Private and Public Bariatric Surgery Trends in New Zealand 2004–2017: Demographics, Cardiovascular Comorbidity and Procedure Selection

Empowering Pacific Patients on the Weight Loss Surgery Pathway: A Co-designed Evaluation Study

PURPOSE

Despite having the highest medical needs by population for weight loss treatment, Pacific patients in Aotearoa New Zealand face substantial levels of attrition in publicly funded weight loss surgery programs. In collaboration with the Auckland City Hospital bariatric surgery team, a Pacific-led preoperative weight loss surgery program was co-designed, delivered, and evaluated between 2020 and 2023.

MATERIALS AND METHODS

This was a single-arm, prospective co-designed evaluation study that took place at Auckland City Hospital in Aotearoa New Zealand. Participants were Pacific patients (n = 14) referred to the weight loss surgery program. Survey and video diaries were analyzed to determine if the program had the potential to increase Pacific patient retention through the preoperative stage of weight loss surgery, increase surgery completion rates, and improve the quality of treatment experiences.

RESULTS

Nine out of 14 participants attended all preoperative sessions. Six participants subsequently underwent weight loss surgery. Program components that had positive impacts on patient success and satisfaction were accessibility, information quality, having Pacific role models, cultural safety, and the group support system. The patients found the program to be culturally anchored and there was support for the implementation of the program going forward.

CONCLUSION

This study demonstrated how a culturally anchored intervention can increase patient retention for those patients who may not respond to mainstream treatment. Adjusting existing preoperative weight loss surgery programs to integrate Pacific-led models of healthcare has the potential to increase Pacific patient resiliency to follow through with surgery.

Development of the national bariatric prioritization tool in Aotearoa New Zealand

BACKGROUND

Bariatric surgery is a proven effective method of reducing obesity and reversing or preventing obesity-related comorbidities. The aim of this study is to describe the development of a tool to assist with the prioritization of patients with obesity for bariatric surgery. The tool would meet the criteria for being evidence-based, fair, implementable and transparent.

METHODS

The development of the tool involved a validated step-by-step process based on the consensus of clinical judgement of the New Zealand Ministry of Health working party. The process involved elicitation of criteria, clinical ranking of vignettes and creation of weightings using the 1000Minds® tool. The concurrent validity was tested by comparing tool rankings of vignettes to clinical judgement rankings.

RESULTS

Four major criteria (impact on life, likelihood of achieving maximum benefit with respect to control of diabetes, duration of benefit and surgical risk) are used to characterize the need and potential to benefit. The impact on life criterion has the largest weighting (up to 44.3%). There was good concurrent validity with a correlation coefficient r = 0.67.

CONCLUSION

The tool as presented is evidence-based, transparent and internally valid. The next step is to assess the predictive validity of the tool using real patient data to evaluate the effectiveness of the tool and determine what modifications may be required.

Variation in publicly funded bariatric surgery in New Zealand by ethnicity: cohort study of 328,739 patients

BACKGROUND

New Zealand health services are responsible for equitable health service delivery, particularly for Māori, the Indigenous peoples of New Zealand. Recent research has indicated the presence of inequities in publicly funded bariatric surgery in New Zealand by ethnicity, but it is unclear whether these inequities persist after adjustment for co-morbidities.

OBJECTIVES

To determine whether receipt of publicly funded bariatric surgery varies by ethnicity, after adjustment for co-morbidities.

SETTING

New Zealand primary care.

METHODS

A cohort study of New Zealanders aged 30-79 years who had cardiovascular risk assessment in primary care between January 1, 2010 and June 30, 2018. Data were collated and analyzed using an encrypted unique identifier with regional and national datasets. Cox proportional hazard modeling was performed to determine the likelihood of receipt of a primary publicly funded bariatric procedure up to December 31, 2018, after adjustment for sex, age, ethnicity, locality, socioeconomic deprivation, body mass index, diabetes status, smoking status, and co-morbidities.

RESULTS

A total of 328,739 participants (44% female, median age 54 yr [interquartile range, IQR, 46-62], 54% European, 13% Māori, 13% Pacific, 20% Asian) were included in the study and followed up for a median of 5.6 years (IQR 4.1-6.9). The likelihood of receipt of bariatric surgery was lower for Māori and Pacific compared with Europeans (adjusted hazard ratio .82 [95% CI .69-.96] and .24 [.20-.29], respectively). The likelihood of receiving bariatric surgery was also inversely related with increasing socioeconomic deprivation and rurality.

CONCLUSIONS

Consistent with data worldwide, there is evidence of unequal access to publicly funded bariatric surgery by ethnicity, locality as well as socioeconomic deprivation among New Zealanders who were cardiovascular risk assessed in primary care.

Missing something? A scoping review of venous thromboembolic events and their associations with bariatric surgery. Refining the evidence base

Background

Venous thromboembolic events (VTE) post-bariatric surgery (BS) lead to morbidity and mortality.

Methods

This scoping review assessed whether reported VTE post-BS could be under/over-estimated; suggested a possible number of VTE post-BS; appraised whether VTE are likely to decrease/increase; examined BS as risk/protective factor for VTE; and mapped the gaps, proposing potential solutions.

Results

VTE appears under-estimated due to: identification/coding of BS and VTE; reporting of exposure (BS); and reporting of outcomes (VTE). The review proposes a hypothetical calculation of VTE post-BS. VTE are unlikely to decrease soon. BS represents risk and protection for VTE. Better appreciation of VTE-BS relationships requires longer-term strategies.

Conclusion

VTE are underestimated. Actions are required for understanding the VTE-BS relationships to in order to crease VTE by better-informed prevention strategy/ies.

Sleeve gastrectomy or gastric bypass: a "post-code" lottery? A comprehensive national analysis of the utilization of bariatric surgery in Switzerland between 2011-2017

BACKGROUND

Sleeve gastrectomy (SG) recently became the most frequently performed bariatric surgery (BS) worldwide, overtaking the long-time standard Roux-en-Y gastric bypass (RYGB). Main indications for one or the other procedure show large inter-center variations and warrant further investigations.

OBJECTIVES

The aim of this study was to identify the influencers of primary BS selection in Switzerland.

SETTING

Switzerland.

METHODS

Retrospective analysis of all hospitalizations in Switzerland January 1, 2011 through December 31, 2017 with anonymized data provided by the Swiss Federal Statistical Office. BS procedures were identified based on ICD-10 and national surgical codes. Statistical analyses were performed with R.

RESULTS

During the study period 27,375 BS were performed. The annual BS caseload doubled over time, whereas inpatient complications decreased (∼-33%). RYGB was the prevailing procedure, although its annual proportion decreased from 80% to 70% over 7 years. Meanwhile, use of SG increased from 14% to 23%. Primary RYGB and SG had similar rates of inpatient mortality (∼.05%) and morbidity (8.0 versus 7.4%, P =.148), with the exception of higher ileus rates following RYGB (.7 versus .1%, P < .001). Patient-related factors favoring the indication of SG were male sex, extremes of age, and metabolic co-morbidities , while gastroesophageal reflux disease and private insurance-favored RYGB. Strikingly, differences between geographic regions outweighed patient-related factors in procedure selection: inhabitants of German- and Italian-speaking areas had higher likelihood (OR 4.6; 3.9, P < .001) to receive SG than those in French-speaking areas.

CONCLUSION

Geographic differences in primary BS procedure selection indicate a lack of objective rationales. Long-term risk-benefit and cost-effectiveness analyses are needed to assist evidence-based decision making.

Five-Year Weight Loss Outcomes in Laparoscopic Vertical Sleeve Gastrectomy (LVSG) Versus Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) Procedures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Laparoscopic vertical sleeve gastrectomy (LVSG) has overtaken the laparoscopic Roux-en-Y gastric bypass (LRYGB) as the most frequently performed bariatric surgical procedure. To date little has been reported on the long-term outcomes of the LVSG procedure comparative to the traditionally favoured LRYGB. We undertook a systematic review and meta-analysis to review the 5-year outcomes of comparing LVSG and LRYGB. We undertook a systematic review and meta-analysis to compare 5-year weight loss outcomes of randomized controlled trials comparing LVSG to LRYGB.

MATERIALS AND METHODS

Searches of electronic databases (PubMed, Embase, CINAHL, Cochrane) were undertaken for randomized controlled trials describing weight loss outcomes in adults at 5 years postoperatively. Where sufficient data was available to undertake meta-analysis, the Hartung-Knapp-Sidik-Jonkman estimation method for random effects model was utilized. The review was registered with PROSPERO and reported following in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

Five studies met the inclusion criteria totaling 1028 patients (LVSG=520, LRYGB=508). Moderate but comparable levels of bias were observed within studies. Statistically significant body mass index loss ranged from -11.37 kg/m (range: -6.3 to -15.7 kg/m) in the LVSG group and -12.6 kg/m (range: -9.5 to -15.4 kg/m) for LRYGB at 5 years (P<0.001). Systematic review suggested that LRYGB produced a greater weight loss expressed as percent excess weight and percent excess body mass index loss than LVSG: this was not corroborated in the meta-analysis.

CONCLUSIONS

Five year weight loss outcomes suggest both LRYGB and LVSG are effective in achieving significant weight loss at 5 years postoperatively, however, differences in reporting parameters limit the ability to reliably compare the outcomes using statistical methods. Furthermore, results may be impacted by large dropout rates and per protocol analysis of the 2 largest included studies. Further long-term studies are required to contradict or validate the results of this meta-analysis.