Travel distance reduces follow-up compliance but has no effect on long-term weight loss success in bariatric patients

Sex- and operation-dependent effects on 5-year weight loss results of bariatric surgery

BACKGROUND

Weight loss response after bariatric surgery is highly variable, and several demographic factors are associated with differential responses to surgery. Preclinical studies demonstrate numerous sex-specific responses to bariatric surgery, but whether these responses are also operation dependent is unknown.

OBJECTIVE

To examine sex-specific weight loss outcomes up to 5 years after laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).

SETTING

Single center, university, United States.

METHODS

Retrospective, observational cohort study including RYGB (n = 5057) and vertical SG (n = 2041) patients from a single, academic health center. Percentage total weight loss (TWL) over time was examined with generalized linear mixed models to determine the main and interaction effects of surgery type on weight loss by sex.

RESULTS

TWL demonstrated a strong sex-by-procedure interaction, with women having a significant advantage with RYGB compared with SG (adjusted difference at 5 yr: 8.0% [95% CI: 7.5-8.5]; P < .001). Men also experienced greater TWL over time with RYGB or SG, but the difference was less and clinically insignificant (adjusted difference at 5 yr: 2.9% [2.0-3.8]; P < .001; P interaction between sex and procedure type = .0001). Overall, women had greater TWL than men, and RYGB patients had greater TWL than SG patients (adjusted difference at 5 yr: 3.1% [2.4-3.2] and 6.9% [6.5-7.3], respectively; both P < .0001). Patients with diabetes lost less weight compared with those without (adjusted difference at 5 yr: 3.0% [2.7-3.2]; P < .0001).

CONCLUSIONS

Weight loss after bariatric surgery is sex- and procedure-dependent. There is an association suggesting a clinically insignificant difference in weight loss between RYGB and SG among male patients at both the 2- and 5-year postsurgery time points.

Factors Impacting One-year Follow-up Visit Adherence after Bariatric Surgery in West China: A Mixed Methods Study

PURPOSE

Quality follow-up (FU) is crucial after bariatric surgery. However, poor adherence after surgery is prevalent. This research aimed to explore the factors related to FU adherence after bariatric surgery in West China.

MATERIALS AND METHODS

This study used a sequential explanatory mixed-methods research design. Participants (n = 177) were identified from the West China Hospital. Demographic information, disease profile, treatment information, and post-surgery FU information were obtained from the bariatric surgery database of the Division of Gastrointestinal Surgery of the West China Hospital. The survey data were analyzed using logistic regression. Semi-structured interviews with participants (n = 10) who had low adherence were conducted. The recording was transcribed verbatim and entered into qualitative data analysis software. Qualitative data were analyzed using a content analysis approach.

RESULTS

Multiple logistic regression revealed that living in Chengdu (OR, 2.308), being employed (OR, 2.532), non-smoking (OR, 2.805), and having less than five years of obesity (OR, 2.480) were positive predictors of FU adherence within one year. Semi-structured interviews suggested that factors related to adherence to FU were lack of motivation, lack of opportunity, insufficient ability, and beliefs regarding consequences.

CONCLUSION

Factors impacting one-year FU visit adherence after bariatric surgery include not only demographic and disease-related factors but also social and family factors. These results will provide evidence to support healthcare professionals in developing personalized postoperative FU management strategies.

Transportation Factors and Postoperative Attendance and Weight Loss Through 24 Months

PURPOSE

Transportation, access to follow-up care, and association with weight loss are understudied in the bariatric population. The objective of this study was to determine how transportation variables associate with postoperative attendance and weight loss through 24 months.

MATERIALS AND METHODS

Seven hundred eighty-seven patients (81.3% female; 59.1% White) who had primary surgery (48.6% gastric bypass) from 2015 to 2019 were included. Sidewalk coverage and number of bus stops from patients' homes, driving distance in miles and minutes from patients' homes to the nearest bus stop and the clinic were measured. Bivariate analyses were conducted with the transportation variables and attendance and %TWL at 2 or 3, 6, 12, and 24 months. One mixed multilevel model was conducted with dependent variable %TWL over 24 months with visits as the between-subjects factor and covariates: race, insurance, surgical procedure, and driving distance to the clinic in minutes, attendance, and %TWL over 24 months; an interaction between distance, attendance, and visits.

RESULTS

There were no significant differences between the majority of the transportation variables and postoperative attendance or %TWL. Patients who had perfect attendance had improved %TWL at 12 months [t(534)=-1.92, p=0.056] and 24 months [t(393)=-2.69, p=0.008] compared to those who missed at least one appointment. Patients with perfect attendance and who had shorter driving times (under 20 min) to the clinic had greater weight loss through 24 months [F(10, 1607.50)=2.19, p=0.016)].

CONCLUSIONS

Overall, transportation factors were not associated with attendance and weight loss, with the exception of the interaction between shorter driving minutes to follow-up and perfect attendance.

Patient Travel Distance to Neurologist Visits

BACKGROUND AND OBJECTIVES

The density of neurologists within a given geographic region varies greatly across the United States. We aimed to measure patient travel distance and travel time to neurologist visits, across neurologic conditions and subspecialties. Our secondary goal was to identify factors associated with long-distance travel for neurologic care.

METHODS

We performed a cross-sectional analysis using a 2018 Medicare sample of patients with at least 1 outpatient neurologist visit. Long-distance travel was defined as driving distance ≥50 miles 1-way to the visit. Travel time was measured as driving time in minutes. Multilevel generalized linear mixed models with logistic link function, which accounted for clustering of patients within hospital referral region and allowed modeling of region-specific random effects, were used to determine the association of patient and regional characteristics with long-distance travel.

RESULTS

We identified 563,216 Medicare beneficiaries with a neurologist visit in 2018. Of them, 96,213 (17%) traveled long distance for care. The median driving distance and time were 81.3 (interquartile range [IQR]: 59.9-144.2) miles and 90 (IQR: 69-149) minutes for patients with long-distance travel compared with 13.2 (IQR: 6.5-23) miles and 22 (IQR: 14-33) minutes for patients without long-distance travel. Comparing across neurologic conditions, long-distance travel was most common for nervous system cancer care (39.6%), amyotrophic lateral sclerosis [ALS] (32.1%), and MS (22.8%). Many factors were associated with long-distance travel, most notably low neurologist density (first quintile: OR 3.04 [95% CI 2.41-3.83] vs fifth quintile), rural setting (4.89 [4.79-4.99]), long-distance travel to primary care physician visit (3.6 [3.51-3.69]), and visits for ALS and nervous system cancer care (3.41 [3.14-3.69] and 5.27 [4.72-5.89], respectively). Nearly one-third of patients bypassed the nearest neurologist by 20+ miles, and 7.3% of patients crossed state lines for neurologist care.

DISCUSSION

We found that nearly 1 in 5 Medicare beneficiaries who saw a neurologist traveled ≥50 miles 1-way for care, and travel burden was most common for lower-prevalence neurologic conditions that required coordinated multidisciplinary care. Important potentially addressable predictors of long-distance travel were low neurologist density and rural location, suggesting interventions to improve access to care such as telemedicine or neurologic subspecialist support to local neurologists. Future work should evaluate differences in clinical outcomes between patients with long-distance travel and those without.

Factors Associated With Loss to Follow-up After Laparoscopic Sleeve Gastrectomy: A Single-Center Retrospective Study

Purpose

After bariatric surgery, postoperative follow-up is important for evaluating long-term outcomes, such as successful weight loss and improvement of metabolic parameters. However, many patients are lost to follow-up within 1 year. This study aimed to identify the follow-up rate of bariatric surgery and predictive factors of loss to follow-up (LTF).

Materials and Methods

We retrospectively reviewed the data of 61 patients receiving bariatric surgery for obesity (laparoscopic sleeve gastrectomy; LSG group) and 872 for early gastric cancer (EGC group) from November 2018 to July 2020 in a single center. After 1:1 matching, we compared the LTF rate. In the LSG group, we analyzed the factors associated with LTF. Additionally, we collected weight data in the LTF group by a telephone survey.

Results

By 1:1 matching, 47 patients for each group were identified. The LTF rates of the LSG and EGC groups were 34.0% (16 patients) and 2.1% (one patient), respectively (P=0.0003). In the LSG group, the LTF rate increased over the postoperative month. Of the patients, 29.5% who missed a scheduled appointment within one year comprised the LTF group. In the analysis, no significant factors associated with LTF were identified. The only factor with borderline significance was dyslipidemia with medication (P=0.094).

Conclusion

The LSG group demonstrated a high LTF rate, although adherence to follow-up was closely related to postoperative outcomes. Therefore, educating patients on the significance of follow-up is important. Particularly, continuous efforts to identify the associated factors and develop a multidisciplinary management protocol after bariatric surgery are necessary.

Factors Associated With Loss to Follow-up During the First Year After Total Knee Arthroplasty

Despite increased pressure to capture patient-reported outcome measures for at least 1 year following total joint arthroplasty (TJA), follow-up rates during the first year after TJA are typically lower than desired and may result in biased findings if data are not missing at random. We conducted a retrospective review of medical records of primary total knee arthroplasty patients treated by a single surgeon at an urban academic private hospital. Main measures were demographics (sex, age, race, and insurance), body mass index, travel distance to clinic, and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Multivariable regression analyses were performed to identify patient characteristics associated with attendance at follow-up visits and predictors of attendance at 6-month follow-up. Among the 205 study patients, follow-up visit attendance declined from a high of 95.7% at day 14 to lows of 69.2% at 6 months and 64.4% at 1 year. Attendance at the previously scheduled follow-up visit was a statistically significant predictor of attendance at 3-month (P=.0015), 6-month (P=.0002), and 1-year (P<.0001) follow-up visits, and travel distance was significantly associated with attending the 1-year follow-up visit (P=.042). Patients with the most favorable KOOS Symptom, Pain, and Function in daily living subscale scores at 3-month follow-up were significantly less likely to attend the 6-month follow-up visit than patients with the least favorable KOOS scores. Prospective studies are needed to identify the full range of factors that may contribute to high rates of loss to follow-up after TJA, which should be of concern to researchers, clinicians, and hospitals. [Orthopedics. 2023;46(2):93-97.].

The Impact of Clinical Follow-Up After Revascularization on the Outcomes of Patients with Chronic Limb Threatening Ischemia

BACKGROUND

Guidelines for optimal follow-up for patients undergoing lower extremity revascularization (LER) for peripheral arterial disease recommend multiple visits with imaging during the first year followed by yearly monitoring thereafter. Critical limb-threatening ischemia (CLTI) patients are at a greater risk for mortality and limb amputation than claudicants and thus necessitate closer monitoring. The goal of this article is to study the effects of compliance with follow-up after revascularization for patients with CLTI on major amputation rates and mortality.

METHODS

A single-center retrospective chart review of consecutive patients undergoing LER for CLTI was performed. Patients were stratified based on compliance with follow-up to compliant or noncompliant cohorts. Patient characteristics, reinterventions, and perioperative and long-term outcomes were compared between the 2 groups.

RESULTS

There were 356 patients undergoing LER and 61% (N = 218) were compliant. There was no significant difference in baseline characteristics between the 2 groups. Noncompliant patients were more likely to undergo endovascular interventions compared to compliant patients (92.8% vs. 79.4%, P = 0.03). There was no difference in perioperative outcomes between the 2 groups with overall 30-day mortality of 0.6%. After mean follow-up of 2.7 years, compliant patients had greater ipsilateral reintervention rates (49.1% vs. 34.1%, P = 0.005) and overall reintervention rates (61% vs. 44.2%, P = 0.002) compared to noncompliant patients. There was no significant difference in mortality or ipsilateral major amputations between the 2 groups.

CONCLUSIONS

Patients who were compliant with follow-up after LER for CLTI underwent more reinterventions with no difference in mortality or major limb amputation. Further research regarding the threshold for reintervention and the optimal schedule for follow-up in patients with CLTI is needed.

Factors associated with loss to follow-up after radiation therapy for head and neck cancer

OBJECTIVES

Head and neck cancer (HNC) patients are at high risk for late occurring radiation-related morbidity and recurrence, necessitating close long-term medical surveillance. This study identified factors associated with becoming lost to follow-up (LTFU) at a comprehensive cancer center.

MATERIALS AND METHODS

Patients were drawn from survivors who received radiation for HNC at a single institution between 2001 and 2018. LTFU was defined as living patients without a clinical encounter within 2 years of the data query.

RESULTS

In total, 537 patients met the inclusion criteria and 57 (10.6%) were identified as LTFU. Individual comparisons identified time since completing radiation, non-White race and being unmarried as associated with LTFU. Multiple regression identified time since treatment and being unmarried as factors associated with LTFU. A decision tree correctly sorted 89.4% using time, distance, and marital status.

CONCLUSION

Time since radiation, distance to clinic, and being unmarried were factors associated with becoming LTFU.

Predictors of 30-day follow-up visit completion after primary bariatric surgery: an analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry

BACKGROUND

Adherence to follow-up visits is often unsatisfactory after bariatric surgery.

OBJECTIVES

To identify predictors, including surgery type and preoperative demographics, body mass index (BMI), medical conditions, and smoking status, of 30-day follow-up visit completion.

SETTING

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participating centers (2015-2018).

METHODS

Patients who underwent primary Roux-en-Y gastric bypass or sleeve gastrectomy were included in this analysis. Data were analyzed using weighted logistic regression. Subanalyses included stratification of the sample by sex and age (<45, 45-60, and >60 years).

RESULTS

Patients (n = 566,774) were predominantly female (79.6%), White (72.4%), non-Hispanic (77.9%), and middle-aged (44.5 ± 11.9 years), with a mean BMI of 45.3 ± 7.8 kg/m². More than 95% of patients completed the 30-day visits. In the whole-sample analysis, older age (odds ratio [OR], 1.02) and the presence of non-insulin-dependent diabetes (OR, 1.04), hypertension (OR, 1.03), hyperlipidemia (OR, 1.10), obstructive sleep apnea (OR, 1.15), and gastroesophageal reflux disease (OR, 1.16) were positive predictors of the 30-day visit completion (P_s < .01). Conversely, sleeve gastrectomy procedure (OR, .86), Black race (OR, .87), Hispanic ethnicity (OR, .94), and the presence of insulin-dependent diabetes (OR, .96) and smoking (OR, .83) were negative predictors (P_s < .01). Several differences emerged in subanalyses. For example, in sex stratification, Hispanic ethnicity lost its significance in men. In age stratification, BMI and male sex emerged as positive predictors in the age groups of <45 and 45-60 years, respectively.

CONCLUSION

Although challenged by small effect sizes, this analysis identified subgroups at a higher risk of being lost to follow-up after bariatric surgery.

Five-year attrition, active enrollment, and predictors of level of participation in the Longitudinal Assessment of Bariatric Surgery (LABS-2) study

BACKGROUND

Reporting high-quality bariatric surgery outcomes depends on participant attrition and level of study participation among enrolled participants.

OBJECTIVES

Our aims are to report participant attrition, active enrollment, and level of participation, and to evaluate pre-surgery sociodemographic, physical health, and psychosocial factors as predictors of attrition and level of participation through 5 years.

SETTING

The Longitudinal Assessment of Bariatric Surgery-2 study which enrolled 2458 adults undergoing a first bariatric surgical procedure at 1 of 6 US cites from 2006 through 2009.

METHODS

In-person research assessments were conducted pre-surgery and annually for five years. Extensive retention strategies including offering remote assessments (telephone, email, mail, or a combination) were fully implemented in 2009. Among living participants, including those inactivated, annual follow-up assessments were categorized as in-person, remote or missed through 5 years.

RESULTS

By year 5, 1.7% of participants had died and 3.2% had withdrawn or were inactivated by the study staff; thus, attrition was 4.9% (n = 121). Controlling for site and calendar year, missed assessments increased from 14.7%-21.8% between years 1 and 2 and then stayed relatively stable (20.8%-19.6%) for years 3-5. Younger age, male sex, White race, lower body mass index, smoking, illicit drug use, and higher weight loss expectations preoperatively were independently associated with a higher likelihood of a missed versus in-person assessment across follow-up.

CONCLUSION

The LABS-2 participant attrition was low. The percentage of missed assessments did not increase after year 2, perhaps due to implementation of a comprehensive retention plan. Predictors of missed assessments highlight subgroups to target for focused retention efforts.

Comparison of single- versus double-anastomosis duodenal switch: a single-center experience with 2-year follow-up

BACKGROUND

Single-anastomosis duodenal switch (SADS) has emerged in recent years as an alternative to the standard double-anastomosis duodenal switch (DADS). The objective of this study was to compare short- and medium-term outcomes between SADS and DADS.

METHODS

Data collected in the Ontario Bariatric Registry between 2010 and 2019 were used for this retrospective study to determine outcomes of patients undergoing primary laparoscopic SADS versus DADS at a Canadian tertiary hospital and bariatric center of excellence. The primary outcome was weight loss at 1 and 2 years after surgery. Short-term secondary outcomes included operative times, intra- and early postoperative complications, hospital length of stay (LOS), and 30-day readmissions. Medium-term secondary outcomes included late postoperative complications as well as nutritional deficiencies and persistent diarrhea at 1 and 2 years after surgery. Subgroup analyses were performed to compare patients undergoing one- and two-stage procedures.

RESULTS

Data of 107 patients who underwent SADS (n = 25) or DADS (n = 82) were included in the study. Follow-up data were available for 59/107 (55.1%) patients at 1 year and 47/107 (43.9%) at 2 years after surgery. Patients in the SADS and DADS groups had similar %TBWL at 1 year (23.6 versus 26.2, P = 0.617) and 2 years (24.8 versus 30.2, P = 0.116) after surgery. Short- and medium-term outcomes were similar between groups. There was no difference between patients undergoing one- versus two-stage procedures.

CONCLUSION

This study showed that patients undergoing SADS and DADS had similar weight loss at 1 and 2 years. Early and late postoperative morbidity, operative times, early readmissions, and LOS were also similar between groups. Further studies with longer follow-up are required to confirm these results.