March 1, 2005 | Health System Risk Management
As doctors and scientists investigate ways to treat overweight and obesity, one option—bariatric surgery—has increasingly become available for patients with severe obesity. Also known as weight-loss surgery and gastric-bypass surgery, bariatric surgery involves a variety of surgical approaches to restrict food intake and to treat extreme obesity* when other treatments, such as lifestyle changes, fail. _____________ * "Overweight" is defined as excess body weight and, according to the National Institutes of Health (NIH), is classified in individuals with a body mass index (BMI) of 25 to 29.9 kg/m. Obesity is categorized by NIH as a BMI of 30 kg/m. Under the NIH classification, a patient is considered extremely obese when his or her BMI is 40 kg/m (or >35 kg/m in the presence of comorbidities). This Guidance Article uses the parameters as defined by NIH when referring to the terms "overweight," "obese," and "extreme obesity." _____________ In the past decade, the number of bariatric procedures performed in this country has increased dramatically, from 16,000 in 1992 to 47,000 in 2001.1 By 2002, as many as 60,000 procedures were performed—a figure that nearly doubled to 103,000 by the end of 2003, according to estimates from the American Society for Bariatric Surgery (ASBS), an organization representing surgeons and other healthcare professionals in the field of bariatric surgery. Some experts predict that within 10 years, bariatric surgery will be the most common operation in general surgery.2
Partly driving the demand for bariatric surgery is the attention these procedures receive in the popular press. For example, separate cover stories in Peoplemagazine featured NBC television weatherman Al Roker from the Today show and how bariatric surgery "transformed his life," as well as pop singer Carnie Wilson, who lost 150 pounds after stomach surgery.3,4 Indeed, the demand for bariatric surgical procedures is increasing even among adolescents.
The publicity surrounding these famous patients and their successful surgeries can significantly influence popular interest in and demand for weight-loss surgery. At the same time, it can include misinformation, as complex, technical surgical procedures are translated for dissemination to the general public, often resulting in incorrect perceptions and unrealistic patient expectations.
Bariatric surgery is also increasingly winning support from groups such as the Agency for Healthcare Research and Quality (AHRQ), which concluded in a July 2004 report that bariatric surgery is an effective weight-reduction measure for extremely obese patients who have unsuccessfully attempted to lose weight through diet and exercise.5 AHRQ's report upheld bariatric surgery as a possibly lifesaving solution for these patients, noting that it can improve severe comorbidities such as heart disease, high blood pressure, and diabetes.
Not surprisingly, bariatric surgery centers are becoming more prevalent. Hospitals and health systems are opening inpatient and hospital-based ambulatory multidisciplinary bariatric centers to cater to the medical and surgical needs of overweight and obese patients. General surgeons are going through advanced training in order to become credentialed in the subspecialty of bariatric surgery. Most recently, bariatric surgery has moved out of the hospital to freestanding ambulatory surgical centers, where patients are kept at least one night postoperatively.6
Risk managers at facilities with bariatric surgery programs or at facilities evaluating whether to start a program must ensure that involved risks are considered, such as physician training and credentialing, patient selection criteria, patient education and informed consent, prevention of injuries to staff handling extremely obese patients, and the safety of this patient population from a facility and equipment perspective. All healthcare providers should be aware of the special needs of these patients and be prepared to meet those needs in a way that ensures high-quality and safe patient care in addition to compassion and respect. While this Guidance Article will focus on specific principles applicable to...