Survey and Chart Review to Estimate Medicare Cost Savings for Home Health as an Alternative to Hospital Admission Following Emergency Department Treatment.

BACKGROUND: Almost 70% of hospital admissions for Medicare beneficiaries originate in the emergency department (ED). Research suggests that some of these patients' needs may be better met through home-based care options after evaluation and treatment in the ED. OBJECTIVE: We sought to estimate Medicare cost savings resulting from using the Home Health benefit to provide treatment, when appropriate, as an alternative to inpatient admission from the ED. METHODS: This is a prospective study of patients admitted from the ED. A survey tool was used to query both emergency physicians (EPs) and patient medical record data to identify potential candidates and treatments for home-based care alternatives. Patient preferences were also surveyed. Cost savings were estimated by developing a model of Medicare Home Health to serve as a counterpart to the actual hospital-based care. RESULTS: EPs identified 40% of the admitted patients included in the study as candidates for home-based care. The top three major diagnostic categories included diseases and disorders of the respiratory system, digestive system, and skin. Services included intravenous hydration, intravenous antibiotics, and laboratory testing. The average estimated cost savings between the Medicare inpatient reimbursement and the Home Health counterpart was approximately $4000. Of the candidate patients surveyed, 79% indicated a preference for home-based care after treatment in the ED. CONCLUSIONS: Some Medicare beneficiaries could be referred to Home Health from the ED with a concomitant reduction in Medicare expenditures. Additional studies are needed to compare outcomes, develop the logistical pathways, and analyze infrastructure costs and incentives to enable Medicare Home Health options from the ED.

Perspectives on Home-based Healthcare as an Alternative to Hospital Admission After Emergency Treatment.

INTRODUCTION: The study objective was to explore emergency physicians' (EP) awareness, willingness, and prior experience regarding transitioning patients to home-based healthcare following emergency department (ED) evaluation and treatment; and to explore patient selection criteria, processes, and services that would facilitate use of home-based healthcare as an alternative to hospitalization. METHODS: We provided a five-question survey to 52 EPs, gauging previous experience referring patients to home-based healthcare, patient selection, and motivators and challenges when considering home-based options as an alternative to admission. In addition, we conducted three focus groups and four interviews. RESULTS: Of participating EPs, 92% completed the survey, 38% reported ordering home-based healthcare from the ED as an alternative to admission, 90% ranked cellulitis among the top three medical conditions for home-based healthcare, 90% ranked "reduce unnecessary hospitalizations and observation stays" among their top three perceived motivators for using home-based care, and 77% ranked "no existing process in place to refer to home-based care" among their top three perceived barriers. Focus group and interview themes included the need for alternatives to admission; the longer-term benefits of home-based healthcare; the need for streamlined transition processes; and the need for highly qualified home-care staff capable of responding the same day or within 24 hours. CONCLUSION: The study found that EPs are receptive to referring patients for home-based healthcare following ED treatment and believe people with certain diagnoses are likely to benefit, with the dominant barrier being the absence of an efficient referral process.

Adipose tissue depot and cell size dependency of adiponectin synthesis and secretion in human obesity.

Adiponectin is an insulin sensitizing fat cell (FC) hormone whose levels are related to adipose tissue (AT) mass and depot distribution. We hypothesized that the nature of AT expansion (hypertrophy vs. hyperplasia) contributes to obesity-related reductions in serum adiponectin and that this effect is influenced by the regional distribution of AT to subcutaneous (S) and visceral (V) depots. Thirteen obese subjects provided paired AT biopsies. Serum total and high molecular weight (HMW) adiponectin levels were determined by ELISA. Secretion was quantified following 24-h explant culture. FC size, number, % large, and % small FC were determined by microscopic analysis. Secretion of total adiponectin was highest by SAT (P = 0.008) and correlated more strongly with serum adiponectin (total: P = 0.015, r = 0.77; HMW: P = 0.005, r = 0.83) than did secretion by VAT (P = 0.05, r = 0.66 for both). FC size was greatest in SAT and correlated negatively with both serum (total: P = 0.01, r = -0.74; HMW: P = 0.03, r = -0.69) and secreted (total: P = 0.05, r = -0.72; HMW: P = 0.02, r = -0.87) adiponectin. The % small FC in SAT correlated positively with both serum (total: P = 0.006, r = 0.87; HMW: P = 0.009, r = 0.79) and secreted (total: P = 0.03, r = 0.75; HMW: P = 0.01, r = 0.92) adiponectin. VAT FC size correlated negatively with serum HMW adiponectin (P = 0.01, r = -0.76) but not with any measure of secretion. VAT had the greatest % small FC, which related positively to serum HMW (P = 0.004, r = 0.81) and to secreted total adiponectin (P = 0.02, r = 0.78). These studies indicate that differences in fat cell size and depot distribution of AT expansion are important influences on adiponectin in obesity.

Laparoscopic gastric bypass for the adolescent patient: long-term results.

BACKGROUND: Obesity is a major public health problem in the developed world. The National Survey of Children's Health 2003 estimated around 17 million children in the USA to be overweight, making this a significantly alarming disease in the young population. Findings from the Third National Health and Nutrition Examination Survey demonstrated at least 30 % of overweight adolescents to be suffering from the metabolic syndrome. Combined metabolic and restrictive bariatric operations have been shown to improve or resolve these various comorbidities, and surgical therapy is recommended as a part of a multidisciplinary approach to the treatment of morbid obesity in adults. Data in the adolescent population are sparse. METHODS: This is a retrospective, descriptive study of prospectively collected data over 10 years. Twenty-five adolescents between the ages of 14 and 18 years underwent laparoscopic Roux-en-Y gastric bypass (RYGBP) using a standard technique by a single surgeon with follow-up of at least 5 years. RESULTS: Twenty of the 25 patients were available for follow-up from 5 to 10 years after their operation. Average BMI preop/postop was 45.7/28.6 kg/m(2). Average percentage of excess body weight loss was 77.7 %. Average BMI change was 17.1. CONCLUSION: Our long-term data demonstrate that laparoscopic RYGBP is a safe and effective operation for morbidly obese adolescents, in the proper setting. We advocate that surgical intervention be recommended for this population using the same NIH guidelines used for adults.

Low anastomotic stricture rate after Roux-en-Y gastric bypass using a 21-mm circular stapling device.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been established as a safe and effective procedure for morbid obesity management. Amongst some of the postoperative complications are gastrojejunal (GJ) anastomotic strictures, with an incidence of 3 to 27 % in some series. This study evaluates the incidence of GJ strictures using a 21-mm circular stapling device and its response to treatment with endoscopic balloon dilation. METHODS: A retrospective chart review was conducted of patients who underwent LRYGB between January 2007 and September 2010. We used our previously published technique of retrocolic, retrogastric Roux-en-Y bypass, using a 21-mm circular stapler to construct the gastrojejunostomy. Postoperatively, patients with persistent food intolerance underwent an endoscopy. Those found to have a GJ stricture (defined as inability to pass the endoscope beyond he anastomotic site) underwent pneumatic dilation with a 12-mm balloon. RESULTS: A total of 338 patients underwent LRYGB. Median follow-up was 57.6 weeks (8-137). Twenty-two patients underwent an endoscopy due to food intolerance. Sixteen patients (4.7 %, 16/338) were identified with GJ stricture and received at least one endoscopic dilation. The other six patients had a normal endoscopic evaluation. GJ strictures presented at an average of 35 days (13 to 90 days) postoperatively. Four patients underwent two endoscopic interventions, and one underwent three endoscopic interventions. CONCLUSIONS: We hereby demonstrate that the construction of GJ anastomosis with a 21-mm circular stapler is associated with a low stricture rate using our standardized technique. Strictures are amenable to balloon dilatation with subsequent long-term resolution of symptoms.

International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is an emerging surgical approach, but 1 that has seen a surge in popularity because of its perceived technical simplicity, feasibility, and good outcomes. An international expert panel was convened in Coral Gables, Florida on March 25 and 26, 2011, with the purpose of providing best practice guidelines through consensus regarding the performance of LSG. The panel comprised 24 centers and represented 11 countries, spanning all major regions of the world and all 6 populated continents, with a collective experience of >12,000 cases. It was thought prudent to hold an expert consensus meeting of some of the surgeons across the globe who have performed the largest volume of cases to discuss and provide consensus on the indications, contraindications, and procedural aspects of LSG. The panel undertook this consensus effort to help the surgical community improve the efficacy, lower the complication rates, and move toward adoption of standardized techniques and measures. The meeting took place at on-site meeting facilities, Biltmore Hotel, Coral Gables, Florida. METHODS: Expert panelists were invited to participate according to their publications, knowledge and experience, and identification as surgeons who had performed >500 cases. The topics for consensus encompassed patient selection, contraindications, surgical technique, and the prevention and management of complications. The responses were calculated and defined as achieving consensus (≥70% agreement) or no consensus (<70% agreement). RESULTS: Full consensus was obtained for the essential aspects of the indications and contraindications, surgical technique, management, and prevention of complications. Consensus was achieved for 69 key questions. CONCLUSION: The present consensus report represents the best practice guidelines for the performance of LSG, with recommendations in the 3 aforementioned areas. This report and its findings support a first effort toward the standardization of techniques and adoption of working recommendations formulated according to expert experience.

Laparoscopic gastric bypass in patients 60 years and older: early postoperative morbidity and resolution of comorbidities.

BACKGROUND: Bariatric surgery has not been routinely presented as an option for patients over 60 years of age. Part of the reason is the long-standing perception that there is additional risk. Additionally, until its recent ruling, Medicare was inconsistent in its coverage, thus making it difficult for some beneficiaries to gain access to the procedures. The aim of this study was to evaluate the perioperative morbidity in our patients who were 60 years of age or older who underwent a laparoscopic gastric bypass Roux-en-Y (LGBRY). We also report the impact of surgery on five objectively graded comorbidities in the early postoperative period. METHODS: Our prospectively maintained database was used to identify and report on all patients operated on at our program from January 2002 through January 2007. RESULTS: One hundred twenty patients were identified with 100% follow-up through the perioperative phase and 85% follow-up at 12 months. The mean age was 62 years (range 60-74) with a mean body mass index of 43 kg/m(2) (range 34-70). All patients underwent an LGBRY. There was no 30-day mortality. Perioperative complications included: 13 strictures, one abscess, two wound infections, three ulcers, two small bowel obstructions, three bleeding episodes in patients who required coumadin, and atrial fibrillation in two patients. The five graded/measurable comorbid conditions (preop/postop) were diabetes mellitus type II (68/17), hypertension (86/10), obstructive sleep apnea requiring continuous positive airway pressure (CPAP; 48/3), hypercholesterolemia (106/18), and hypertriglyceridemia (60/5). CONCLUSIONS: LGBRY can be done safely in patients over 60 years of age in an experienced bariatric program, even in patients with relatively high risk based on their comorbid conditions preoperatively. Resolution of associated comorbidities far exceeds that found with any other treatment modality.