Bariatric Times - August 2008 - (Page 12) 12 Bariatric Center Spotlight Bariatric Times • August 2008 Establishing a Laparoscopic Bariatric Surgery Program in the Nation’s Oldest Public Hospital Bellevue Hospital Center New York, New York by Manish Parikh, MD; JK Saunders, MD; Marina Kurian, MD; George Fielding, MD; Christine Ren, MD; and H. Leon Pachter, MD All from the Department of Surgery, NYU School of Medicine RATIONALE FOR INITIATION OF A NEW PROGRAM Of the millions of morbidly obese Americans eligible for bariatric surgery, a disproportionate number are minorities, poorly educated, or impoverished, and up to 38 percent rely on Medicare or Medicaid1 for their health insurance. Of the morbidly obese population: • 21% are African-American • 10% are Hispanic • 29% live near or below the poverty line • 54% have a high school education degree or less • 19% have Medicaid. Despite increasing numbers of bariatric procedures performed nationwide, (from 72,000 in 2002 to 200,000 in 2007), the subset of morbidly obese described above are underutilizing bariatric surgery, likely due to lack of healthcare access. In a recent analysis of nationwide trends of bariatric surgical procedures being performed, Hantry et al2 found that a disproportionate, higher number of patients with private insurance or who reside in wealthy zip codes seek bariatric surgery, and these proportions have been increasing over time. Contrarily, an increasingly lower percentage of patients undergoing bariatric surgery are those earning less than $25,000 or those who are Medicaid patients. Thus there is a significant mismatch between the population needs for bariatric surgery and its availability. Nineteen percent of morbidly obese people have Medicaid insurance, yet only five percent of the bariatric operations are being done on Medicaid patients. There are clearly substantial numbers of patients who are eligible for bariatric surgery who are unable to receive this lifesaving operation due to the lack of access to obesity surgery treatment. These patients have financial limitations that preclude them from seeking bariatric surgery at private hospitals. Bellevue Hospital Center in New York City is the oldest public hospital in the US (founded in 1736). As the flagship 900-bed facility and tertiary referral center of New York City’s Health and Hospitals Corporation (comprising 13 hospitals overall), Bellevue handles 500,000 outpatient clinic visits, 100,000 emergency patients, and 26,000 inpatients each year. The hospital has an attending physician staff of 1,800 and over 1,000 housestaff from its neighboring academic affiliate, New York University School of Medicine. Over 80 percent of Bellevue’s patients come from the city’s medically underserved populations. Demographic data of the Bellevue Hospital Adult Primary Care Clinic revealed that 41 percent of patients have BMI>30kg/m2 and 10 percent have BMI>40kg/m2. In other words, 1 out of every 10 adults seen at Bellevue fulfills National Institutes of Health (NIH) criteria for bariatric surgery! It is only fitting that Bellevue Hospital offers laparoscopic bariatric surgery in order to make a major impact on the underserved morbidly obese of New York City. GUIDELINES FOR STARTING A LAPAROSCOPIC BARIATRIC PROGRAM The most critical factor for success in starting a new program is an institutional commitment at the highest level (medical and administrative). Armed with clinical and financial data, we created a blueprint of the potential program. Planning commenced in September 2007 with the creation of a Bariatric Surgery Task Force that established clinical and administrative workgroups responsible for the development of various aspects of the program. In order to ensure the delivery of bariatric surgical care with the highest levels of efficacy and safety, the Center of Excellence (COE) criteria set forth by the American Society for Metabolic and Bariatric Surgery (ASMBS) were used as guidelines (Table 1). The workgroups formed centered on fulfilling these COE criteria ranging from credentialing/privileging issues (medical staff), space preparation and support needs—including appropriate furnishings, and floor-mounted toilets (facilities management), and operating room equipment/supplies, including highweight capacity surgical beds, long laparoscopic trays, heavy duty chairs, and larger-sized patient gowns (materials management and perioperative services). In addition, a staff education workgroup was formed to coordinate educational in-services for clinical and nonclinical staff. Quality management developed performance-monitoring tools (based on the Bariatric Outcomes Longitudinal Database [BOLD] created by the Surgical Review Corporation) and data collection resources and established an interdisciplinary forum for the continuous review and evaluation of the bariatric program. The public relations department developed program brochures (in English and Spanish) and informational materials for patients. Fortunately, we were able to draw upon the vast experience and expertise of the highly successful NYU Program for Surgical Weight Loss (Drs. Kurian, Fielding, and Ren). The goal of this program is to develop a comprehensive “Center for Obesity and Metabolic Diseases” that encompasses medical weight management, nutritional counseling, psychological therapy, and bariatric surgery. A preexisting Medical Weight Management Clinic (for patients with BMI>30) serves as the referral base for the bariatric surgery program. The medical weight management clinic receives 20 to 30 referrals monthly, has a six-month waiting list of over 200 patients, and has a payor mix of 57% Medicaid, 24% uninsured, 14% Medicare, and 5% commercial insurance. We work closely with the finance department to enroll the uninsured morbidly obese in Medicaid or a managed Medicaid program. The weekly bariatric surgery clinic opened in November 2007. Nutritional
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