How patients make choices

Right now, the news is obviously focused elsewhere, and it’s hard to talk about anything else. But, health policy and health care is what we focus on here, and so we shall. I’m also still at the PAS meeting, so I’m catching up on my reading.

There was a great article in the NYT a few days ago talking about a study recently published in Obesity*. It’s entitled, “Fat Redistribution Following Suction Lipectomy: Defense of Body Fat and Patterns of Restoration“. It sounds complicated, but it’s actually ingeniously simple. Here’s the beginning of the abstract:

No randomized studies in humans have examined whether fat returns after removal or where it returns. We undertook a prospective, randomized-controlled trial of suction lipectomy in nonobese women to determine if adipose tissue (AT) is defended and if so, the anatomic pattern of redistribution.

Healthy women with disproportionate AT depots (lower abdomen, hips, or thighs) were enrolled. Baseline body composition measurements included dual-energy X-ray absorptiometry (DXA) (a priori primary outcome), abdominal/limb circumferences, subcutaneous skinfold thickness, and magnetic resonance imaging (MRI) (torso/thighs). Participants (n = 32; 36 ± 1 year) were randomized to small-volume liposuction (n = 14, mean BMI: 24 ± 2 kg/m2) or control (n=18, mean BMI: 25 ± 2) following baseline. Surgery group participants underwent liposuction within 2–4 weeks. Identical measurements were repeated at 6 weeks, 6 months, and 1 year later. Participants agreed not to make lifestyle changes while enrolled. Between-group differences were adjusted for baseline level of the outcome variable.

Let me walk you through this. Women undergo liposuction usually to remove fat in a targeted manner from an area of their body. But no one has ever really looked at what happens to women after they have liposuction. Does the fat that’s removed come back? And if so, does it come back to the same place? What the researchers did was enroll 32 women who wanted liposuction on their lower abdomen, hips, or thighs into a randomized controlled trial. Half the women got the liposuction they wanted within 2-4 weeks. The other half were asked to wait. In order to make this palatable to them, they were told that they could get the surgery at the end of the study if they still wanted it, at a reduced price.

So what happened? It turns out that one year after the surgery, the fat came back; all of it. Some of it relocated, from the thigh to the abdomen, but the fat came back.

To me, this sounds like a great reason not to have liposuction. But here’s the kicker: the researchers told all the women in the control group (whose who had not yet had liposuction) the results of the study. And half of them still underwent the procedure.

I’m not telling you this in order to condemn personal choices or because I think everyone should make the ones that I do. It’s their money, it’s their bodies, and it’s their decision. But, when we talk about public money, and public decisions, this serves as a good reminder that not everyone thinks the same, and that many, many people would make decisions that would be considered irrational, or a waste, by others. I think that when we discuss public money, we should be able to have discussions that it’s OK to say no to some things that individuals might want.

Private insurance does that all the time. But when it comes to public money, the talk quickly heads to DEATH PANELS. When we talk about public money, many people would rather just not have the conversation, and spend less on everyone, than try and confront the issue.

*The full paper is behind a firewall.  Sorry.

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