Weight Loss Patient Safety Recommendations

The Betsy Lehman Center's Expert Panel on Weight Loss Surgery today released its updated recommendations on patient safety. This six-month effort involved over 100 specialists from the across the state and across the many disciplines involved in the field of weight loss surgery.

"Overwhelming new data highlighted in this report demonstrate reductions in known disease risk factors, improvements in health, and significant reductions in mortality after weight loss surgery," said Commissioner John Auerbach. "We expect this report to continue to set the standard for improving the safety of weight loss surgery in the Commonwealth and beyond."

Nationwide, the number of weight loss operations climbed 800 percent between 1998 and 2004. Between 2005 and 2006, it grew another 11 percent increasing from approximately 180,000 procedures to more than 200,000. Across all age groups, the fastest growth occurred among adults aged 55 to 64, with a 20-fold increase between 1998 and 2004. In Massachusetts, the number of weight loss operations climbed from 200 to 3036 procedures between 1998 and 2004. Between 2004 and 2006, it grew another 14 percent increasing from approximately 3036 procedures to 3447.

"There's been significant growth and many changes in the field since the last report," said Nancy Ridley, Director of the Lehman Center. "The information in this update is critical to the best interests of our weight loss surgery patients," she explained.

New data reflect a trend toward the use of procedures that not only restrict stomach size, as with laparoscopic banding, but also reroute part of the digestive tract, as is done with laparoscopic gastric bypass, the most commonly performed weight loss surgery in the U.S. In 1990, gastric bypass accounted for 55 percent of all weight loss operations; by 2000, that figure had climbed to 93 percent.

In 2006, growing popularity of the laparoscopic banding procedure changed the ratio of gastric bypass (both open and laparoscopic) to laparoscopic banding to 70:30.

As the number of weight loss surgeries increased, the national inpatient death rate fell 78.7 percent from 0.89 percent in 1998 to 0.19 percent in 2004. Male inpatient deaths have historically been higher than those for women, yet the gap narrowed substantially during those years, decreasing by close to 50 percent Length of hospital stay also fell by 38.5 percent from nearly 5 days to 3.1 days. The oldest patients had the longest length of stay and the highest inpatient mortality rate. Over the past two years, the average inpatient mortality rate for weight loss surgery in the Commonwealth of Massachusetts has been 0.07 percent significantly below the national inpatient death rate.

Other new findings show that:

* There are a growing number of surgical options available, including sleeve gastrectomy and biliopancreatic diversion;

* Laparoscopy has displaced open surgery as the predominant approach;

* Weight loss surgery accreditation/credentialing programs have been established within the past three years;

* Weight loss surgery patients have a higher prevalence of mental health disorders, with preliminary evidence indicating substance abuse problems;

* Approximately 4 percent of U.S. children suffer from extreme obesity;

* Advances in anesthesiology allow for more precise dosing of muscle relaxants and novel applications of anesthetic agents;

* There are new national credentialing standards in perioperative nursing;

* New patient transport and lift technologies can reduce healthcare workplace injuries;

* Optimal treatment requires greater collaboration between members of a multidisciplinary care team;

* 99 percent of patients who are eligible for weight loss surgery do not receive it;

* The need to accommodate growing numbers of severely obese patients will require wide-ranging changes in new and existing healthcare facilities; and that

* The Centers for Medicare and Medicaid Services and other payers now only reimburse procedures performed at accredited weight loss surgery centers.

The Expert Panel included a consumer representative and leading authorities in the fields of obesity treatment, patient safety, nutrition, medical practice, managed care, pediatrics, nursing, and ethics. It was chaired by George L. Blackburn, M.D., Ph.D., from Beth Israel Deaconess Medical Center. Matthew Hutter, M.D., from Massachusetts General Hospital served as the Panel's Vice Chair.

Dr. Blackburn explained that the panel used a state-of-the-art model of evidence-based medicine to develop its findings. "These recommendations are based on a comprehensive review of the best and most current literature on weight loss surgery," he said. "They're grounded in established methodology and vetted by nationally-recognized experts."

Dr. Hutter noted fast-paced change in how operations are performed. "The growing need for effective treatment has prompted the development of new or revised weight loss surgery procedures, and numerous efforts are underway to develop investigational approaches," he said. These issues were addressed through the Expert Panel's 11 different Task Groups, which included a new group added to examine the emerging field of endoscopic interventions.

"We have an older, heavier population, and a rapidly-evolving surgical specialty," said Dr. Blackburn. "With up to 1 in 10 U.S. adults a potential candidate for weight loss surgery, the need to protect the safety and well-being of patients who undergo these procedures is more critical than ever."

"The mortality rate in the Commonwealth speaks to our commitment to patient safety," said Ms. Ridley. "The earlier version of this document was dedicated to that end. It was instrumental in shaping policy and setting best practice standards on a national and international scale. We expect nothing less from this 2007 update," she said.