Gastric bypass: It pays to keep military hospitals busy

Military Medicine, Sep 2003 by Chang, Craig G, Helling, Thomas S, Dezutti, Brian, Koenig, Chad, Cruz, Sandy

This study was performed to review the surgical treatment of obesity at a community military hospital and compare costs to TRICARE reimbursement rates (the cost of sending a patient to a civilian surgeon for obesity surgery). The preoperative, operative, and postoperative phases are described in detail. The expenses of five consecutive patients were calculated and averaged. Each operation at our hospital cost $1,710, whereas the TRICARE cost was at least $6,950. A saving of $5,240 per operation was achieved in our military hospital. These five patients subjectively graded their outcomes as very good to excellent at a mean of 7.9 months from surgery. These patients lost an average of 70% of their excess body weight. All patients with weight-related comorbidities reported resolution of at least one problem.

Introduction

Severe obesity is a national health crisis. The prevalence of obesity (body mass index [BMI] > or = 30 kg/m^sup 2^) increased from 12.0% in 1991 to 30.5% in 2000.1,2 Currently, 4.7% of the American population is considered severely obese (BMI 40 kg/m^sup 2^).2 This trend will likely worsen as more than 25% of American children are obese. The cost of obesity-related health problems is staggering. In 1995, it was estimated that 100 billion dollars was lost treating obesity and its complications in the United States alone.3 This figure is certainly higher today.

It is clear that obesity is associated with many medical problems. Hypertension, type 2 diabetes, sleep apnea, high cholesterol, and chronic arthritic, cardiac, and pulmonary problems all benefit from as little as a 10% weight loss. Likewise, longitudinal studies have shown a twofold increased mortality rate for persons 50% above average weight. Mortality rates increased from fivefold to eightfold when these obese persons had other serious comorbidities like diabetes and heart disease.4-6 The mainstays of medical treatment have been diet, exercise, and anorectic medications. Unfortunately, long-term studies typically show high attrition rates and a high incidence of regaining weight.7 In contrast, multiple studies have documented the efficacy and durability of surgery for obesity. Currently, there are two National Institutes of Health sanctioned operations for weight loss: the vertical banded gastroplasty and the gastric bypass. Of these, gastric bypass has emerged as the superior operation.8-14 Gastric bypass may be considered when a patient's BMI is 35.0 to 39.9 and weight-related comorbidities are present (see above). It may also be considered with a BMI greater than 40, regardless of comorbidities.

The military health care system cares for approximately 8.4 million people (Great Plains Regional Command, personal communication). It would be expected that up to 2.5 million (30%) military health care beneficiaries are obese and 395,000 (4.7%) are severely obese. Extrapolation of data suggests that the cost of treating these patients for obesity-related problems would approximate 3.8 billion dollars per year. Obesity is not isolated to dependents and retirees. According to the 1998 Department of Defense Survey of Health-Related Behaviors, 22.9% of military personnel under age 20 years were overweight and 19.5% of military personnel over age 20 years were overweight (Healthy People 2000 Guidelines).15 For these individuals, failure to meet height and weight standards jeopardizes fitness for duty, mission readiness, and promotability.16

Currently, most military hospitals provide weight management programs geared for the medical treatment of obesity. However, few provide comprehensive surgical programs. This study was undertaken to review our surgical experience at a military hospital and to compare costs to the TRICARE reimbursement rate for gastric bypass.

Subjects

The primary author (C.G.C.) evaluated all patients referred for gastric bypass. A protocol was initiated to standardize the evaluation. Patients were evaluated over 3 to 6 months to prepare them for surgery. The protocol consisted of three preoperative clinic visits spaced 4 weeks apart. At the first visit, the patient was asked to fill out a detailed questionnaire about weight history, previous diets, and reasons for failure. Patients were also queried about medications for weight loss, medical history (with a special emphasis on weight-related comorbidities), surgical history, social history, and family history of obesity. A complete physical examination was performed, and patients were then counseled about the preoperative protocol. They were asked to obtain information about gastric bypass from the Internet, to see the nutritionist, and to embark on a medical plan for weight loss. Typically, patients were asked to loose 10 to 15 lbs before surgery with a combination of dietary change and exercise. All patients were extensively counseled about the need for lifestyle changes before surgery. Patients were offered the opportunity to attend the bariatric support group that met on a weekly basis. Group participants included preoperative and postoperative patients.

At the second visit, new questions were answered and a standard set of laboratory tests were ordered. They included a complete blood count, routine chemistry, liver function studies, and thyroid-stimulating hormone/free T4. Follicle-stimulating hormone, leutinizing hormone, and adrenocortotropic hormone were ordered when clinically appropriate. A gallbladder ultrasound was routinely performed. Patients were also referred to a licensed psychologist who assessed them for eating disorders and psychiatric problems. This psychologist also served as the support group facilitator.