By Adolph J. “Chick” Yates Jr., MD
Careful planning, frank discussions best serve a difficult patient population
An increasing number of Americans are overweight; many meet the definition of obesity (body mass index of 30 or more). While the lay press trumpets an “obesity epidemic,” the orthopaedic literature is also increasingly reporting on the higher rates of perioperative complications associated with the overweight patient. Many orthopaedic ailments are associated with weight, especially arthritis of the hip and knee.
According to the Centers for Disease Control and Prevention, in 2006, only four states had a prevalence of obesity less than 20 percent (Fig. 1). Given these demographics, orthopaedic groups need to consider how best to serve these patients. It behooves you to plan proactively for this patient group in terms of access, compassion, education, risk management, and economic impact.
Obese patients face obstacles to access in every office. Older buildings or conversions will sometimes have surprisingly narrow doorways to crucial rooms. At times, these doorways are too narrow even for normal wheelchairs and certainly cannot accommodate wider wheelchairs.
To avoid complaints about uncomfortable or tight chairs, an orthopaedic practice should have a variety of larger chairs; loveseats or couches are options in practices not involved with hip arthroplasty. The practice staff should also be aware of the weight limitations of older exam and radiograph tables to avoid embarrassment and breakdowns. Investing in scales made to accommodate a wider range of patients is recommended, and each facility should have a back-up system for the few patients that might exceed the scale’s limits.
When scheduling an obese patient for surgery, be sure to request a wider bed, special table extensions for the operating room, and a wide wheelchair in advance. This avoids unnecessary embarrassment, discomfort, and potential injury for the patient and saves you time. Every practice should have a protocol that covers door-to-door care.
Courtesy, respect, and compassion
Obese patients rarely need to be reminded of their condition. Many overweight patients have suffered from the taunts of others since childhood and encounter recurring admonishments from health professionals on almost every visit. A surgeon’s use of words such as “fat” or “morbidly obese” are not necessary and only confirm the patient’s expectations.
But neither should the topic be ignored. Although it might seem euphemistic, references to “bigger” people or “large” patients are not as painful to the ear and even carry some positive attributes. It takes patience, but spending a few extra minutes listening to patients describe their frustrations about their weight can help to allay their anxieties in establishing a relationship with a new physician.
Education and resources
Softening your language should be coupled with being frank about the facts, particularly about the impact of obesity on health. If you have a literature rack, stocking it with brochures that discuss the implications of obesity in terms of arthritis and surgery can be an easy way of broaching the topic without confrontation.
Every exam room should have a Body Mass Index (BMI) chart visible for education; patients frequently do the calculations before the physician arrives and may be ready to discuss the surprising results. If surgery is contemplated, patient and surgeon should have a frank discussion of the increased risks involved and this conversation should be well documented.
You may not want to manage weight-loss programs, but patients may frequently ask for your advice as a physician. Being a resource does not always imply the need to manage the course of treatment. Instead, be sure your office is stocked with lists of different diets, information on dieticians and local weight-loss programs, and referral information to bariatric surgery programs. Such resources are invaluable and show your willingness to direct and help.
Risk, performance, and reward
Some surgeons already shun obese patients, mostly because of time and effort considerations. Surgical times are longer, and these patients physically demand more energy and stress. Although the literature demonstrates the benefits that overweight patients obtain from surgery for arthritic joints, it also makes clear that those benefits are coupled with significantly higher risk for complications that also take time and interrupt work-flow.
In addition, a unique group of financial “disincentives” are evolving that could decrease the number of surgeons willing to accept obese or other high-risk patients. State and federal measures of performance are increasing public awareness of a surgeon’s complications rate. A surgeon’s reimbursement level may be lowered based on his or her complications rate, and an increasing number of insurers are mimicking the Centers for Medicare and Medicaid Services and refusing to pay for hospital-acquired complications. Hospitals will also be more likely to admonish surgeons that routinely admit high-risk patients.
Although these disincentives will apply to other high-risk patient groups, the sheer numbers of overweight patients might be incentive enough for surgeons to find better ways to mitigate the risks. As the percentage of obese individuals in society increases, it may accelerate the adaptation of risk adjustment tools and reimbursement schedules to reflect the added effort involved in providing surgical care for this patient group.
No immediate answer to this potential increase in risk avoidance exists. Risk adjustment to even the playing field is poorly—if ever—done, and the methodologies for doing this in orthopaedics are not well developed. Some regions have increased reimbursement for different levels of obesity, but this is a very isolated phenomenon; most major insurance carriers ignore the “22” modifiers for obesity. Each practice should have objective criteria as to what is considered a safe BMI for surgery and have protocols available to help patients reach that goal.
The obesity “epidemic” poses many challenges to an orthopaedic practice. It costs little to provide access and compassionate care, but disincentives to surgical interventions are increasing. Orthopaedic practices will need to balance those disincentives with the positive aspects of providing care for a growing number of usually very grateful patients, taking into account the individual surgeon’s skills, training, and local support.
Lowering potential external barriers to access to care for obese patients and other at-risk patient groups is beyond the scope of this essay; such efforts might ultimately be best led by coalitions of professional societies and patient advocacy groups.
For more information on practice-management related issues, visit the AAOS online Practice Management Center, www.aaos.org/pracman
Adolph J. “Chick” Yates Jr., MD, is a member of the Practice Management Committee, representing academic practices. He can be reached at email@example.com