Pornthep Prathanvanich, MD, Katherine Bohnstedt, APN, P Marco Fisichella, MD, Sharfi Sarker, MD, Bipan Chand, MD. Loyola University Chicago Stritch School of Medicine.
Introduction
Morbidly obese patients seeking surgical weight loss therapy are often required to meet arbitrary months of dietary counseling prior to surgical intervention. Often there is a discrepancy between the amount of insurance required preoperative visits and the amount of visits based on clinical needs. We sought to analyze these differences and their effects on outcomes.
Methods
All individuals seeking obesity treatment undergo education on obesity risks, treatment options as well as thorough medical, psychological and nutritional validated screening questionnaires prior to individual multi-disciplinary visits. Patients are considered high or low risk for intervention based on face-to-face interaction evaluating for presence of eating disorders, significant life-threatening illnesses, super obesity, and revisional bariatric surgery. Payors also require an arbitrary number of preoperative visits with varying duration times prior to surgical intervention. Analyzed are insurance requirements, time in a clinical pathway, demographics, and outcomes of low and high risk patients undergoing bariatric surgery.
Results
In this IRB approved registry, 90 individuals met criteria for analysis. Based on insurance policies, 66 patients required no insurance mandated nutritional visits and 24 patients required 3 – 6 months of preoperative nutritional (Table1).
Then patients were divided in to four groups for further analysis. Group 1 had no insurance mandated preoperative time constraints and was considered low risk. Group 2 had 3-6 months of insurance mandated visits with low risk. Group 3 had no insurance mandated preoperative time constraints yet was considered high. Group 4 required 3-6 months of mandatory preoperative visits and was considered high risk. The primary outcome was change of BMI at various perioperative time points.
There were no demographic or anthropometric measurement differences between the four groups and type of surgery. Group4, despite having an increased time in the program, had an overall significant increase of BMI (1.21±1.25) prior to surgery (p= 0.02 with Group1 and p=0.008 with Group2). The other groups had a modest decrease in BMI that was not significantly different. Body mass index at initial visit, after insurance mandated time and post-operatively are shown without statistical difference.
Conclusion
Arbitrary insurance mandated preoperative visits did not influence perioperative changes in body mass index. Clinical pathways better predict the need for individualized medical and psychological optimization prior to surgical intervention. This imbalance of mandated healthcare service should be re-evaluated in today’s medical environment.
| Insurance requirement | P value | Clinical pathway | P value | |||
| 0 month | 3-6 months | Low risk | High risk | |||
| ( N = 66 ) | ( N = 24 ) | ( N = 58 ) | ( N = 32 ) | |||
| LRYGB/LSG/LAGB | 25/11/30 | 6/7/11 | 0.329 | 20/12/26 | 11/6/15 | 0.971 |
| Time before suragery (Days) | 136.21±98.12 | 180.42±109.11 | 0.070 | 140±82 | 163±131.99 | 0.315 |
|
Starting BMI (kg/m2) |
45.89±8.58 | 48.54±8.83 | 0.203 | 46.27±7.32 | 47.18±10.82 | 0.636 |
| BMI at time of surgery | 44.83±7.72 | 47.68±8.49 | 0.135 | 44.88±6.41 | 46.88±10.23 | 0.259 |
| Decrease in BMI before surgery | 1.05±2.61 | 0.85±2.99 | 0.755 | 1.38±2.98 | 0.30±1.95 | 0.069 |
| BMI at last FU | 37.27±7.67 | 40.38±8.88 | 0.107 | 37.42±7.01 | 39.34±9.72 | 0.283 |
| TimeFU(Days) | 270.30±109.13 | 257.25±104.68 | 0.613 | 253.38±101.49 | 291.19±115.36 | 0.111 |
| Decrease in BMI at last FU | 7.55±4.35 | 7.30±4.00 | 0.799 | 7.46±4.18 | 7.53±4.41 | 0.940 |
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