Weight Loss Surgery: Why do patients drop from the program?

For today’s Bariatric Friday, Kemal Erkan, CEO of American Surgery Center, is joined by Dr. Isaias Irgau, President of Christiana Institute of Advanced Surgery (CHRIAS). Dr. Irgau specializes in weight loss surgery, also known as bariatric surgery. Bariatric surgery is the treatment of morbid obesity, obesity where the weight is at least one hundred pounds greater than a person's ideal weight. Morbid obesity can also be defined as a body mass index (BMI) greater than forty or greater than thirty-five if the person has other related illnesses such as type 2 diabetes, high blood pressure, or sleep apnea. When a person meets the above criteria, they become a candidate for bariatric surgery.

Today, the pair will continue to discuss the journeys of Katrina and Samantha, hypothetical bariatric surgery patients. Katrina and Samantha are in the weight loss surgery program provided by CHRIAS. They began their journey along with a few other patients; however, the others have fallen out of the program along the way. In this discussion, Dr. Irgau and Erkan want to break down and understand why this has happened, and reasons why bariatric surgery patients fail to complete the program. “The program is a period of preparation for bariatric surgery,” Dr. Irgau states, “patients needed to be educated, evaluated, and prepared by a multidisciplinary team… all that requires time… we put a lot of emphasis on this preparation”. “One of the reasons that patients are dropping is the process itself; the insurance is making this so difficult,” Erkan mentions, “insurance is asking for six consecutive months… it is set up in a way where you change your mind if you keep this long enough.” The current structure does not allow the surgeon to set the parameters necessary to prepare the patient for surgery; instead, the insurance company sets the guidelines for the process based on their requirements. Therefore, this makes it difficult for the patient, as if they must put in time to earn the right to gain approval for the surgery. This should not be the case. “There is no other field of medicine that functions in this way,” Dr. Irgau proclaims. The current six-month process set up by the insurance companies is discouraging. Dr. Irgau and Erkan have been working hard to make sure that their program is encouraging for patients to ensure retention, so patients are able to complete the process. “The old-fashioned thinking of morbid obesity is ‘you don’t need the surgery,’ so if you keep the process long enough, then patients are already struggling and will fail,” Erkan says. It is absurd that this process is the norm and accepted. Dr. Irgau expresses, ”It all stems from the fact that there is a stigma associated with obesity that puts people in a shameful place where they’re almost afraid to defend themselves… nobody enjoys the struggles they have to go through when they are morbidly obese, and yet, people are meant to think as if it is their fault and, therefore, any type of treatment that is given to them is almost a charitable act on the part of society”. The obstacles imposed by society on the morbidly obese is acceptable due to this stigma; however, those with morbid obesity should be offered the treatment needed to ensure a happy and healthy life.

Christiana Institute of Advanced Surgery ensures that patients feel hopeful and want to continue throughout the entirety of the program. “Our drop rate improved by almost 25%,” Erkan states. He explains how they encourage patients and hold their hand throughout the process. The one-on-one connection is extremely important to patient retention, so CHRIAS ensures all patients feel supported throughout their journey. A requirement of the program is that each bariatric patient sees appointed specialists; it is important to have a cohesive program that guides the patient. “We want our patients to succeed throughout the process,” Dr. Irgau comments. “Some patients are dropping out because of the high deductibles and out-of-pocket expenses… this can be done in the surgery center… this helps the patients with their out-of-pocket costs,” Erkan explains. The cost of the surgery in the hospital can be three to six times more expensive. The

patient can avoid high hospital costs by having their bariatric surgery performed safely as an outpatient at the American Surgery Center.

Erkan mentions that the male patient dropout rate is much higher than the female dropout rate. Dr. Irgau explains that males are more reluctant to seek treatment for any ailment or issue, and this translates to bariatric surgery as well. Smokers also tend to postpone getting bariatric surgery; the physician needs to address this issue early in the bariatric surgery process. A patient needs to stop smoking to receive this procedure. It is vital that the patient receives education on smoking cessation, its benefits, all the while feeling supported through this time. “As we all know, stopping smoking by itself is one of the hardest things anybody can try to do especially for the long term… if we add an issue where it becomes a punitive thing, then it becomes even harder for them and it's likely they will drop out of the program,” Dr. Irgau states. Support through the tough time will equate to a greater rate of success.

The safety of bariatric surgery has improved greatly over time. The various tests to check the patient's overall health is one factor that contributes to this. For example, cardiac testing can reveal heart disease even if the patient has had no obvious symptoms. In this case, the cardiologist may need to postpone bariatric surgery until it is safe to proceed. This process translates to other various diseases as well. Any detected issue needs management by the appropriate specialist prior to the surgery. “That’s why we have the preparation and the program because we need to address these issues before bariatric surgery so bariatric surgery can be undertaken in such a safe manner,” Dr. Irgau states.

“The treatment of morbid obesity should start in the primary care physician’s office,” Erkan mentions. Physicians should be comfortable communicating this in their offices. Knowledge is key. Many times, patients are not aware until much later that there is an issue. People need help. “It can be raised in an educational way when we relate it to the health problems that the patient is suffering… when all these issues are addressed individually it becomes ineffective,” Dr. Irgau says. It is important to explain how these concerns are all related back to morbid obesity. Even if a patient is not ready for surgery, the patient should still be given the option to receive aid for weight loss through other avenues.