New Data Argue Against Pre–Bariatric Surgery Waiting Period

Miriam E Tucker

November 02, 2017

WASHINGTON, DC — Requirements for mandatory participation in medical weight-loss programs prior to receiving bariatric surgery do not improve weight-loss outcomes and may even diminish them, new research suggests.

Findings from three studies presented here yesterday at Obesity Week 2017 add to a growing literature calling into question the rules imposed by many insurance companies requiring patient participation in a medically supervised weight-management program for up to 6 months before reimbursing for bariatric surgery, generally with the rationale that the process improves compliance to lifestyle management.

However, the new data suggest that weight loss and safety outcomes aren't improved in patients who participate in those programs.

"From our chart review, we haven't seen any significant benefits to having patients wait longer before their surgery. There are trends that show the opposite — patients are less likely to show weight loss before or after the operation," Stanford University second-year medical student Victor Eng told Medscape Medical News.

Session moderator Maher El Chaar, MD, a bariatric surgeon at St Luke's University Health Network, Bethlehem, Pennsylvania, told Medscape Medical News, "My concern isn't just that we're wasting our time, but that the outcome may be worse, particularly in patients with uncontrolled hypertension, bad sleep apnea, or uncontrolled diabetes….A delay of 6 months can affect their [conditions]."

Dr El Chaar said he sometimes recommends presurgery medical weight management for 3 or 6 months for selected patients, such as those who had a previous bariatric procedure and now need a revision, since those surgical outcomes typically aren't as positive. But, he said, "I think it has to be left to the judgment of the physician," rather than the insurance companies.  

Indeed, in a 2016 position statement, the American Society for Metabolic and Bariatric Surgery (ASMBS) called for an end to the requirements, stating, "The discriminatory, arbitrary, and scientifically unfounded practice of insurance-mandated preoperative weight loss contributes to patient attrition, causes unnecessary delay of lifesaving treatment, leads to the progression of life-threatening comorbid conditions, is unethical, and should be abandoned."

But Amy Rothberg, MD, PhD, director of the Michigan Medicine Weight Management Program, Ann Arbor, pointed out in an interview with Medscape Medical News that in the real world the weight-management programs that bariatric-surgery candidates are referred to are often suboptimal, typically with just once-monthly visits that don't include the type of intensive lifestyle behavior advice and education that is necessary to achieve durable weight loss.

"I agree that if that's the prescription they're getting then there's no reason for the wait time," she said. "But if people are enrolled in intensive behavioral intervention with frequent follow-up of more than once per month…that might make a difference."  

Dr Rothberg, who has published on the clinical and cost benefits of intensive medical weight management (Obesity. 2013;211:2157-2162), also noted that the percentage of excess weight loss at 6 months to 1 year — an outcome measure in all three studies — isn't the only important outcome.

"Everything is predicated on percent weight loss following surgery, but there are other measures they may not be capturing. You may not know whether in 5 years the interventions prior to undergoing bariatric surgery will make a difference in terms of less recidivism. If patients are not indoctrinated with certain lifelong lifestyle skills, they're not going to be successful. I just think 1 year isn't enough time to consider that," Dr Rothberg said.

Time to Surgery Doesn't Affect Weight-Loss Outcomes

Mr Eng and colleagues retrospectively reviewed charts with 1-year follow-up data for 427 patients who underwent bariatric surgery — 61% laparoscopic Roux-en-Y gastric bypass, 36% sleeve gastrectomy, and 3% gastric band — at Stanford during 2014–2015.

Time to surgery, defined as the number of days between consult visit and immediate preoperative visit, was 0 to 3 months for 27% of the patients, 3 to 6 months for 35%, and more than 6 months for 38%. The reason for the delays wasn't available from the charts, but mandatory insurance company requirements are likely to be among them, Mr Eng explained.

Overall, there was a nonsignificant trend for greater preoperative excess weight loss with shorter time to surgery, from 2.07% for 0 to 3 months to 1.96% for 3 to 6 months, and 1.47% for 6+ months (= .44).

In multiple regression models, time to surgery was a significant predictor of decreased percentage of excess weight loss for gastric bypass (= .0006), while there was a nonsignificant trend for sleeve gastrectomy (= .06).

The decrease in weight loss with increased wait time to surgery continued after the surgery. For sleeve gastrectomy, this trend was significant at 3 months, when excess weight loss was 47% for 0 to 3 months' time to surgery vs 45% for 3 to 6 months and 38% for 6+ months (= .026). There was a nonsignificant trend at 6 and 12 months (= .10 and .69, respectively). Similar trends were seen with gastric bypass, but were not significant at 3, 6, or 12 months postsurgery.  

"None of our data presented thus far have shown any benefit in patients who delay their bariatric surgery, and we are seeing trends that suggest the opposite," Mr Eng commented.

In a secondary analysis, there were no differences in surgical complications or readmissions by time to surgery.

"We believe that preoperative weight loss should be goal-oriented rather than time-mandated and that any delay to receiving bariatric surgery should be minimized," he concluded.

Number of Visits Doesn't Seem to Matter

In a second study, presented by Genna FP Hymowitz, PhD, of Stony Brook Medicine, New York, a total of 107 patients who had undergone an overall average of five monthly medically supervised weight-management visits prior to surgery were followed for up to 1 year postsurgery. There were no associations between the individuals' number of presurgery visits and percentage of excess weight lost at any time point from 3 weeks, 3 months, 6 months, or 1 year postsurgery.

"Participation in a monthly supervised weight-management group before surgery may not directly impact weight loss following surgery," Dr Hymowitz concluded, adding that a more effective approach might be to focus on postsurgical interventions that address weight regain following surgery, alcohol-use disorders, and loss-of-control eating.

Insurance-Mandated Programs May Not Affect Outcomes

The third study, presented by surgery resident Andrew Schneider, MD, of Greenville Health System, South Carolina, directly examined the effect of insurance-mandated medically supervised preoperative weight-management programs on postoperative weight loss and safety outcomes.

Dr Schneider explained that Medicare requires only documentation of unsuccessful medical treatment for obesity but does not mandate a specific length of time or amount of weight loss. In contrast, private insurers typically mandate a documented weight-loss program that varies from 3 to 12 months. Some require weight loss as well but then will deny surgery if too much weight is lost. In general, he said, they are "typically very strict with requirements."

Indeed, Dr El Chaar told Medscape Medical News that the denial for patients who lose too much weight is particularly egregious, given that some of those patients may still have uncontrolled diabetes or other major medical comorbidities. "It's like a game. You feel like you can't take care of your patient."

In their study, Dr Scheider and colleagues compared chart information for 266 bariatric-surgery patients who had participated in insurance-mandated weight-management programs with 88 who had not during 2014–2016. Of those who had participated, 64% had private health insurance, 26% had Medicare, 10% Medicaid, and 0% self-paid. Among the nonparticipants, those proportions were 55%, 0%, 29.5%, and 16%, respectively.

Time to surgery was 182 days for the program participants compared with 109 days for the nonparticipants (< .001), a significant difference.

However, there were no significant differences between the two groups in operation duration (= .59), postoperative length of stay (= .88), or rates of follow-up up to 1 year (= .08). Readmissions (19 in a program, six no program) and reoperations (one each) also didn't differ significantly (= 1.00 and 0.43, respectively).

Postoperative excess weight loss also didn't differ at any time point, and was nearly identical at 1 year (61.6% program, 61.9% no program; P = .085).

"Our data on outcomes are consistent with the ASMBS statement against insurance-mandated preoperative weight-management programs," Dr Schneider concluded.

"A Singular Voice"

In her comments to Medscape Medical News, Dr Rothberg said she believes "there is certainly a role for bariatric surgery," particularly if patients want it or if no intensive behavioral and medical weight-loss interventions are available. "I think we need to think about our patients and their preferences first, then about availability. If there isn't a good [medical] weight-loss program, that person may be in a better position to have bariatric surgery…or vice versa."

In addition, she said, "I think we need to work together and have a singular voice. I think bariatric medical providers need to help the surgeons pre- and postsurgery, and surgeons need to realize the value of medical intervention….We have to have a multifaceted, multipronged approach to obesity. It's a lifelong chronic disease, so we need to provide an array of services."

Mr Eng, Dr Scheider, Dr Hymowitz, and Dr El Chaar report no relevant financial relationships. Dr Rothberg receives research funding from Nestlé.

Obesity Week 2017. November 1, 2017; Washington, DC. Abstracts A124, A125, A126.  

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