by Elizabeth Hofheinz, M.P.H., M.Ed., September 3, 2019
We really don’t have a good solution when it comes to performing joint replacement on obese patients, says one orthopedic surgeon. “If someone loses 100 pounds they are still at an increased risk for complications,” he states. “We are not sure why, but it is likely that their elevated inflammatory markers leave them open to infections.
“Patients may think they’re ready for surgery if they lose some weight—and while that is certainly beneficial if the patient has any other conditions such as diabetes—but there remains an increased risk for surgeons. This is important because now we are personally accountable for our surgical infections. Let’s say I have an overall infection rate of 1% and then I operate on obese patients whose infection rate is 2.5%. This is still low, but it makes me an outlier. Should we endanger our statistics for nonemergent elective procedure? We are not indentured servants…they can’t force us to perform elective surgery. If someone doesn’t want to operate on a patient because of their color or race, then that is unethical and unacceptable. But if you judge that a BMI of 50 carries too heavy of an infection rate then you can choose not to perform the surgery.”
“These days hospitals and practices are tracking surgeries involving a BMI above 45/50—and if those patients end up with infections then you are held responsible. There is no risk adjustment for weight.”
“Making things more complex is that obesity is a modifiable risk factor. If someone undergoes bariatric surgery and goes from 500 pounds to 200 pounds, then their risk is probably lower than before…but is it not zero.”
“If you tell someone with a bad knee to come back after he or she loses 50 pounds the fact is that it is difficult for them to lose weight if they can’t exercise. And besides, the data show that if you do a procedure on a patient with an arthritic knee or hip, then the average person gains weight after surgery.”
“It’s not like with smoking where when you stop you stop. If your blood sugar is too high, then you can take medication. If someone can’t lose weight, then you might send the person to a medical weight loss clinic where they offer nutritional shakes. Well, those shakes are not covered by insurance so where does that leave them?”
“The bottom line is that we are not obligated to operate on high-risk patients—AND it is not in our best interests. If you have a common area for sheep grazing, and if each sheep consumes as much as possible, then the area will be overgrazed, and no one in the group can eat. But if you rotate grazing each day then all the sheep will have a chance.”
“Ultimately, you can bankrupt a hospital if you are operating under bundled payments. It is the tragedy of the commons as there is only so much money out there. If you do ten joint replacement on high risk patients and it costs $1 million because of the complication, where do you stand ethically if you could have done 100 surgeries for the same amount of money? Hospitals are working with a limited budget and thus there are patients who won’t be able to get surgery.”
