A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional
Bariatric Times • September 2011
ASMBS Update
incidence ratio of 2.1 for any fracture and 1.9 for fractures of the hip, spine, wrist, or arm after bariatric surgery. Additional studies for gastric bypass exist. One study9
an eight-percent decrease in total hipbone mineral density within nine months. Femoral neck bone density decreased by nine percent within one year of gastric bypass in a separate study of 23 patients.10
A third study11 of 15 patients reported
Postoperative surveillance for osteoporosis. Postoperative surveillance is similar to previous recommendations. Check the following labs every six months for two years and then annually: calcium, albumin, phosphate, creatinine, 24(OH) D, and parathyroid hormone.
of
42 patients reported a seven-percent decrease in spine bone density and a 10- percent decrease in total hipbone density a year after gastric bypass. The most recent prospective study12 of 59 women three years after GBP concluded that Menopausal women and women with greater lean body mass loss were at a higher risk for osteopenia, but that fracture risk in this short follow up period was low. All of these studies are small in numbers of patients and short in terms of follow up and in addition rely on bone scanning that may have some technical limitations in interpretation. Mechanism of bone loss after gastric bypass. Whether you lose weight by dieting or surgery, any voluntary or involuntary weight loss will result in some bone loss and increase fracture risk. This may be accelerated when coupled with a procedure that changes the absorption of calcium. Other contributions to bone loss may be the body's signals about decreased skeletal loading with weight loss, and changes in fat-secreted hormones. Patients with adjustable gastric band may not have risk associated with changes in absorption but they are eating far less food and will have bone loss with weight loss. Vitamin D deficiency can be a problem for patients with obesity before and after bariatric surgery. Prior to surgery. Check serum 25- hydroxyvitamin D (25[OH] D) levels and prescribe preoperative treatment to augment vitamin D in patients with low levels. Make sure you have documented consent of the patient on the vitamin deficiencies and subsequent problems, such as calcium and vitamin D deficiency. Use of second-generation consent forms will help provide clear information about these issues. Make sure you have a plan for postoperative supplementation. The following are our current
recommendations for supplementation recommended to patients after all weight loss procedures: • Multivitamin (must contain 20 nutrients and at least 18mg of iron per serving)—two servings per day
• Calcium citrate with vitamin D— 1,500mg per day
• Vitamin D3 supplementation of 800 to 2,000 IU per day of vitamin D3 can be met as part of the calcium supplementation
• B50-Complex— one serving per day • Sublingual B12 (gastric bypass only)—1,000mcg per week.
If the parathyroid hormone level is high, but the 25(OH) D level is low, treat with additional vitamin D supplementation. If the parathyroid hormone level is high and the 25(OH) D level is ideal, check the patient's 24-hour urinary calcium, and if that is low, increase calcium intake.
All patients should be encouraged to get 60 to 80mg of protein daily and exercise daily. DEXA scans. Suggested at baseline (if the patient can fit into the scanner, especially if post menopausal to document status of bone) and every one to two years after surgery.
It is critical that the surgeon and the program have a coherent and clear plan of communication and consent with the patient undergoing a bariatric procedure regarding the need for postoperative supplementation of minerals and vitamins and the prevention of osteoporosis. Preferably this is reviewed both in writing and verbally (documented in the medical record) with an indication of patient understanding (e.g., true/false test or signed second generation consent form).
ASMBS Bariatric Surgeon Compensation Survey. About 18 months ago, I transitioned from almost 20 years of being in private practice to becoming a hospital employee. As I began to look into the transition, I found little help available outside of some generous consultations from colleagues I knew who had undergone a similar transition. When putting together the new course for ASMBS on Coding and
Reimbursement, which will be featured at the ASMBS Fall Event in Chicago, ASMBS recruited an expert in this field, Bruce Maller, CEO BMS Consulting, Inc. His first talk on this issue featured at the ASMBS annual meeting June 2011 was met with tremendous interest. A recent letter from ASMBS, member
Teresa LaMasters, MD, FACS, brought up the important issue that compensation surveys regarding hospital-employed surgeons were very sparse, with the most recent Medical Group Management Association (MGMA) survey including only a small sample of 26 surgeons. She also stated that 50 percent of surgeons are currently employed. Based on Dr. LaMasters request that ASMBS develop more information, we began working with Toms Augustin, MD, MPH, a MIS fellow with Ann Rogers, MD, the Director at the Penn State Surgical Weight Loss Program, Hershey, Pennsylvania; and Bruce Maller on the development of a bariatric surgery compensation survey to send to all
ASMBS members October 2011. The confidential survey questions are being developed now. The following are suggestions to be formatted and included:
1. What is monetary compensation? 2. Is the monetary compensation (salary) based on relative value units (RVUs)?
3. What is the compensation per RVU and how is it determined?
4. What does the compensation include (e.g., retirement, medical, life insurance, and disability, continuing medical education)?
5. What is the total compensation package?
6. How many RVUs or collections correlates with that salary?
7. Define compensation by specific regions of the country
8. What percentage of the surgeon's practice is dedicated to bariatric surgery and not general surgery? (>20%, 21–50%, 51–80%, >80%)
9. What type of practice (e.g., Solo private, group private, university, solo hospital, group hospital, multispecialty group)?
10. 11.
12. this location)
Years in practice (total, and at Years of bariatric experience
Volume of bariatric procedures per year and total experience 13. Fellowship training: Yes or No
If you have any suggestions for questions for survey, please send them to
robin.blackstone@asmbs.com. 3.
The United States Department of Health and Human Services demonstrates the Standard Summary of Benefits and Coverage based on a policy excluding obesity treatment and bariatric surgery. One of the goals of the Patient Protection and Affordable Care Act (PPACA) is to standardize the way that specific benefits in the plan are conveyed to the public. The National Association of Insurance Commissioners (NAIC) was charged with assembling a group to develop a standard form and glossary of terms and instructions. The ASMBS Access to Care Committee, led by John Morton, MD, and members of the Obesity Care Continuum, The Obesity Society (TOS), American Diatectic Association (ADA), Obesity Action Coalition (OAC), and the ASMBS, representing more than 100,000 patients has been tracking this work carefully to make sure that no language adverse to bariatric surgery and obesity treatment was included. Unfortunately and inexplicably, the final document came out with the form filled out using a policy that excludes both obesity treatment and bariatric surgery. The NAIC and the coalition met three times in order to try and find out what process had ensued between the final draft and the public document where the change was made. The final document also included pregnancy as
4. 5. 6.
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an excluded benefit, but somehow that was corrected. Although the NAIC claimed to have communicated our concerns to HHS, we were very discouraged to find that the final public document came out with the exclusion for the treatment of obesity and bariatric surgery intact. To view the document, visit
http://s3.amazonaws.com/publicASMBS/ top5/september2011/0911%20Potomac %20Current.pdf
Bariatric surgery is covered by 40 percent of small employers (i.e., 10 to 499 employees) and 70 percent of companies with over 20,000 employees, it is also covered in 47 state Medicaid policies and by 44 state employee health plans and by Medicare. Clearly the decision by HHS to release this particular policy is not representative of the country.
The ASMBS Access Team knows we will not prevail in every battle, but for HHS to contribute to the stigma of obesity by singling out the treatment of this one disease in their example is unfortunate and not consistent with the leadership we hope Secretary Sibelius and HHS will show in the Essential Health Benefit.
References 1.
2.
Centers for Disease Control and Prevention. Overweiight and obesity. http://www.cdc.gov/obesity/index.htmlAccesse d 9/8/11.
K Thorpe, Yang Z. Impact of weight loss on lifetime medical spending among obese medicare beneficiaries. American Public Health Association. 2010. http://apha.confex.com/apha /138am/webprogram/Paper233943.html. Accessed 9/8/11.
Livingston EH, Ko CY. Socioeconomic characteristics of the population eligible for obesity surgery. Surgery. 2004;135(3):288–296.
Nguyen NT, Masoomi H, Magno CP, et al. Trends in use of bariatric surgery, 2003–2008. J Am Coll Surg. 2011; 213(2): 261–266.
Livingston EH. The incidence of bariatric surgery has plateaued in the U.S. Am J Surg. 2010;200(3):378–385.
Ogden CL, Carroll MD. NCHS Health E-Stat. Prevalence of overweight, obesity, and extreme obesity among adults: United States, trends 1960–1962 through 2007–2008. http://www.cdc.gov/nchs/data/
hestat/obesity_adult_07_08/obesity_adult_07_ 08.htm. Accessed 9/8/11.
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Aills L, Blankenship J, Buffington C, Furtado M, Parrott J. ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient. Surg Obes Relat Dis. 2008;4(5 Suppl):S73-108.
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Heber D, Greenway FL, Kaplan LM, et al. Endocrine and nutritional management of the post-bariatric surgery patient: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2010;95:4823–4843.
9.
Coates PS, Fernstrom JD, Fernstrom MH, et al. Gastric bypass surgery for morbid obesity leads to an increase in bone turnover and a decrease in bone mass. J Clin Endocrinol Metab. 2004;89(3):1061–1065.
10. Fleischer J, Stein EM, Bessler M, et al. The decline in hip bone density after gastric bypass surgery is associated with extent of weight loss. J Clin Endocrinol Metab. 2008; 93:3735–3740.
11. Carrasco F, Ruz M, Rojas P, et al. Changes in bone mineral density, body composition and adiponectin levels in morbidly obese patients after bariatric surgery. Obes Surg. 2009; 19(1):41–46.
12. Vilarrasa N, San José P, García I, et al. Evaluation of bone mineral density loss in morbidly obese women after gastric bypass: 3- year follow-pp. Obes Surg. 2011;21:465–472.