title: Is selection bias toward super obese patients in the rationing of metabolic surgery justified?--A pilot study from the United Kingdom.
abstract: BACKGROUND
  Recent evidence suggests that National Health Service (NHS) rationing of bariatric surgery is biased toward super-obese patients without scientific basis. The aim of this study was to compare health, quality of life, and employment outcomes in morbidly obese (MO) versus super-obese (SO) patients after laparoscopic Roux-en-Y gastric bypass (LRYGB) to provide a basis for rationing.
  
  
  METHODS
  Consecutive patients undergoing LRYGB from January 2008-September 2009, with baseline body mass index (BMI)<45 kg/m(2) (MO) and BMI>60 kg/m(2) (SO) were identified from a prospective database. Seventy-six eligible patients were invited to complete a questionnaire comprising BAROS (bariatric analysis and reporting outcome system), EQ-5D (EuroQol-5D), EQVAS (Euro-QoL visual analog score), and employment status preoperatively and postoperatively. Anthropometric, demographic, and clinical data were recorded.
  
  
  RESULTS
  Fifty-one patients responded: 23 MO and 28 SO. Groups were matched for demographic characteristics and co-morbidities. The MO group had significantly higher percentage excess weight loss (%EWL) (82% versus 53%; t test: P<.001) and mean BAROS score (5.47 versus 4.21; t test: P = .025) than the SO group. EQ-5D improved significantly for both groups in 3 domains (self care, anxiety/depression, and pain/discomfort); there was no significant difference in improvement between groups. EQVAS was significantly higher for the MO group (90 versus 70; Mann-Whitney U: P = .001). Employment status changed for 8 patients postoperatively, but there was no significant difference between groups.
  
  
  CONCLUSIONS
  These results suggest that MO patients appear to benefit more than SO patients from LRYGB and yet seem to be disadvantaged in some NHS Trusts in the United Kingdom for access to bariatric surgery. This study provides a baseline framework for further research to generate evidence for more scientific rationing of bariatric surgery.
authors.affiliation: Department of Upper Gastrointestinal Surgery, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom.
authors.forename: Ravindra S
authors.initials: RS
authors.lastname: Date
authors.forename: Sarah-Jane Y
authors.initials: SJ
authors.lastname: Walton
authors.forename: Neil
authors.initials: N
authors.lastname: Ryan
authors.forename: Salma N
authors.initials: SN
authors.lastname: Rahman
authors.forename: Natasha C
authors.initials: NC
authors.lastname: Henley
mesh_terms: D000328:Adult; D050110:Bariatric Surgery / Q000191:economics / Q000379:methods; D015992:Body Mass Index; D015331:Cohort Studies; D005260:Female; D015390:Gastric Bypass / Q000191:economics* / Q000379:methods / Q000706:statistics & numerical data; D015276:Health Care Rationing / Q000191:economics*; D006801:Humans; D010535:Laparoscopy / Q000191:economics / Q000379:methods; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000175:diagnosis / Q000453:epidemiology* / Q000601:surgery*; D010865:Pilot Projects; D011788:Quality of Life; D018570:Risk Assessment; D015983:Selection Bias; D011795:Surveys and Questionnaires; D016896:Treatment Outcome; D006113:United Kingdom; D015431:Weight Loss
keywords: Employment; Morbid obesity; Rationing of healthcare service; Super-obese quality of life