It is important to understand the prevalence of obesity among older adults. The number of obese Americans has tripled from 1950 to 2000 and continues to increase (Picot et al., 2009). Although obesity is considered a public health challenge in America, little attention has been placed on obesity in older adults until recently. Nurses are well acquainted with the projected increase of older adults in the United States. By 2030, adults older than 65 will represent approximately 20% of the population (Ortman, Velkoff, & Hogan, 2014). As the proportion of older adults increases, it is expected that obesity rates in this population will rise as well. The Centers for Disease Control and Prevention (CDC; 2012b) estimate that more than one third of adults older than 65 are obese. Since 1999, this figure has increased, particularly among those ages 65 to 74, who represent the “young old” (CDC, 2012b). Despite recognition of the deleterious effects of obesity and efforts to reduce obesity rates, the CDC (2010) reported that no state met the Healthy People 2010 goal of decreasing obesity rates by 15%.
The Impact of Obesity
Obesity is recognized as a significant contributor to morbidity and mortality (Ortman et al., 2014). As a complex condition, obesity is influenced by biological (i.e., genetics, diseases, hormonal imbalances) and societal (i.e., cultural beliefs, socioeconomic status, access to healthy foods) factors (CDC, 2012a). Obesity is the result of an energy imbalance in which more calories are consumed than expended, and it is defined as having a body mass index (BMI) greater than 30 kg/m2 (CDC, 2012a; National Institutes of Health, 1998). Obese older adults have difficulty losing weight. Excess body weight is associated with functional declines that may impede physical activity (Lang, Llewellyn, Alexander, & Melzer, 2008; Newman, 2009).
An association seems to exist between obesity and certain chronic conditions. Excess body weight contributes to type 2 diabetes, hypertension, dyslipidemia, osteoarthritis, obstructive sleep apnea, urinary incontinence, cataracts, and certain types of cancer (Villareal et al., 2005). Heart disease, cancer, and diabetes are among the leading causes of death in older adults. A meta-analysis by Guh et al. (2009) found increased disease burden in obese adults. In addition, an association exists between obesity and mortality (Calle, Thun, Petrelli, Rodriguez, & Heath, 1999; Dorn, Schisterman, Winkelstein, & Trevisan, 1997).
Obesity has a profound impact on health care costs as well. In 2008, the costs associated with obesity were $147 billion, and this figure is expected to increase (CDC, 2012a). Cawley and Meyerhoefer (2012) estimate that these costs comprise 21% of total health care spending in the United States. Costs include both direct and indirect costs. Direct costs include diagnostics tests and treatments for comorbid conditions, as well as bariatric surgery. Work absenteeism and increased costs of insurance coverage represent indirect costs (CDC, 2012a).
Bariatric surgery is considered a secondary option to medical treatment, which includes medications, diet, and exercise. When these interventions do not yield adequate therapeutic response, many older adults and providers may turn to bariatric surgery. Between 2005 and 2009, an exponential increase occurred in the number of older adults undergoing bariatric surgery (Dorman et al., 2012). This trend is expected to continue. However, a number of policy barriers exist, impeding access to bariatric surgery for many older adults who would benefit from these procedures.
The first bariatric procedures were developed in the 1960s. The introduction of laparoscopic approaches increased the popularity and safety of bariatric surgeries. Three common procedures include Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric banding (LAGB), and sleeve gastrectomy (SG) (Picot et al., 2009). During RYGB surgery, a 50 milliliter pouch is created in the proximal portion of the stomach, which is attached to the small intestine. This procedure essentially alters digestion, thus leading to weight loss. LAGB is a reversible and the preferred procedure among older adults. A band is laparoscopically placed in the superior portion of the stomach, thus restricting food intake. The band may be adjusted at follow-up visits. However, an SG divides the stomach, reducing it to 25% its normal size. This portion of the stomach maintains its function. SG is irreversible and generally performed laparoscopically (Picot et al., 2009).
Interdisciplinary health care teams assess which procedure is appropriate for a patient by evaluating medical diagnoses, age, diet, BMI, and patient preference. Most major health care organizations highlight the importance of medical and lifestyle interventions; however, some guidelines state that those with a BMI greater than 50 kg/m2 may consider surgery a first-line option (Picot et al., 2009).
Early studies evaluating bariatric surgery outcomes of Medicare beneficiaries indicated an increased mortality among these patients (Flum et al., 2005). As a result of these safety concerns, the Centers for Medicare & Medicaid Services (CMS) issued a national coverage determination (NCD) in 2006, which limited Medicare reimbursement for bariatric surgery to Centers of Excellence (COE), as designated by either the American College of Surgeons (ACS) or American Society for Metabolic and Bariatric Surgery (ASMBS) (Dimick, Nicholas, Ryan, Thumma, & Birkmeyer, 2013). Procedures covered included RYGB (laparoscopic or open), LAGB, and biliopancreatic diversion with duodenal switch (BPD/DS), but not SG. Another stipulation of the NCD was that institutions must perform at least 125 bariatric surgeries per year to qualify as COEs (Schirmer & Jones, 2007). This decision was supported by research indicating that hospital volume directly impacts mortality for some surgical procedures (Finks, Osborne, & Birkmeyer, 2011).
Under this policy, Medicare beneficiaries had to meet the following criteria for coverage of bariatric surgery: severe obesity (BMI >35 kg/m2) with at least one comorbid condition and documented unsuccessful weight loss with other treatments. The 2006 NCD was an effort to improve bariatric surgery outcomes among Medicare beneficiaries. As a consequence, an increased interest in studies examining bariatric surgery outcomes in high-risk groups, including older adults, developed.
Individual studies examining the efficacy of bariatric surgery in older adults tend to have small samples. As such, a literature review was performed to understand safety and outcomes of bariatric surgery in older adults. All English language studies published after 2002 that either (a) compared outcomes between individuals older than 60 to those younger than 60 or (b) evaluated outcomes of individuals older than 60 alone were included. Older adult was defined as any individual 60 and older, as this was most commonly used in the literature. Twenty-three studies met the inclusion criteria for this review. Main outcomes of interest included weight loss, surgical complications, disease burden, and mortality.
Weight loss was addressed in 16 studies, representing 70% of the total sample. Although older adults experienced lower total weight loss, 75% of these studies concluded that older adults experienced statistically significant weight loss from baseline (Alhamdani et al., 2012; Clough, Layani, Shah, Wheatley, & Taylor, 2011; Dunkle-Blatter et al., 2007; Hallowell et al., 2007; Leivonen, Juuti, Jaser, & Mustonen, 2011; Nelson et al., 2006; O’Keefe, Kemmeter, & Kemmeter, 2010; Quebbemann, Engstrom, Siegfried, Garner, & Dallal, 2005; Ramirez, Roy, Hidalgo, Szomstein, & Rosenthal, 2012; Sosa, Pombo, Pallavicini, & Ruiz-Rodriguez, 2004; Trieu, Gonzalvo, Szomstein, & Rosenthal, 2007; Willkomm, Fisher, Barnes, Kennedy, & Kuhn, 2010). Different measures were used to evaluate weight loss, including change in BMI, percentage of excess weight loss, and weight loss in kilograms. The use of three different measures to quantify weight loss decreases the ability to compare studies. However, these data indicate that older adults benefit from bariatric surgery by experiencing significant weight loss.
The most common surgical complications were bleeding, pneumonia, deep vein thrombosis or pulmonary embolism, and wound infections. Regarding surgical complications, 13 (62%) of 21 concluded that the rate of surgical complications in older adults was similar to the rate in patients younger than 60 (Alhamdani et al., 2012; Busetto et al., 2008; Clough et al., 2011; Dorman et al., 2012; Dunkle-Blatter et al., 2007; Hallowell et al., 2007; Hazzan et al., 2006; O’Keefe et al., 2010; Quebbemann et al., 2005; Ramirez et al., 2012; Sosa et al., 2004; Taylor & Layani, 2006; Willkomm et al., 2010). One study suggested that SG may lead to higher early complications and nutritional deficiencies in older adults. Thus, SG may be associated with greater complications compared to LAGB and RYGB (Leivonen et al., 2011).
The area for which bariatric surgery has gained the most notoriety is its capability to resolve or reduce disease burden. Disease burden was measured in one of two ways: either the number of comorbid conditions present or medications taken to treat these conditions. In this sample, the greatest benefit was seen in hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, and osteoarthritis. Hypertension improved in eight studies (Clough et al., 2011; Dunkle-Blatter et al., 2007; Nelson et al., 2006; O’Keefe et al., 2010; Quebbemann et al., 2005; Ramirez et al., 2012; Sosa et al., 2004; Willkomm et al., 2010). Similarly, seven studies noted improvements in type 2 diabetes (Busetto et al., 2008; Clough et al., 2011; O’Keefe et al., 2010; Quebbemann et al., 2005; Ramirez et al., 2012; Taylor & Layani, 2006; Willkomm et al., 2010). Lastly, four studies reported improvements in dyslipidemia (Clough et al., 2011; O’Keefe et al., 2010; Ramirez et al., 2012; Taylor & Layani, 2006). Older adults in these studies experienced improvements in disease burden, which can have a significant impact on overall quality of life (Busetto et al., 2008; Taylor & Layani, 2006).
Furthermore, 14 (70%) of 20 studies reported mortality rates among older adults undergoing bariatric surgery that were comparable to rates among patients younger than 60 (Alhamdani et al., 2012; Clough et al., 2011; Dunkle-Blatter et al., 2007; Hallowell et al., 2007; Hazzan et al., 2006; Leivonen et al., 2011; O’Keefe et al., 2010; Ramirez et al., 2012; St Peter, Craft, Tiede, & Swain, 2005; Sugerman et al., 2004; Taylor & Layani, 2006; Trieu et al., 2007; Willkomm et al., 2010; Wittgrove & Martinez, 2009). These rates may be due to a number of factors that improved safety of bariatric procedures, including enhancements in bariatric surgery fellowships, surgeon technique, and standardized patient care (Dimick et al., 2013; Tunis & Messner, 2013). Regardless, the mortality rate of older bariatric surgery patients seems to be low compared with other surgical procedures (Finks et al., 2011).
Access to Care
Several factors exist that limit access to care among Medicare beneficiaries. First, although beneficiaries older than 65 comprised 83% of individuals with Medicare in 2012, they represent only a small number of Medicare beneficiaries undergoing bariatric surgery (Chronic Conditions Data Warehouse, 2014). More than 90% of Medicare beneficiaries receiving bariatric surgery are younger than 65 (Elmore & Phillips, 2006). Therefore, older adults are disproportionally underrepresented. Second, limiting Medicare coverage to COEs is another barrier. Approximately 73% of all hospitals offering bariatric surgery are classified as low volume, whereas high volume hospitals perform 74% of all procedures (Livingston, Elliot, Hynan, & Engel, 2007). COE status may not be an indicator of improved outcomes but rather represents institutions that had the financial resources or motivation to become COEs. Lastly, Schirmer (2011) and Bayham, Greenway, and Bellanger (2012) asserted that SG in older adults is associated with increased weight loss compared with LAGB and with fewer surgical complications compared with RYGB. Therefore, SG’s efficacy is comparable to that of other procedures; however, CMS does not cover it.
In September 2013, CMS issued an updated decision that eliminated the COE requirement for Medicare reimbursement. This decision has generated debate from both proponents and critics. Those in support of the new decision identify its potential to increase access to care for Medicare beneficiaries. On the other hand, concerns over quality of care and potential harm to patients treated in non-COEs have been voiced. Some experts believe that the data evaluated by CMS are inconclusive and do not warrant a change in the policy (Tunis & Messner, 2013). Some studies, such as those conducted by Nguyen et al. (2010) and Flum et al. (2011), attributed improvements in bariatric surgery outcomes to the 2006 NCD, whereas Dimick et al. (2013) questioned these findings and attributed improved outcomes to several factors, including increased surgical expertise and a shift toward LAGB and laparoscopic procedures. Still, others believe that the 2006 addition of LAGB as a covered procedure makes it difficult to decipher if improved outcomes were a result of the NCD or shifts in procedural trends (Schirmer, 2011).
This new decision emerged as a direct result of studies that found no difference in outcomes between COE and non-COE institutions (Birkmeyer et al., 2010; Livingston, 2009). Although 15% of all individuals eligible for bariatric surgery are Medicare beneficiaries, they only represent 5% of all bariatric surgery patients (Livingston & Ko, 2004). This disparity in need versus access may be narrowed by CMS’ new decision to expand care beyond COEs.
In addition, SG continues to be excluded as a covered procedure. However, under the new decision, local Medicare Administrative Contractors are allowed discretion to cover any bariatric surgery procedure, including those not included under the CMS decision. Medicare beneficiaries and their providers who believe SG is the most appropriate procedure for them may request coverage.
CMS’ decision only impacts Medicare beneficiaries; however, most data indicate that obese Medicaid beneficiaries underuse bariatric surgery. Livingston and Ko (2004) asserted that a larger proportion of Medicaid patients are obese and can benefit from bariatric surgery. In an analysis of Medicaid coverage of obesity treatment, Lee, Sheer, Lopez, & Rosenbaum (2010) discovered that all states, with the exception of five states, cover bariatric surgery with varying restrictions. These restrictions are similar to those established by CMS for Medicare patients in 2006. It seems that state Medicaid programs modeled their reimbursement policies off of the 2006 NCD. As CMS expands Medicare coverage of bariatric surgery, it will be interesting to observe the impact increased Medicare coverage may have on state Medicaid programs.
A need exists for continued evaluation of bariatric surgery outcomes in older adults. The BMI requirement of >35 kg/m2 may limit access to bariatric surgery for many older adults who have significant disease burden but do not meet this criterion (DeMaria et al., 2007; Yermilov, McGory, Shekelle, Ko, & Maggard, 2009). It is known that BMI may vary based on age, race, body composition, and gender. Therefore, BMI may be an inaccurate measure of true risk related to obesity. Novel criteria for determining eligibility may expand coverage to older individuals with significant disease burden who may benefit from bariatric surgery.
In addition, Courcoulas et al. (2013) identified the need for studies that evaluate the long-term outcomes of bariatric surgery, as most studies follow patients for 2 years or less. Of the 23 studies included in the current literature review, only 16 (70%) followed patient outcomes for at least 1 year (Alhamdani et al., 2012; Busetto, 2008; Clough et al., 2010; Dunkle-Blatter, 2007; Hallowell et al., 2007; Leivonen et al., 2011; Nelson et al., 2006; O’Keefe et al., 2010; Quebbemann et al., 2005; Ramirez et al., 2012; Sosa et al., 2004; St Peter et al., 2005; Sugerman et al., 2004; Taylor & Layani, 2006; Trieu et al., 2007; Wittgrove & Martinez, 2009). In addition, a need exists for increased reporting of race/ethnicity, gender, and socioeconomic status to comprehend how these factors influence outcomes following bariatric surgery in older adults. Approximately one half of the studies in the literature review did not report on any of these demographic characteristics (Clough et al., 2011; Dunkle-Blatter et al., 2007; Hallowell et al., 2007; Hazzan et al., 2006; Nelson et al., 2006; O’Keefe et al., 2010; Quebbemann et al., 2005; St Peter et al., 2005; Taylor & Layani, 2006; Trieu et al., 2007; Willkomm et al., 2010).
September 25, 2014, will mark 1 year since CMS eliminated the COE requirement for Medicare beneficiaries. It is important to evaluate how this decision has affected the use of bariatric surgery and outcomes among older adult Medicare beneficiaries. The safety and efficacy of SG must also be examined. CMS and accrediting organizations, such as ACS and ASMBS, should continuously evaluate the impact of this policy decision to ensure continued patient safety and quality care.
With increased access to bariatric procedures, obese older adults contemplating surgery may turn to nurses for guidance. Therefore, gerontological nurses must be aware of emerging trends in bariatric surgery among this population.
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