Obese patients ‘surgery ban’ in York, England and is the future?

14192739_961430727319920_9123964988708776032_nInteresting fact, there is a move that could see obese patients refused surgery in an attempt to save money is to be reviewed after Britain’s national NHS bosses intervened. This article (3 September 2016
From the section 
York & North Yorkshire) peaked my interest because it could and probably will happen here in the U.S.A. if and when the single payer system is finalized.

It is a known fact that cigarettes are highly addictive, but they are legally available without limitation to the public. Users do pay a tax for use but it does not come anywhere close to paying for their overall increased health care cost due to smoking. Obesity is rapidly increasing in this country- by 250% incidence over the past 20 years. While the causes of obesity are multifactorial, there is no doubt the singularly major factor is consumption of excess calories. The sources of these excess calories frequently are sugary foods and fast foods, yet there is no limit on what may be consumed nor is there any tax on these foods to help offset the increased costs associated with obesity. If there were a way to require those who engage in ill-advised health behaviors to pay for their impending increased utilization of the health care system, then this may be a viable alternative. To penalize those who have already developed these conditions by withholding care seems foolish and punitive unless there are outcome studies demonstrating specific procedures or interventions have a high failure rate in these patients. A proposed restriction by the NHS Vale of York Clinical Commissioning Group would have seen non-life threatening procedures delayed by a year for those with a body mass index exceeding 30.

The rule would also apply to smokers. NHS England, which can intervene as the CCG is under special measures, said the group had agreed to rethink the move.

Under the move, obese patients in the Vale of York area could have secured a referral in less than a year if they shed 10% of their weight.

Similarly, if smokers refused to quit they would face having procedures delayed for up to six months, which could be accelerated if they stopped smoking for eight weeks.

The CCG said the proposals, announced as part of a package of measures being considered to reduce costs, came at a time when the local system was under “severe pressure”.

The new rules would only apply to elective surgery for non-life threatening procedures, for example hip and knee operations.

‘No blanket bans’

But a spokesman for NHS England said: “Reducing obesity and cutting smoking not only benefits patients, but saves the NHS and taxpayers millions of pounds.

“This does not and cannot mean blanket bans on particular patients such as smokers getting operations, which would be inconsistent with the NHS constitution.”

Chris Hopson, the head of NHS Providers representing acute care, ambulance and community services, said he was worried about plans such as this being made.

NHS bosses now believed they had reached the point at which the health service was simply being asked to deliver too much for the funding that was available, he told BBC Radio 4’s Today programme.

He said rather than commissioning groups making “piecemeal decisions”, there should be a national debate about the future of the healthcare system.

Robert Pigott, BBC health correspondent analyzed this possibility looking at the financial impact.

When front-line health services revealed a deficit of £460m for the first three months of the financial year, hospital trusts said it was time for a national debate about what the NHS could now afford to do if it were to remain free.

Although it is now under review, the proposal by the Vale of York Clinical Commissioning Group to exclude obese people and smokers from non-emergency surgery has started that debate in earnest.

The CCG estimates obesity cost the NHS in the Vale of York £46m in 2015, but is it right to target obese people to bring costs down?

There is a clinical rationale. Obese patients suffer more complications during and after surgery than those of “normal” weight.

Despite this, some might see the decision as sending a signal of disapproval to those who are overweight.

The implication could be that being overweight is a personal lifestyle choice, adopted at the expense of the wider community.

Obesity has been linked with being poorer, and living in so-called “obesogenic” environments, where unhealthy, fattening, food is easier to get than more expensive, healthy, alternatives.

It is often hard to lose weight to which the body has adapted itself, and delaying operations on hips and knees might further limit the prospect of success.

The proposal could have benefited obese people as well as the health service if it succeeded in persuading them to lose weight.

Whatever the rights and wrongs of the Vale of York approach, it does, in effect, suggest a revised contract with patients – a new deal that requires people to take reasonable steps to preserve their own health, rather than expecting the NHS to pick up the pieces.

Shaw Somers, a bariatric surgeon based in Portsmouth, said it was a fairly logical step to save money, but was short-term and discriminatory.

“Obesity is an illness and for these people, they are not deliberately waking up each morning thinking ‘how do I stay fat?’,” he told the Today programme.

“They are trying to lose weight in the vast majority of cases and to deny them treatment that they need on the basis of their weight, without then offering them effective help to help them lose weight is rather like discriminating [against] a segment of the population on the basis of their colour or religious persuasion.”

Body Mass Index

  • Body mass index (BMI) is used to calculate whether a person is underweight, a healthy weight, overweight or obese for their height
  • It is calculated by dividing someone’s weight in kilograms by the square of their height in metres
  • Generally the higher your BMI, the greater your risk of a large range of medical problems
  • A BMI above 30 is medically classified as obese
  • Some doctors say it can be inaccurate if you’re an athlete or very muscular

The Royal College of Surgeons (RCS) described the proposed restrictions as “some of the most severe the modern NHS has ever seen”.

Clare Marx, RCS president, said: “Smokers and overweight patients should unquestionably be helped to stop smoking or lose weight prior to surgery for their overall health.

“We would support any attempts by Vale of York to expand its weight loss and smoking cessation programmes, but introducing blanket bans that delay patients’ access to what can be life-changing surgery for up to a year is wrong.”

A major study of the global obesity problem by Imperial College scientists found there were 6.8 million obese men in the UK in 2014, and 7.7 million obese women.

Former health minister Norman Lamb said: “This is just the latest in a growing list of local decisions to ration care – any rationing not based on clinical need is outrageous.”

A statement from the Vale of York Clinical Commissioning Group said: “NHS England has today asked us to review the draft approach, which we will now do, and will hold off implementing anything until we have an agreed way forward.

“We will ensure any plans are implemented in line with national guidance, are in the best interests of our patients and are clinically robust.”

It said the group wanted to support work to help people in the community to stop smoking and, where needed, lose weight.

Clinical Commissioning Groups were introduced in 2013 and became responsible for commissioning or buying local health and care services but are overseen by NHS England, a national body formed by the same parliamentary act.

A number of studies showed various conclusions such as The influence of body mass index on functional outcome and quality of life after total knee arthroplasty authored by J. Y. Chen, N. N. Lo, H. C. Chong, H. R. Bin Abd Razak, H. N. Pang, D. K. J. Tay, S. L. Chia, S. J. Yeo investigated the influence of body mass index (BMI) on the post-operative fall in the level of haemoglobin (Hb), length of hospital stay (LOS), 30-day re-admission rate, functional outcome and quality of life, two years after total knee arthroplasty (TKA) studying a total of 7733 patients who underwent unilateral primary TKA between 2001 and 2010 were included. The mean age was 67 years (30 to 90). There were 1421 males and 6312 females. The patients were categorised into three groups: BMI < 25.0 kg/m2 (normal); BMI between 25.0 and 39.9 kg/m2 (obese); and BMI ≥ 40.0 kg/m2 (morbidly obese).

They concluded that though morbidly obese patients have a longer LOS and higher 30-day re-admission rate after TKA, they have a smaller drop in post-operative Hb level and larger improvement in OKS and KSKS at two years follow-up. The ten-year rate of survival of TKA was also comparable with those with a normal BMI.

Take home message: Morbidly obese patients should not be excluded from the benefits of TKA from the article: Bone Joint J 2016;98-B:780–5.

Another study (http://www.ncbi.nlm.nih.gov/pubmed/25232084#) concluded that morbid obesity significantly increased the risk of subsequent revision, reoperation, and reinfection following two-stage revision total knee arthroplasty for infection. In addition, these patients had worse pain relief and overall function at intermediate-term clinical follow-up. Although two-stage revision should remain a standard treatment for chronic periprosthetic joint infection in morbidly obese patients, increased failure rates and poorer outcomes should be anticipated.

As well as another study (http://www.ncbi.nlm.nih.gov/pubmed/25845948#) that also saw a higher complication rate Morbid obesity is associated with increased rates of re-revision, reoperation, and PJI after aseptic revision TKA. As the time-sensitive nature of revision surgery may not always allow for patient or comorbidity optimization, these results emphasize the need for improving our care of patients with morbid obesity earlier on during the osteoarthritic process. Additional studies are needed to risk stratify patients in the morbidly obese population to better guide patient selection and effective optimization.

There are 2 separate issues here, firstly is it reasonable to deny treatments where risk variables can be changed, especially where the outcomes are measurably poorer. I suspect that most people would accept this premise, and if patients are unable to alter their weight, or habits, then perhaps the treatment thresholds should vary to reflect the changed risk profile.

The second question is however, should we consider those less perfect people ‘undeserving’ of publicly funded healthcare, the modern equivalent of the victorian ‘undeserving poor?’

Before answering that, consider that in almost every country in the world, smokers and drinkers would have contributed far more in voluntary taxes than economically matched controls, and are likely to have a reduced life expectancy, mainly in retirement, saving pension payments by the public purse.

Deciding who is and is not deserving of treatment is not something that anyone should have to do, and particularly not a doctor, whose obligation is to treat the patient to the best of his or her ability.

The important issue here in US is that we are soon to be payed on outcomes and “value”. CMS/Medicare will not pay for re-admissions for surgical complications and so the surgeon and the hospital will have to “eat” the cost of the admission and the cost of treatment.

However, as one learns in a very litigious society if we do not limit elective procedures to those who have a lower complication risk, we heath care providers and society will suffer.

I also consider blood sugars in my own criteria. If the patient has a blood sugar higher than 200 the patient’s elective surgery gets delayed until their weight is below a BMI of 39.5 and their blood sugars are controlled below 200. I have canceled cases just before surgery in those who do not comply. A surprisingly large number of patients remain tobacco-free 6 and 12 months after surgery. I have had a few patients (very few) get angry with me about this policy in my 33 years of practice, but it is not rare to have someone call me 1-2 years later and thank me for my insistence. Most smokers say they “knew” they should quit, but never had a physician demand quitting before helping them.

Research findings published in the December issue of the Journal of the American College of Surgeons, Chicago, December 3, 2013, confirm that factors such as smoking and obesity increase the odds of early implant loss in women who undergo mastectomy and immediate breast reconstruction with implants. Further studies concluded that smoking, obesity, and hypertension were similarly associated with reconstructive failure.

An additional multiple logistic regression analysis of complications following microsurgical breast reconstruction from the Department of Plastic Surgery, Georgetown University Hospital, Washington, DC, USA corroborates findings from previous studies. Tobacco use was demonstrated to be a significant risk factor for infection, seroma, and pneumonia. Obesity was demonstrated to be a significant risk factor for infection.

With these considerations and that it all goes to a financial bottom line set of decisions, if a single payer government health care system is what we end up with we will see these panels, whatever you want to call them, making broad decisions restricting surgical care and eventually medical care in general.

Is this what we really want? It is already what is seen in other single payer government run health care systems. Beware!!!

What do you think about this plan? Would this decision affect you?

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