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“Obesity Adds to OR Time for Lung Surgery” — or does it?

January 4, 2013

This article, “Obesity Adds to OR Time for Lung Surgery,” showed up in my MedPage Today email, and I just had to see if this was real. I’ve had two grandparents with lung cancer, so this kind of thing is of interest to me. I also wonder if the conclusions in this study also apply to other types of surgeries (I’m betting they do).

Heftier patients take a little longer in the operating room for lung cancer resection, although with an effect that appears limited to costs rather than outcomes, researchers found.

Duration of the procedure from room entry to exit rose by 7.2 minutes with every 10 kg/m2 higher body mass index.

This seems to be saying that a patient with a BMI of 35 will have a surgery that lasts 7.2 minutes longer than a patient with a BMI of 25. Operating room time has been estimated to cost $62 per minute, so this could be part of the reason for spiraling health care costs — doctors are taking longer to do surgeries on fat patients.

You know that insurance companies have access to these numbers, and they’ve run the analyses that tell them it’s more expensive to pay for operations on fat people because of the time factor. Let’s not even get started on how hospitals don’t always have the proper equipment to properly take care of fat patients, from large gowns to sturdy operating tables or longer medical instruments (this is covered later on in the article).

They analyzed the [Society of Thoracic Surgeon’s] general thoracic surgery database for all 19,337 patients who had lobectomy for primary lung cancer from 2006 through 2010.

Among them, 25% fit into the obese category with a BMI of 30 kg/m2 or greater and 3% were morbidly obese with a BMI of at least 40 kg/m2.

For a morbidly-obese patient at the extreme end of that scale with a BMI of 45 kg/m2, lobectomy took about 15 minutes longer than for a normal-weight patient at 25 kg/m2.

For comparison, black race conferred the same impact on total operating time as an extra 10 kg/m2 of BMI, at 7.2 minutes.

Men took 19.2 extra minutes, while preoperative chemotherapy and preoperative chest radiotherapy were associated with 12 minute and 16.8 minute longer OR times, respectively.

Fat people spend more time in the OR, but so do black people, men, and those who have had pre-operative chemotherapy or pre-operative chest radiotherapy. Yet you notice they don’t quote percentages for anything but fat people… I wonder why?

I’d like to know the percentages of black people in that database, and how many of them were fat. I’d like to know what the percentage of men in that database, and how many of them were fat. And how many of those patients in that database had pre-operative chemotherapy/chest radiotherapy and were fat. What was the intersectionality of fat with all the other conditions that resulted in longer OR time? Was that controlled for, or was it ignored? And if that intersectionality of fat/other conditions was ignored, I’d like to know why.

Now, I find the following very interesting, because it seems to directly contradict the title of the article:

Notably, hospitals that did a higher volume of lobectomies and with a higher proportion of their case mix being obese didn’t see any difference in the association between BMI and operative time.

BMI was linked to hospital stay, but in an inverse direction because of the disproportionately longer stays seen among underweight patients compared with all other weight groups (9.3 days versus 7 days at normal weight to 6.5 days among morbidly obese).

Weight category didn’t correlate significantly with 30-day mortality.

Let me get this straight: hospitals that do more lobectomies on fat people don’t actually spend more time in the OR. Really? Could it be that the more experience a surgeon has in operating on fat people, the less time it takes him? Surgeons who have access to the proper equipment don’t spend more time in the OR with fat people? Whodathunkit?

The other interesting little factoid here is that fatter people spend less time in the hospital after surgery than “normal-weight” people. Oh yeah, and weight didn’t have any significant effect on 30-day mortality. I’m betting that’s a backhanded way of saying that fat people survive surgery just as well as, if not better than, their thinner peers.

What this study is telling me is that if I ever need to have surgery of any kind, I need to find a hospital that’s equipped to deal with fat patients, has surgeons who have operated on lots of fat people, and is generally better-able to deal with fat patients than is usually the case with hospitals.

The thing I find really sad in all of this is that for a lot of fat people, none of the things a fat person needs to do to try and assure a good outcome are possible for a lot of us. Access to health insurance, so far, is spotty at best for fat people. And when a fat person can get health insurance, they’re looking at higher premiums, higher deductibles, and higher co-pays. That can make the decision to have surgery or not a difficult one, even in life-threatening circumstances (and that’s if the insurance company will even pay for life-saving procedures for a fat person with insurance).

Vesta44

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10 Comments leave one →
  1. January 4, 2013 11:04 am

    Excellent review. Will be in my newsletter this week!

  2. January 4, 2013 12:38 pm

    Great find, I love it when headlines capture the most sensational aspects of a medical study and ignore the caveats. A more realistic headline would be something like “The less experience you have operating on fatties, the more time it takes.” But that’s not very eye-catching, is it?

    Peace,
    Shannon

  3. vesta44 permalink
    January 4, 2013 2:55 pm

    The thing that really caught my attention later on in the article was that it takes more time to even prep fat people for surgery – mainly because those hospitals just aren’t equipped to deal with fat people. They don’t have the proper stretchers, operating tables, surgical instruments, gowns, beds, wheelchairs, enough staff, etc. Everything that it takes to ensure that fat patients have a good outcome from their surgeries is lacking in a lot of hospitals (unless they also do a lot of bariatric surgery, then they have everything they need to deal with fat patients….headdesk). Even though they’re lacking in what it takes to make it easier to operate on fat people and ensure good outcomes, fat people still recover faster and don’t die any more often than their thinner peers. Testimony to how being fat can be a good thing.

  4. Duckie Graham permalink
    January 4, 2013 11:10 pm

    do we really want to start charging for medical care by the minute?

    • vesta44 permalink
      January 5, 2013 12:35 am

      They’re already charging by the minute for surgery, and who knows how long they’ve been doing that. With the way Medicare/Medicaid reimbursement policies are going (down, and down, and down goes the amount the government is willing to pay for care), I don’t think it will be too long before hospitals and doctors figure out that they just might get more money from the government if they charged by the minute for everything else. After all, if a normal doctor visit is 15 or 30 minutes and Medicare/Medicaid is charged $56 but only paid $17, why wouldn’t it make sense for them to charge by the minute – say $2 per minute – at a reimbursement rate of 30%, they’d get paid $9 for a 15 minute appt, and $18 for a 30 minute appt. Either way, they’re coming out ahead. Not by much it’s true, but add that up over a day’s worth of appts, times 5 days times 52 weeks, and it adds up, especially for clinics who have multiple doctors under contract. I’m just surprised that they haven’t already thought of it and put it into effect (and with the higher reimbursement from health care insurance, they’d be making even more money).

  5. Paul Ernsberger permalink
    January 5, 2013 11:19 am

    Surgery on an obese body takes longer because there is an additional protective layer to go through. Fortunately, adipose tissue has very little blood supply and can be sliced away or suctioned out without damaging the patient. This is why liposuction doesn’t cause people to bleed to death, by the way. Suctioning out muscle tissue or any other tissue in the body would lead to a total bleed-out and death.
    The real concern for surgeons is income. They are paid by the procedure, not for their time. A surgeon’s time is worth a lot of money. A thinner clientele means they can afford that second Ferrari.

    • January 5, 2013 3:06 pm

      But doesn’t the study suggest that with the right tools, training and experience, surgeons can operate on fat patients without sacrificing time? So, is it just that they don’t want to invest up front in operating on fat people?

      Peace,
      Shannon

  6. January 6, 2013 1:24 pm

    As I read this, I was thinking the same thing Paul commented on. Yes, it does take time to move the fat, (muscle e.g. body builder) or anything else in the way. Like Atchka said, better tools and training would improve. Sarcasm alert, so let me see if I get this, lets just charge by the minute……that way the Dr. can do it quicker and slopier…..or will they take their time and be paid more? It is all so rediculous. I guess all that they can do is charge us for the extra time. If your car took longer to fix, should you be charged more than someone who’s car didnt take as long for the same thing? Im rambling on, just asking questions…Do all lung surgeries cost the same? I dont think there is an answer to this one although it is a very good blog. I always wondered why womens sizes cost more than sizes
    2-16 size. If it is the fabric, then every size would have to pay more. The difference in size 2 to a 16 is more fabric than a size 16 to an 18 yet the 18 has to pay more. There is nothing fair about any of this. So let me go back to the Dr. doing the surgery. If he has to move fat out of the way and it takes him extra time and knowledge to do no harm, is it wrong for him to charge extra? I dont know.

  7. vesta44 permalink
    January 6, 2013 6:00 pm

    Marla – Using your analogy with a car and a mechanic, I can give you some information on that that is pertinent to people and surgery (using my thyroidectomy as an example).
    My father was a mechanic for years and they go by a manual that lists the time it should take to do repairs on a vehicle. Garages use that manual to decide what it costs to fix your car – they charge so much an hour, say $80, and if the manual says it takes 2 hours to replace the timing belt on a car, and set the timing, then the car’s owner will be charged $160 for that 2 hours. Now, some garages will charge you that $160 even if their mechanic has lots of experience with changing timing belts/setting timing and can do the job in and hour and a half instead of 2 hours (meaning, for that hour and a half of work, you should have only been charged $120, thus giving them a clean profit of $40 and more time to work on other cars and charge again for that time that was designated for your car). If you get a mechanic that has little to no experience with that job, it will take him longer and you will be charged for the extra time he took – if it takes him 3 hours to do a 2-hour job, you will be charged $240 for that 3 hours, even though the job is only supposed to take 2 hours. And sometimes there will be problems with changing the timing belt and setting the timing that even an experienced mechanic didn’t foresee, and this will cause him to need more time to complete the job (and you will be charged for that extra time).
    This is relevant to surgery and what it costs for the time it takes to do any particular surgery, as you will see. Using the example in the article I quoted, let’s say that surgical time costs $62 per minute. I had to have my thyroid removed and the surgeon told me that particular surgery should take about 3.5 hours (210 minutes X $62 = $13,020). My surgeon was very experienced with this particular surgery, she had done over 300 of them, so she should know how long it takes to remove a thyroid. It took her 4.5 hours to remove mine, not because I’m fat, but because my thyroid was so enlarged, it was more difficult to be sure she got it all out. So my surgery would have been more expensive because of the longer amount of time I was in the OR (270 minutes X $62 = $16,740). Now, a surgeon with less experience on thyroidectomies might have taken even longer than that with mine, and probably would have taken longer with a routine thyroidectomy, thus adding to the cost of the time spent in the OR.
    To take the analogy a bit further, using the other one you mentioned – clothing and how much more expensive larger sizes are than straight sizes. I’ve made clothing for people who wear anything from a size 6 to a size 32, so I have a lot of experience with how much fabric it takes to make clothing in a variety of sizes. If I make a top for my friend who wears a size 12, and I make that same top for myself in a size 32, it’s going to take more fabric – 1 1/4 yards for the size 12 vs 2 yds for the size 32. It’s also going to take a few more minutes to make the larger top because the seams are longer, the sleeve openings are bigger around to hem, and the bottom of the top is bigger around to hem. So, if I pay $5 a yard for the fabric, that’s $6.25 for the size 12 and $10 for the size 32. Time at minimum wage is $7.25 – I’m experienced enough that I can make a top in 2 hours, so that size 12 would have $14.50 for labor, and the size 32 would probably take me 2 1/4 hours, $16.31 for labor. Total cost fabric and labor for the size 12: $20.75. Total cost for the size 32: $26.31. That is part of the reason that plus-size clothing costs more than straight sizes (and I didn’t include all the other costs that go into making clothing – notions, overhead, etc).
    Charging by the minute could go either way – it could be an incentive for surgeons to take more time, be more meticulous, and generally do a better job. Or it could be an incentive to hurry up and get the patient in and out so more patients can be operated on. A lot of how it’s seen as an incentive would depend on the surgeon/hospital and whether they’re more concerned with the quality of the work they do or the quantity of work done – and isn’t that the way it works with any business?

  8. The Real Cie permalink
    January 9, 2013 6:55 pm

    If they had to do abdominal surgery on me, it might take a bit more time because I have more adipose tissue in my abdomen than a thinner person. But the area where my lungs are contained does not, except for my breasts. Many women have breasts. Damn women and their breasts!
    I really don’t know, the whole thing is ridiculous.

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