Obesity and the Impact on Surgical Quality

and Delivery
Robert R. Cima, MD, MA
National Press Foundation Obesity Program
February 2016

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Disclosures

No relationships to report

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Outline

Obesity trend
Impact of obesity on surgical outcomes
Impact of obesity on the delivery of care

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Obesity: a clinical measurement

Body Mass Index (BMI): a persons
weight (kg) divided by the square of their
height (m)

On average, there is a direct relationship

between increased BMI and high body
fatness

BMI is a tool to screen groups based

upon an objective measurement that
may be associated with other serious
health conditions

It is not a diagnostic tool to specifically

determine body fat or to assess an
individuals overall health

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February 8, 2016

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Prevalence of Self-Reported Obesity Among U.S.

Adults by State and Territory, BRFSS, 2011

*Sample size <50 or the relative standard error (dividing the standard error by the prevalence)
30%.

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Prevalence of Self-Reported Obesity Among U.S.

Adults by State and Territory, BRFSS, 2014

*Sample size <50 or the relative standard error (dividing the standard error by the
prevalence) 30%.

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Prevalence of Self-Reported Obesity Among U.S.

Adults by State and Territory, BRFSS, 2014
No state had a prevalence of obesity less than 20%
5 states and the District of Columbia had a prevalence of
obesity between 20% and <25%
23 states, Puerto Rico, and Guam had a prevalence of
obesity between 25% and <30%
19 states had a prevalence of obesity between 30% and
<35%
3 states (Arkansas, Mississippi and West Virginia) had a
prevalence of obesity of 35% or greater
Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be
compared to prevalence estimates before 2011.

http://www.cdc.gov/obesity/data/prevalence-maps.html

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Surgical Outcomes
How do we measure success after surgery?
Patient centered: short term morbidity, long-term functional
recovery, mortality
Surgeon centered: technical success, morbidity, mortality
Hospital centered: resource utilization, cost
Society centered: appropriateness, resource utilization, cost, short
and long-term value

Obesity has an important negative impact in nearly all

of these domains with the exception of mortality

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Impact of BMI on Surgical Morbidity

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Impact of BMI on Surgical Morbidity

Recent analysis of outcomes after colorectal

cancer surgery for morbidly obese patients

Hussan et al. World J Surg. Published On-line Dec 7, 2015

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Implications of Postoperative
Complications
Across surgical specialties major postoperative
complications are associated with
Increased length of hospital stays
Increased readmissions
Decreased rate of dismissals to home
Increased costs

In patients with malignancies, postoperative infectious

complications linked to decreased long-term survival
Colorectal cancer (Artinyan et al. Ann Surg 2015;261:497)
Esophageal cancer (Baba et al. Ann Surg 2015 Dec 10; E
Published)
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Long-term Functional Outcomes Associated with

BMI after Total Hip Replacement

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Resource Utilization
Obesity alone is associated with increased cost of
care

Mayo Clinic studied non-instrumented spine surgery

patients and found a significant difference between
obese and non-obese patients
Increased anesthesia and operative times
Increased length of hospital stay
Increased ICU admissions
Increased need for ventilator use
Overall increased cost of care
Planchard et al. Global Spine J 2015;5:287293

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Changing Surgical Equipment &

Instrumentation
Unique challenges

Obtaining and maintaining a safe airway as well as ventilating

Keeping the patient safe on the operating table
Harder to visualize and physically reach where you need to operate

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Changing Surgical Equipment &

Instrumentation

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Impact on Imaging

Abdom Imaging (2013) 38:630646

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Changing Surgical Equipment &

Instrumentation

http://www.liko.com/Albums/Products/Patient%20Transfer%20Aids/Airpal/airpal-transfer.jpg

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Impact of BMI on the Delivery of Care

Statistically what is the most dangerous

industry in the US?

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What Type of Injuries Occur?

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Hospital Related Injuries

The vast majority of injuries are associated with
patient care activities especially repositioning,
moving patients or assisting with personal hygiene
needs especially toileting

Increased patient size is the number one risk factor

To address this growing problem, hospitals are
needing to significantly alter:
Infrastructure including equipment, structures and
sometimes processes of care

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http://www.aviationexplorer.com/airline-seating.jpg

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Larger Capacity Wheelchair

450 lbs. capacity
22 wide seat
Provides the patient with more room and comfort
Taller handles support correct ergonomic posture

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Power Wheelchair
220-750 lbs. capacity
Rear wheel drive chair
Staff stands on a stand plate that is affixed to the rear of the chair for
patient transport

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Dane Wheelchair Mover

Fits most standard wheelchair sizes and models
Assists in transporting patients safely and securely
Reduces the potential for strain and injury to staff

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Bariatric Sizewise Motorized Chair

750 lbs. capacity
Reclines for patient comfort
Ability to raise and lower patient legs
Reduces strain and injuries to staff

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Vehicle Extractor
30 reach and a 40 lifting range
475 lbs. capacity
Used to extract seated patients and patients lying down in vehicles;
reduces transfer injuries
Low leg base slides under almost any vehicle

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Air Transfer Mattress

1000 lbs. weight capacity
Provides a cushion of air that reduces force to latterly move a
patient

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Expanded Capacity Portable Lift

1000 lbs. weight capacity
Reduces manual lifting of patient

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Expanded Capacity Portable Stand

Assist
800 lbs. weight capacity
Reduces force to manual assist patients to standing position

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Expanded Capacity Bed

1000 lbs. capacity
Expands from 36 to 48

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http://www.vitalgosys.com

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Ceiling Lifts
1000 lbs. weight capacity
Utilized for all modes of transfer/movement

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Bariatric Commode
1000 lbs. capacity

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http://www.liftseat.com/products/ls600

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http://www.acorneng.com

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Changing Hospitals

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http://well.blogs.nytimes.com/2015/08/24/bigger-hospital-rooms-for-bigger-patients/

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https://www.advisory.com/daily-briefing/2014/08/07/hospitals-invest-in-costly-equipment-for-obese-patients

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http://www.hammesco.com/obesity_bariatrics_hospital_design.html

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Long-term Care

Over 25% of nursing home patients are obese

Very difficult to modernize facilities to accommodate these patients due to cost
Difficulty caring for obese patients is a major concern and is often a leading reason for declining
referral

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Summary
Obesity is a significant risk factor for an individual
to have poor outcomes after surgical procedures
Delivering healthcare for the obese patient is
challenging

Processes and equipment are altered by obesity

Obesity is a major risk factor for healthcare worker injuries
Facilities require significant changes
Obesity alone can be a barrier to ensuring patients get the care
they need

All of these issues significantly contribute to the

increased cost of healthcare for everyone
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The Needs of the Patient Come First- W.J. Mayo

Questions & Discussion

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