Rationalizing Denial of Care for Obesity

The Knife GrinderHealth systems seem adept at denial of care for the most prevalent chronic disease in America, obesity. To understand this, just look at the hurdles a patient must clear to receive that most effective treatment with the longest track record: metabolic surgery. The goal is to pick the people for surgery who will have the most stellar results, as David Benalcazar and Marco Cascella explain:

“A thorough pre-operative evaluation of patients undergoing weight loss surgery is indispensable to ensure the adequate selection of eligible candidates and to achieve good outcomes after surgery.”

But if the goal is to improve health, this is a mistake. All the energy that goes into screening patients for access to obesity care appears to serve only for rationalizing the denial of care.

Are We Screening or Caring?

Ming Ji and colleagues set out to test a model for prospectively identifying patients who benefit most from metabolic surgery. They used baseline characteristics from 1,341 patients from the BELONG study to determine what factors might be most useful. In the end, only three factors made a difference: being Black, a BMI over 50, and the type of operation.

In other words, they found nothing that would have any practical value. Discriminating against Black patients is no good. Denying care to patients with the most severe disease (BMI > 50) would also be wrong. Limiting the options for the procedure a patient and surgeon can choose makes little sense, either. So Ji et al explain and conclude:

“Other life-saving operations for conditions related to obesity, such as coronary artery revascularization, do not require such extensive screening and selection for patients

“Our findings combined with many others support a move away from extensive screening and selection of patients at the time of surgery to a focus on improving access to this treatment.”

Letting Go of Implicit Bias

It is painfully slow. But healthcare systems are letting go of bad habits that serve only for the denial of access to obesity care. Such habits result from pervasive, implicit bias that people need only to behave differently. The bias supposes that if they do, obesity will cease to be a problem. It is a stubborn and false presumption.

One example of a better way can be found in a new guidance from the National Institute for Health and Care Excellence (NICE). It drops a requirement that a patient must try everything else and be receiving care from an advanced center for obesity before they can get an evaluation for metabolic surgery. In other words, NICE recommends ditching an obsolete requirement. It held that patients should run out of all other options before they could even think about surgery.

Hurdles like this need to go. Because all they do is deny care for obesity to people who need it and make complications of untreated obesity inevitable.

Click here for the study by Ji et al and here for more on the new guidance from NICE.

The Knife Grinder, painting by Kazimir Malevich / WikiArt

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September 4, 2023