Commentary

Withholding elective surgery in smokers, obese patients


 

No one will argue that obesity and tobacco aren’t serious public health issues, underlying many causes of morbidity and mortality. As a result, they’re driving factors behind a fair amount of health care spending.

In England, the county of Hertfordshire recently adopted a new approach to this: a ban on routine, nonurgent surgeries for both. Those with a body mass index of 30-40 kg/m2 must lose 10% of their weight over 9 months to qualify for a procedure, while those with a BMI above 40 must lose 15%. Smokers have to go 8 weeks without a cigarette and take breath tests to prove it.

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The group that formulated the plan noted that resources to help these groups achieve such goals are (and will continue to be) freely available.

Not unexpectedly, the plan is controversial. Robert West, MD, a professor of health psychology and director of tobacco studies at the University College London, told CNN that “rationing treatment on the basis of unhealthy behaviors betrays an extraordinary naivety about what drives those behaviors.”

Of course, this debate is nothing new. In December 2014, I wrote about surgeons in the United States who were refusing to do elective hernia repairs on smokers because of their higher complication rates.

A lot of this is framed in terms of money, since that’s the driving factor. Obese patients and smokers do have higher rates of surgical complications in general, with longer recoveries and, hence, higher costs. This policy tries to put greater responsibility on patients to maintain their own health and well-being. After all, financial resources are a finite, shared commodity.

Dr. Allan M. Block, a neurologist is Scottsdale, Ariz.

Dr. Allan M. Block

You can argue this in the other direction, too. Putting off elective procedures (let’s use knee replacements as an example) could increase other expenses: more visits to pain specialists, more tests, a greater risk of falls, and increased use of steroid and cartilage injections, NSAIDs, and narcotics with their respective complications. The financial sword cuts both ways.

Like everything in modern health care, there’s no easy answer. Insurers and doctors try to balance better outcomes vs. greater good and cost savings.

Medicine is, and always will be, an ongoing experiment, where some things work, some don’t, and we learn from time and experience.

Unfortunately, patients and their doctors are often caught in the middle, trapped between market and political forces on one side and caring for those who need us on the other. That’s never good, or easy, for those directly involved with individual patients on the front lines of medical care.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

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