifiable predictors of an unsatisfactory psychological outcome. They conducted a search of appropriate computerized databases for studies that evaluated psychological and psychosocial status both before and after elective cosmetic surgery. They identified 37 relevant studies of varying cosmetic procedures that utilized disparate methodologies. Overall, patients appeared generally satisfied with the outcome of their procedures, although some exhibited transient and some exhibited longer-lasting psychological disturbance. Factors associated with poor psychosocial outcome included being young, being male, having unrealistic expectations of the procedure, previous unsatisfactory cosmetic surgery, minimal deformity, motivation based on relationship issues, and a history of depression, anxiety, or personality disorder. Body dysmorphic disorder was also recognized by some studies as a predictor of poor outcome, a finding reinforced by reference to the psychiatric literature. The authors conclude that although most people appear satisfied with the outcome of cosmetic surgical procedures, some are not, and attempts should be made to screen for such individuals in cosmetic surgery settings.     

Appropriateness Criteria for Bariatric Surgery: Beyond the NIH Guidelines

Careful selection of bariatric patients is critical for successful outcomes. In 1991, the NIH first established patient selection guidelines; however, some surgeons operate on individuals outside of these criteria, i.e., extreme age groups. We developed appropriateness criteria for the spectrum of patient characteristics including age, BMI, and severity of eight obesity‐related comorbidities. Candidate criteria were developed using combinations of patient characteristics including BMI: ≥40 kg/m², 35–39, 32–34, 30–31, <30; age: 12–18, 19–55, 56–64, 65+ years old; and comorbidities: prediabetes, diabetes, hypertension, dyslipidemia, sleep apnea, venous stasis disease, chronic joint pain, and gastroesophageal reflux (plus severity level). Criteria were formally validated on their appropriateness of whether the benefits of surgery clearly outweighed the risks, by an expert panel using the RAND/UCLA modified Delphi method. Nearly all comorbidity severity criteria for patients with BMI ≥40 kg/m² or BMI = 35–39 kg/m² in intermediate age groups were found to be appropriate for surgery. In contrast, patients in the extreme age categories were considered appropriate surgical candidates under fewer conditions, primarily the more severe comorbidities, such as diabetes and hypertension. For patients with a BMI of 32–34, only the most severe category of diabetes (Hgb A1c >9, on maximal medical therapy), is an appropriate criterion for those aged 19–64, whereas many mild to moderate severity comorbidity categories are “inappropriate.” There is overwhelming agreement among the panelists that the current evidence does not support performing bariatric surgery in lower BMI individuals (BMI <32). This is the first development of appropriateness criteria for bariatric surgery that includes severity categories of comorbidities. Only for the most severe degrees of comorbidities were adolescent and elderly patients deemed appropriate for surgery. Patient selection for bariatric procedures should include consideration of both patient age and comorbidity severity.     

Metabolic surgery for type 2 diabetes mellitus

Background: Metabolic surgery for morbid obesity induces significant weight loss and resolution of many obesity-related comorbidities, the most notable of which is remission of type 2 diabetes mellitus (DM). Such changes seem to precede significant weight loss in this population shortly after undergoing diversionary procedures.Objective: This article explores the evidence for salutary metabolic benefits of bariatric surgery, with special emphasis on glycemic control and remission of type 2 DM.Methods: We conducted a query of the PubMed database for articles published in English within the past 15 years using the search terms bariatric surgery, obesity, type 2 diabetes, gastric bypass, gastric banding, incretins, enteroinsular axis, GLP-1 (glucagon-like peptide-1), and GIP (glucose-dependent insulinotropic polypeptide). We targeted review articles as well as those discussing the effects of bariatric surgery on the enteroinsular axis and the respective effects on glyce-mic control.Results: Most of the clinical reports indicated a high remission rate (≥85%) for type 2 DM, and relatively higher rates in patients who underwent diversionary procedures. Studies with small cohorts and laboratory data suggested a role for gastrointestinal hormones in the regulation of glucose homeostasis after bariatric surgery.Conclusions: Gastrointestinal surgery for severe obesity, through restrictive and/or neurohormonal effects, is an effective treatment for type 2 DM. Surgically induced weight loss was found to be sustainable, durable, and associated with remission of type 2 DM, a reduction in mortality, and improvement in quality of life.     

Randomized trial of a video-based patient decision aid for bariatric surgery

The decision to have bariatric surgery should be based on accurate information on possible risks and benefits of all treatment options. The goal of this study was to determine whether a video-based bariatric decision aid intervention results in superior decision quality compared to an educational booklet. We conducted a prospective, randomized controlled trial among adult patients in a single health plan who met standard criteria for bariatric surgery. Patients were randomly assigned to review either a video-based decision aid (intervention) or an educational booklet on bariatric surgery (control). Changes in patient decision quality were assessed using bariatric-specific measures of knowledge, values, and treatment preference after 3 months. Of 152 eligible participants, 75 were randomly assigned to the intervention and 77 to the control. The 3-month follow-up rate was 95%. Among all participants, significant improvements were observed in knowledge (P < 0.001), values concordance (P = 0.009), decisional conflict (P < 0.001), decisional self-efficacy (P < 0.001), and in the proportion who were "unsure" of their treatment choice (P < 0.001). The intervention group had larger improvements in knowledge (P = 0.03), decisional conflict (P = 0.03), and outcome expectancies (P = 0.001). The proportion of participants choosing bariatric surgery did not differ significantly between groups, although there was a trend toward decreased surgical choice in the intervention group (59% booklet vs. 42% video at 3 months; P = 0.16). The use of bariatric surgery decision aids was followed by improved decision quality and reduced uncertainty about treatment at 3 months. The video-based decision aid appeared to have a greater impact than the educational booklet on patient knowledge, decisional conflict, and outcome expectancies.