Status of venous thromboembolism prophylaxis among bariatric surgeons: have we changed our practice during the past decade?

BACKGROUND: Venous thromboembolism (VTE) is considered one of the principal causes of morbidity and mortality in patients requiring bariatric surgery. A survey to all members of the American Society for Metabolic and Bariatric Surgery was conducted in 1998 and published in 2000 in the journal "Obesity Surgery." METHODS: A survey was repeated to all physician members of the American Society for Metabolic and Bariatric Surgery to determine the current practices for VTE prophylaxis. The results were compared with those of the previous study. RESULTS: Of the members, 35% completed the survey for a total of 332 responses. The number of cases annually per surgeon almost doubled since 1998 (145 versus 85). Laparoscopic gastric bypass has replaced open gastric bypass as the most common procedure performed, followed by laparoscopic gastric banding as the second most common procedure. Most surgeons (95%) use chemical prophylaxis to prevent VTE, but almost 60% preferred low-molecular-weight heparin compared with 13% in 1998. More than 60% of bariatric surgeons discharged their patients with chemical prophylaxis compared with 12% in 1998. Inferior vena cava filters for prophylaxis are considered by 55% compared with only 7% in 1998. The incidence of reported deep vein thrombosis was significantly lower in 2007 (2.635 versus .93), as was the incidence of pulmonary embolism (.95% versus .75%). Almost 50% of surgeons still reported > or =1 fatality because of VTE complications. CONCLUSION: Chemical prophylaxis for VTE with some type of heparin is the standard of care for patients undergoing bariatric surgery. Low-molecular-weight heparin is now used by two thirds of the respondents to this survey. Most surgeons who responded to the survey discharged their patients home with heparin, and many consider the use of inferior vena cava filters for VTE prophylaxis. Our findings support the American Society for Metabolic Bariatric Surgery position statement regarding VTE prophylaxis in this patient population. Research is necessary to establish the role of inferior vena cava filters, discharging patients with chemoprophylaxis and to determine the adequate dosage and duration of prophylaxis.

Diabetes white paper: Defining the delivery of nutrition services in Medicare medical nutrition therapy vs Medicare diabetes self-management training programs.

Registered dietitians (RDs) have a defined and unique role in care for patients with diabetes that differs depending on whether the service is for medical nutrition therapy (MNT) or part of a diabetes self-management training (DSMT) program (DSMT and diabetes self-management education [DSME] are used interchangeably in this article). The purpose of this article is to describe the current regulatory and practice framework that supports nutrition care under Medicare Part B for people with diabetes. A description of MNT and DSMT provided under Medicare Part B is included. The role of RDs and other health care professionals involved as program instructors in DSMT programs is also addressed. Revisions to the National Standards for Diabetes Self-Management Education are discussed to clarify RDs' involvement in DSME programs.