RESUMO
Background: The aim of a tier 3 specialist weight management service (SWMS) is to encourage patients to lose and maintain clinically significant levels (5-10%) of weight, NICE CG43 [1], through a holistic, patient centred multidisciplinary approach. The service consists of specialist dietitians, clinical psychologist, physiotherapist and consultant endocrinologist. As levels of obesity worldwide increase, bariatric surgery is not a viable and long-term, population wide treatment option (secondary to the associated costs and patient risk). The aim of this service evaluation was to identify the cost effectiveness of a community based specialist weight management service. Methods: Using SWMS outcome database, patients were identified within this retrospective study if they had attended at least one 3 month review and had available anthropometric information. Weight changes were analysed using SPSS 20 statistical software and compared with costs identified in the literature search. Costs associated with providing the service were obtained via the service's finance department which accounts for the salaries of the healthcare professionals, room hire, and other overhead costs. A literature search was performed and manual identification within references, to determine weight loss and associated cost savings of type 2 diabetes mellitus (T2DM) diagnosis occurrence and bariatric surgery costs. This retrospective analysis was logged with the service's Trust clinical governance and did not require ethical approval. Results: Of the 249 patients within the database, 128 patients were included in this evaluation with a mean starting BMI of 42.4 kg/m2 (SD±5.6). Patients within this study had been within the service for different lengths of time ranging from 3-15 months. The mean weight loss of the cohort was 3.5% of their starting body weight, with 37 (28.9%) of patients achieving >5% weight loss. The average BMI reduction for males and females were 1.2 and 1.6 units respectively. The literature search found bariatric surgery costs ranging from £5,500 to £17,900 (depending on surgical costs, pre and post-operative appointments and complications) per person. Projected costs using UK literature of T2DM occurrence and associated treatment costs were £6411.76/ year/patient. The possibility of diagnosis of T2DM for patients of high risk was 11% diagnosis/ year. The cost of the SWMS service was £242, 000 per year. Discussion: It has been estimated that the direct cost of treating obesity and associated co-morbidities is £480m to the national health service (NHS) expenditure in England NationalAudit Office [2]. If the above findings were applied to the SWMS weight loss results, 15% of patients would no long qualify for bariatric surgery which equates to a saving of £71500-232000/ year. For patients that achieved a 5% weight loss reduction, 1.86 of these patients are less likely to develop T2DM with a potential saving of £11925.87. Savings identified in this evaluation sample total to £83,425.87-£243,925.87. Further savings associated with the reduction in obesity would be recommended for future investigations including cardiovascular disease treatments, prescription drug utilisation and other health care costs. Conclusions: There is an indication that the SWMS has the potential to be a cost neutral weight loss provider. Further research is required to gain a greater understanding of it's broader cost savings
RESUMO
Abdominal pain is a common symptom in pregnancy. Its etiology is diverse and diagnosis often poses a problem. Inflammatory disorders of extra-uterine origin such as appendicitis should always be considered as a possible cause. Three cases of appendicitis complicating pregnancy managed at the Queen Elizabeth Hospital, Barbados during the year 1993 are documented. Two presented in the antenatal period and the third postpartum. The clinical manifestations and the difficulties encountered in diagnosis are emphasised.