Dr. Maria S. Altier

Current criteria for bariatric / metabolic surgery guidelines need to be updated to include patients with a BMI of 30 to 35 kg / m.2: (Lesson 1 Obesity), says lead author of new research

Research has shown that “bariatric surgery is effective in eliminating weight loss and joint disease” in Class 1 obese patients who do not meet the current standards used by most insurers.

Altieri և and his colleagues found that 25% to 60% of patients with grade 1 obesity, type 2 diabetes, or hypertension or hypercholesterolemia had recurrence of these joint diseases three years after bariatric surgery.

“This further confirms the need to modernize current guidelines,” said Altieri, an associate professor of bariatric minimally invasive surgery at the University of Carolina, Greenville, North Carolina.

The study was presented at the June 21, 2021 annual meeting of the American Society of Metabolic Bariatric Surgery (ASMBS).

Bariatric surgery in patients with grade 1 obesity

Results of bariatric procedures – also called metabolic surgery – when this method of weight loss can lead to improved metabolic diseases such as type 2 diabetes. -30-34.9 kg / m in patients with BMI2:mainly below the guidelines used by insurers, reported mainly in small, single-center center studies.

Altieri և and his colleagues aimed to assess weight loss որոշ to determine the three main causes of obesity: type 2 diabetes, hypertension, and hypercholesterolemia, three years after bariatric surgery in obese patients, based on a large national database.

They found 566 patients և 720 patients with Roux-en-Y gastric shunt in 2007-2020.

The mean BMI of the patients was 33.5 kg / m2: և 82% were women. Most of the patients were over 46 years old և White.

Participants in both surgical groups had similar changes in BMI over time, losing up to 20% of their original BMI by age 3.

Those who were younger or a woman or had one of the three concomitant diseases associated with obesity had greater weight loss.

Two years after bariatric surgery, about 45% of patients with type 2 diabetes had remission that did not differ from the type of surgery.

At age 2, approximately 50% of those who underwent Roux-en-Y gastric bypass grafting underwent 25% of those with gastrectomy (25%).

And 3 years after surgery, initially in hypertensive patients, 60% of patients who underwent Roux-en-Y gastric bypass graft had 50% of patients with gastrectomy.

“The consequences, risks and benefits of bariatric surgery are the same for BMI 30-34.9 as for BMI> 35,” Altieri said.

Do insurance coverage guidelines need to be updated?

Most health insurers follow the 30-year guidelines developed by the National Institutes of Health (NIH) in 1991.

The old guidelines were given when bariatric surgery was an open procedure, but now it is mostly laparoscopic. State weight loss surgery should be considered for patients with a BMI> 40 kg / m>.2:or “in some cases” with a BMI of 35-40 kg / m2: լուրջ Serious weight-related joint disease.

Over the next few decades, as more data became available, 45 professional companies, including ASMBS and the American Diabetes Association, issued a joint statement in 2016 recommending, among other things, that bariatric surgery be performed as well. should be considered for patients. [type 2 diabetes] and BMI 30.0–34.9 kg / m2: if hyperglycemia is poorly controlled despite optimal treatment with oral or injectable medications. ”

Similarly, in the 2018 position announcement, ASMBS advised: “BMI for patients with 30-35 kg / m disease2: ությունները Concomitant diseases associated with obesity, which do not achieve significant, local weight loss և With reasonable non-surgical methods of comprehensive improvement, bariatric surgery should be offered as an option for the appropriate people.

“There are several insurance providers that now provide metabolic surgery for patients with a BMI of 30-35 kg / m.2: who have poor control of type 2 diabetes, ”said Dr. Stacey Bretauer, a bariatric surgeon at Columbus Ohio State University Wexner Medical Center. Medscape Medical News e-mail

“However, most US payers still do not cover the metabolic surgery of such patients,” he said, “despite overwhelming evidence that it changes the course of diabetes much more dramatically than medical therapy.”

Dr. Monique Hassan

Co-author of the session Monique Hassan, PhD, bariatric surgeon at Baylor Scott & White Health, Temple, Texas, said: Medscape Medical News Bariatric surgery insurance for patients with this low-grade obesity is very rare in Texas.

“Most of the patients [with type 1 obesity and comorbidities] “They are advised that if they want these procedures, they have to pay out of pocket,” Altieri said. is further growth. health disproportions. ”

“This is a huge problem,” Hassan said.

Ob emission is an epidemic: Don:t Use surgery as a last resort

“Ob is an epidemic,” Hassan said. “Just because a person has a BMI below 35, they may not be clinically healthy yet. With type 2 diabetes, hypertension and sleep apnea, they risk early death.”

“Moreover, most of the patients who really meet the eligibility criteria for bariatric surgery are not referred for it,” he said. “Send patients,” he urged doctors.

“The guidelines published by the ADA և ASMBS are actually quite clear on how to treat BMI 30-35 և patients with poorly controlled diabetes,” says Bretauer.

“The problem with the current paradigm,” he said, “is that surgery is the last resort for these patients.” However, the evidence is clear that the sooner you have diabetes surgery, the better your results. ” cancer or any chronic disease).

“Joint efforts with insurance companies, doctors and national companies will be required to make a change,” Altieri said.

According to Bretauer, “The new guideline should focus on proposing surgery to treat diabetes and metabolic diseases earlier. [disease] of course, so that the probability of a local pardon is higher. ”

In the meantime, bariatric surgeons “must continue to push payers for coverage.” [bariatric surgery]”Continue to defend our needs for patients in need of treatment,” he said.

State differences in bariatric surgery rates

Yet another study found that the rate of bariatric surgery, even among eligible patients, ranged from just 2% to 10% in different US states.

“The overall use of bariatric surgery remains low; there are significant variations,” said lead researcher Xunjun Kim, a resident of Rush University in Chicago, Illinois, at the ASMBS meeting.

Using the Commercial, Medicare, Medicaid, and other state insurance Mariner (PearlDiver) databases, as well as self-payment requirements, Kim and her colleagues identified 1,789,457 patients eligible for bariatric surgery in 2010-2019.

Of these, 99,173 eligible patients (5.5%) underwent gastrectomy or Roux-en-Y gastric bypass, while the remaining 1,690,284 eligible patients did not.

Compared to eligible patients who did not undergo bariatric surgery, those who did were younger (mean age 44 to 52 years) և women (79% vs. 66%) were more likely to have commercial insurance (81% vs. 70%) քում live in the Northeast (31% vs. 21%).

Bariatric surgery rates for eligible patients ranged from 2.1% in Vermont to 10.4% in New Jersey and 4.5% in the Midwest to 8.0% in the Northeast.

Less than 30% of surgeries in Alaska, North Dakota, Rhode Island, had a gastrectomy, while in New Jersey, NJada, Mississippi, more than 80% of the surgeries were a gastrectomy.

Barrier surgery was mainly covered by commercial insurance or Medicaid in the Northeast, and by Medicare in the South West.

“These state disparities in use ները the factors contributing to it need to be better understood և addressed to ensure equal access to bariatric surgery և to reduce the burden of obesity in America,” says Dr. Scott Schimpke, lead author of Invasive Bariatric Surgery at ASB. in a statement released during the survey.

The researchers did not provide any relevant financial information.

ASMBS 2021 Annual Meeting. Submitted on June 12, 2021.

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