There is no clinical benefit for patients who complete a medically supervised weight management programme before insurance companies approve them for weight-loss surgery, according to researchers from Prisma Health, Greenville, SC. In fact, the data shows this controversial requirement does nothing to improve treatment or safety outcomes, and may actually hinder weight loss success. The study, presented at the American Society for Metabolic and Bariatric Surgery (ASMBS) Annual Meeting, adds to a growing body of evidence that calls into question the clinical rationale for delaying surgery to fulfil this requirement imposed by insurers.
Weight management programme requirements vary among insurers. Some require patients to simply complete a programme; others expect patients to maintain weight within a defined period; others may deny payment for surgery if patients gain or even lose weight. The duration of these programmes range from three to 12 months.
Many insurance companies believe that participation in a weight management programme preoperatively results in patients with fewer complications, better health outcomes and decreased healthcare costs.
"Believing is one thing, proving is another. Patients in the insurance-mandated weight management programmes did not achieve greater weight loss before or after bariatric surgery, did not have fewer post-operative complications, and did not have better resolution of obesity-related diseases when compared to patients who had no such insurance requirement," said study-co-author Deborah Hutcheon, Doctor of Clinical Nutrition (DCN) and RD, Prisma Health. "The data shows the requirement only served to diminish outcomes and unnecessarily delay patient access to a life-saving medical intervention."
In the single-institution retrospective study, researchers reviewed the weight loss and safety outcomes of 1,056 patients who had either laparoscopic gastric bypass surgery (572) or sleeve gastrectomy (484) from 2014 to 2019. A total of 779 patients completed a medically supervised weight management programme as mandated by their insurance company. Patients were followed for up to five years, which researchers note, to their knowledge, is the longest duration of follow-up to date for a study of this kind.
Patients not required to complete the weight management programme prior to surgery had, on average, greater weight loss (1% to 5% more) in both the short- and long-term, and had better resolution or improvement of obesity-related diseases including hypertension, diabetes, and hyperlipidaemia. No differences were seen in the rate of complications. However, weight management programme patients who received gastric bypass had a significantly higher reoperation rate 13 months after surgery (3.8%), while gastric bypass patients who did not participate in the program did not require any reoperations.
Patients with the weight management programme requirement waited an extra two months on average to have surgery, which researchers theorise may have resulted in a reduced long-term commitment to diet, exercise, and lifestyle modification after surgery, contributing to less weight loss.
In a 2016 position statement, the ASMBS called for an end to insurance mandated preoperative supervised weight loss requirements and mandates, 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."
"Some insurers are following the data and discontinuing their mandates, but many still cling to the misguided assumption that requiring completion of a weight loss management program before bariatric surgery improves results. There is simply no scientific basis to this assumption and this practice has to stop," said bariatric surgeon, Dr Teresa LaMasters, ASMBS President-Elect, who was not involved in the study. "Every day delayed is another day denied access to the most effective long-term treatment for obesity. The preparation of the patient for metabolic bariatric surgery rests with the surgeon in collaboration with a multidisciplinary team. Arbitrary barriers should not stand in the way of these life-saving procedures."