Comorbidities Climb After Bariatric Denials

Major Finding: Rates of new-onset comorbidities in the denial and bariatric cohorts, respectively, were 9.2% and 0.3% for diabetes; 41.9% and 0.9% for hypertension; and 19.4% and 0.6% for GERD.

Data Source: A retrospective study comparing comorbidities in 587 bariatric surgery patients with 189 patients who did not undergo surgery.

Disclosures: Dr. Al Harakeh and discussant Dr. John Morton reported having no financial conflicts of interest.

LAS VEGAS — Morbidly obese individuals who do not undergo bariatric surgery because of insurance denials have a higher incidence of new comorbidities over a short follow-up than do surgical patients, despite no significant change in body mass index, a study has shown.

Dr. Ayman B. Al Harakeh and his colleagues at Gundersen Lutheran Medical Foundation in LaCrosse, Wisc., compared the natural history and metabolic consequences of morbid obesity for patients who were denied bariatric surgery and those who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) at their institution in 2001-2007. The researchers found that the 189 patients who were denied the surgery were significantly more likely to develop new comorbidities (including diabetes, hypertension, obstructive sleep apnea, lipid disorders, and gastroesophageal reflux disease) within a 3-year follow-up period, despite no change in BMI, compared with the 587 patients in the LRYGB cohort. Patients were denied surgery even though they satisfied National Institutes of Health criteria and were deemed appropriate surgical candidates.

The age and sex of patients in the denial and LRYGB cohorts were similar at baseline, as was the initial median BMI (47.3 kg/m

The statistically significant higher prevalence of hypertension, GERD, and lipid disorders in the denial group placed them at higher risk than the surgical group, “yet they were denied surgery that could improve or resolve many of the their obesity-related complications,” Dr. Al Harakeh pointed out.

An assessment of major comorbidities at 36 months after the initial evaluation showed the following rates of new-onset comorbidities in the denial and LRYGB cohorts, respectively: 9.2% and 0.3% for diabetes; 41.9% and 0.9% for hypertension; 34.2% and 0.4% for obstructive sleep apnea; 11.2% and 0.3% for lipid disorders; and 19.4% and 0.6% for GERD, said Dr. Al Harakeh. The respective mean BMIs in the denial and surgery groups at 36 months were 46.8 and 30.5, he said.

Because study data were collected retrospectively, specific reasons for the insurance denials were unavailable, he stated. However, in his experience, denials are frequently arbitrary. In fact, a previous study by Dr. Al Harakeh's colleagues showed that nearly 30% of patients deemed suitable for surgery by the bariatric team in 2001-2005 did not undergo the surgery for insurance-related reasons. According to the investigators, coverage was often denied because the insurer determined that the procedure was not a medical necessity or because the individuals' comorbid conditions were being managed by conventional medicine. “Even though the NIH has clearly defined the criteria for morbid obesity surgery, individual insurers are free to establish their own unique requirements,” the authors wrote (Surg. Obes. Relat. Dis. 2007;3:531-6).

My Take

'Clear and Present Danger' Shown

The high rate of new comorbidity development over a short follow-up period observed in obese patients denied bariatric surgery for insurance reasons demonstrates “a clear and present danger to at-risk obese patients,” according to discussant Dr. John Morton.

Though powerful, the study results may be skewed somewhat by a “surveillance effect,” Dr. Morton suggested. “A lot of these patients don't have primary care available to them, or at least not very good primary care,” he said, noting that perhaps the extensive presurgery evaluation for bariatric procedures “woke people up about the potential problems that could be occurring.” It's reasonable to assume that some of the most prevalent comorbidities observed during the evaluation, such as hypertension, GERD, and sleep apnea, may have been present but undiagnosed previously, he said.

Potential surveillance effect notwithstanding, the findings clearly confirm that failing to intervene “is a recipe for continued progression of comorbidities in these patients and that bariatric surgery is a powerful tertiary prevention measure for comorbidities.”

DR. MORTON is director of bariatric surgery and surgical quality at Stanford Hospital and Clinics in Palo Alto, Calif. He had no financial conflicts to disclose.

Vitals

Major Finding: Rates of new-onset comorbidities in the denial and bariatric cohorts, respectively, were 9.2% and 0.3% for diabetes; 41.9% and 0.9% for hypertension; and 19.4% and 0.6% for GERD.

Data Source: A retrospective study comparing comorbidities in 587 bariatric surgery patients with 189 patients who did not undergo surgery.

Disclosures: Dr. Al Harakeh and discussant Dr. John Morton reported having no financial conflicts of interest.

LAS VEGAS — Morbidly obese individuals who do not undergo bariatric surgery because of insurance denials have a higher incidence of new comorbidities over a short follow-up than do surgical patients, despite no significant change in body mass index, a study has shown.

Dr. Ayman B. Al Harakeh and his colleagues at Gundersen Lutheran Medical Foundation in LaCrosse, Wisc., compared the natural history and metabolic consequences of morbid obesity for patients who were denied bariatric surgery and those who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) at their institution in 2001-2007. The researchers found that the 189 patients who were denied the surgery were significantly more likely to develop new comorbidities (including diabetes, hypertension, obstructive sleep apnea, lipid disorders, and gastroesophageal reflux disease) within a 3-year follow-up period, despite no change in BMI, compared with the 587 patients in the LRYGB cohort. Patients were denied surgery even though they satisfied National Institutes of Health criteria and were deemed appropriate surgical candidates.

The age and sex of patients in the denial and LRYGB cohorts were similar at baseline, as was the initial median BMI (47.3 kg/m

The statistically significant higher prevalence of hypertension, GERD, and lipid disorders in the denial group placed them at higher risk than the surgical group, “yet they were denied surgery that could improve or resolve many of the their obesity-related complications,” Dr. Al Harakeh pointed out.

An assessment of major comorbidities at 36 months after the initial evaluation showed the following rates of new-onset comorbidities in the denial and LRYGB cohorts, respectively: 9.2% and 0.3% for diabetes; 41.9% and 0.9% for hypertension; 34.2% and 0.4% for obstructive sleep apnea; 11.2% and 0.3% for lipid disorders; and 19.4% and 0.6% for GERD, said Dr. Al Harakeh. The respective mean BMIs in the denial and surgery groups at 36 months were 46.8 and 30.5, he said.

Because study data were collected retrospectively, specific reasons for the insurance denials were unavailable, he stated. However, in his experience, denials are frequently arbitrary. In fact, a previous study by Dr. Al Harakeh's colleagues showed that nearly 30% of patients deemed suitable for surgery by the bariatric team in 2001-2005 did not undergo the surgery for insurance-related reasons. According to the investigators, coverage was often denied because the insurer determined that the procedure was not a medical necessity or because the individuals' comorbid conditions were being managed by conventional medicine. “Even though the NIH has clearly defined the criteria for morbid obesity surgery, individual insurers are free to establish their own unique requirements,” the authors wrote (Surg. Obes. Relat. Dis. 2007;3:531-6).

My Take

'Clear and Present Danger' Shown

The high rate of new comorbidity development over a short follow-up period observed in obese patients denied bariatric surgery for insurance reasons demonstrates “a clear and present danger to at-risk obese patients,” according to discussant Dr. John Morton.

Though powerful, the study results may be skewed somewhat by a “surveillance effect,” Dr. Morton suggested. “A lot of these patients don't have primary care available to them, or at least not very good primary care,” he said, noting that perhaps the extensive presurgery evaluation for bariatric procedures “woke people up about the potential problems that could be occurring.” It's reasonable to assume that some of the most prevalent comorbidities observed during the evaluation, such as hypertension, GERD, and sleep apnea, may have been present but undiagnosed previously, he said.

Potential surveillance effect notwithstanding, the findings clearly confirm that failing to intervene “is a recipe for continued progression of comorbidities in these patients and that bariatric surgery is a powerful tertiary prevention measure for comorbidities.”

DR. MORTON is director of bariatric surgery and surgical quality at Stanford Hospital and Clinics in Palo Alto, Calif. He had no financial conflicts to disclose.

Vitals

Major Finding: Rates of new-onset comorbidities in the denial and bariatric cohorts, respectively, were 9.2% and 0.3% for diabetes; 41.9% and 0.9% for hypertension; and 19.4% and 0.6% for GERD.

Data Source: A retrospective study comparing comorbidities in 587 bariatric surgery patients with 189 patients who did not undergo surgery.

Disclosures: Dr. Al Harakeh and discussant Dr. John Morton reported having no financial conflicts of interest.

LAS VEGAS — Morbidly obese individuals who do not undergo bariatric surgery because of insurance denials have a higher incidence of new comorbidities over a short follow-up than do surgical patients, despite no significant change in body mass index, a study has shown.

Dr. Ayman B. Al Harakeh and his colleagues at Gundersen Lutheran Medical Foundation in LaCrosse, Wisc., compared the natural history and metabolic consequences of morbid obesity for patients who were denied bariatric surgery and those who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) at their institution in 2001-2007. The researchers found that the 189 patients who were denied the surgery were significantly more likely to develop new comorbidities (including diabetes, hypertension, obstructive sleep apnea, lipid disorders, and gastroesophageal reflux disease) within a 3-year follow-up period, despite no change in BMI, compared with the 587 patients in the LRYGB cohort. Patients were denied surgery even though they satisfied National Institutes of Health criteria and were deemed appropriate surgical candidates.

The age and sex of patients in the denial and LRYGB cohorts were similar at baseline, as was the initial median BMI (47.3 kg/m

The statistically significant higher prevalence of hypertension, GERD, and lipid disorders in the denial group placed them at higher risk than the surgical group, “yet they were denied surgery that could improve or resolve many of the their obesity-related complications,” Dr. Al Harakeh pointed out.

An assessment of major comorbidities at 36 months after the initial evaluation showed the following rates of new-onset comorbidities in the denial and LRYGB cohorts, respectively: 9.2% and 0.3% for diabetes; 41.9% and 0.9% for hypertension; 34.2% and 0.4% for obstructive sleep apnea; 11.2% and 0.3% for lipid disorders; and 19.4% and 0.6% for GERD, said Dr. Al Harakeh. The respective mean BMIs in the denial and surgery groups at 36 months were 46.8 and 30.5, he said.

Because study data were collected retrospectively, specific reasons for the insurance denials were unavailable, he stated. However, in his experience, denials are frequently arbitrary. In fact, a previous study by Dr. Al Harakeh's colleagues showed that nearly 30% of patients deemed suitable for surgery by the bariatric team in 2001-2005 did not undergo the surgery for insurance-related reasons. According to the investigators, coverage was often denied because the insurer determined that the procedure was not a medical necessity or because the individuals' comorbid conditions were being managed by conventional medicine. “Even though the NIH has clearly defined the criteria for morbid obesity surgery, individual insurers are free to establish their own unique requirements,” the authors wrote (Surg. Obes. Relat. Dis. 2007;3:531-6).

My Take

'Clear and Present Danger' Shown

The high rate of new comorbidity development over a short follow-up period observed in obese patients denied bariatric surgery for insurance reasons demonstrates “a clear and present danger to at-risk obese patients,” according to discussant Dr. John Morton.

Though powerful, the study results may be skewed somewhat by a “surveillance effect,” Dr. Morton suggested. “A lot of these patients don't have primary care available to them, or at least not very good primary care,” he said, noting that perhaps the extensive presurgery evaluation for bariatric procedures “woke people up about the potential problems that could be occurring.” It's reasonable to assume that some of the most prevalent comorbidities observed during the evaluation, such as hypertension, GERD, and sleep apnea, may have been present but undiagnosed previously, he said.

Potential surveillance effect notwithstanding, the findings clearly confirm that failing to intervene “is a recipe for continued progression of comorbidities in these patients and that bariatric surgery is a powerful tertiary prevention measure for comorbidities.”

DR. MORTON is director of bariatric surgery and surgical quality at Stanford Hospital and Clinics in Palo Alto, Calif. He had no financial conflicts to disclose.

Vitals