Sociodemographic Factors Associated with Loss to Follow-Up After Bariatric Surgery

Study protocol for a non-inferiority, multicenter, randomized study to evaluate a smartphone app-based follow-up program after bariatric surgery (BELLA plus trial)

INTRODUCTION

Adherence to follow-up (FU) care after bariatric surgery is poor despite strong recommendations. In our pilot Bella trial, we demonstrated that a completely remote follow-up program via smartphone is feasible and safe for patients after bariatric surgery. Building on this, we aim to verify our results in a multicenter, randomized controlled setting.

METHODS

This trial plans to enroll 410 participants undergoing primary bariatric surgery in seven German bariatric centers. Participants are randomized into two groups: a control group receiving in-person FU according to the standard in the bariatric centers, and an interventional group monitored using a smartphone application (app). The app sends standardized questionnaires and reminders regarding regular vitamin intake and exercises. The built-in messaging function enables patients to communicate remotely with medical care professionals. After one year, all participants are evaluated at their primary bariatric centers. The primary outcome is weight loss 12 months after surgery. The secondary outcomes include obesity-related comorbidities, quality of life, serum values of vitamins and minerals, body impedance analysis, visits to the emergency department or readmission, patient compliance, and medical staff workload.

DISCUSSION

The current study is the first prospective, individually randomized-controlled, multicenter trial where a mobile application completely replaces traditional in-person visits for post-bariatric surgery follow-ups in bariatric centers.

Sociodemographic factors related to bariatric follow-up appointment attendance and weight outcomes

BACKGROUND

Follow-up care after bariatric surgery is essential in preventing postsurgical complications and promoting long-term weight loss maintenance. However, many patients do not attend postsurgical appointments with the bariatric team, which may contribute to poor surgical outcomes.

OBJECTIVES

This study sought to understand sociodemographic factors related to follow-up appointment attendance and weight outcomes. The first objective was to determine whether there was a relationship between 1-year follow-up appointment attendance and sociodemographic factors. The second objective was to determine whether patients from certain sociodemographic groups were more likely to attend a 2-year follow-up appointment. The third objective was to determine whether there were differences in weight outcomes for patients who attended follow-up appointments compared with those who did not attend.

SETTING

University hospital, United States.

METHODS

This study was a retrospective observational study. Participants included 841 adult patients who underwent bariatric surgery, of whom 505 (60.05%) attended a 1-year appointment with the bariatric team (348 attended a follow-up visit with another medical provider), and 398 (47.32%) who had any follow-up medical visit at 2 years after surgery. Sociodemographic variables were collected during a presurgical psychological evaluation. Weight-related variables were obtained through patients' electronic medical records 12 and 24 months after surgery.

RESULTS

Younger patients and those with lower education levels were less likely to attend the 1-year follow-up appointment with the bariatric team. People who attend 1-year follow-up with bariatric team have more favorable weight outcomes at 1 year and 2 years after surgery.

CONCLUSIONS

Follow-up appointment attendance with the bariatric team may be a critical factor in the effectiveness of bariatric surgery. Bariatric surgery teams should employ strategies to increase attendance at the 1-year follow-up visit with the surgical team. Additional strategies should be enacted to increase follow-up appointment attendance for patients with lower education levels.

Factors Impacting Follow-Up Care in Allergic Fungal Rhinosinusitis

OBJECTIVE

The purpose of this study was to analyze barriers to medical care and follow-up in patients with allergic fungal rhinosinusitis (AFRS).

STUDY DESIGN

Cross-sectional questionnaire-based study with retrospective chart review.

SETTING

Tertiary Medical Center.

METHODS

Subjects with AFRS and chronic rhinosinusitis with nasal polyps (CRSwNP) were prospectively recruited for completion of the Barriers to Care Questionnaire (BCQ) and formal chart review.

RESULTS

Fifty-nine AFRS and 51 CRSwNP patients participated. AFRS patients were more likely to be lost to follow-up within 6 months of surgery (35.6% vs 17.7%, P = 0.04) and no-show at least 1 appointment (20.3% vs 5.9%, P = 0.03) compared to CRSwNP patients. Men with AFRS were more likely to have only a single follow-up visit (37.0% vs 3.1%, P < 0.001) and be lost to follow-up (66.7% vs 9.4%, P < 0.001) than women. There were no significant differences in the BCQ between groups; however, rate of questionnaire completion was lower in the AFRS group than the CRS group (62.7% vs 80.4%, P = 0.042). AFRS patients who did not complete the BCQ were more likely to be male (63.6% vs 35.1%, P = 0.034), lost to follow-up (77.3% vs 10.8%, P < 0.0001), and have a single follow-up visit (40.9% vs 5.4%, P < 0.0001). Younger age was associated with increased likelihood of having a single follow-up visit (odds ratio 1.143, 95% CI 1.022-1.276).

CONCLUSION

Young, male AFRS patients are more frequently lost to follow-up after surgery and less likely to complete questionnaires assessing barriers to care. Further investigation is needed to assess barriers to follow-up in these at-risk groups.

After Anterior Cruciate Ligament Injury, Patients With Medicaid Insurance Experience Delayed Care and Worse Clinical Outcomes Than Patients With Non-Medicaid Insurance

Purpose

To evaluate the effects of socioeconomic factors on the operative treatment of anterior cruciate ligament injuries and outcomes following surgical reconstruction.

Methods

A retrospective cohort study of primary anterior cruciate ligament reconstruction surgeries at a single institution performed from 2011 to 2015 with minimum 2-year follow-up was conducted. Patient demographics, insurance type, workers' compensation status, surgical variables, International Knee Documentation Committee score, and failure were recorded from chart review. Education level and income were obtained via phone interview. Differences between functional outcome were compared between Medicaid and non-Medicaid groups.

Results

In total, 268 patients were included in the analysis (43 patients in the Medicaid group and 225 patients in the non-Medicaid group, overall mean follow-up of 3.1 ± 0.8 years). The Medicaid group demonstrated lower annual income (P < .001) and a lower level of completed education compared with the non-Medicaid group (P < .001). Patients who received Medicaid had a greater duration between time of initial knee injury and surgery compared with the those in non-Medicaid group (11.8 ± 16.3 months vs 6.1 ± 16.5 months, P < .001). At the time of follow-up, patients in the non-Medicaid group had a significantly greater International Knee Documentation Committee score compared with patients who received Medicaid (82.5 ± 13.8 vs 75.3 ± 20.8, P = .036).

Conclusions

Patients with Medicaid insurance were seen in the clinic significantly later after initial injury and had worse outcomes compared with patients with other insurance types. Also, patients in higher annual income brackets had significantly better clinical outcomes scores at a minimum of 2 years postoperatively.

Level of Evidence

Level III, retrospective cohort study.

Remote Follow-up with a Mobile Application Is Equal to Traditional Outpatient Follow-up After Bariatric Surgery: the BELLA Pilot Trial

PURPOSE

Medical follow-up after bariatric surgery is recommended. However, the compliance was poor. This study aimed to evaluate the feasibility of a smartphone-based fully remote follow-up (FU) program for patients after bariatric surgery.

METHODS

In the interventional group, patients were followed up using a smartphone application (app), through which questionnaires were sent regularly. Participants in the control group underwent standard FU at the outpatient clinic every three months. After 12 months, all the participants were evaluated at an outpatient clinic.

RESULTS

Between August 2020 and March 2021, 44 and 43 patients in the interventional and control groups, respectively, were included in the analysis after three patients were lost to FU, and three withdrew their informed consent because they wished for more personal contact with medical caregivers. After 12 months, total weight loss (TWL), %TWL, and percentage of excess weight loss (%EWL) did not differ between groups. There were no significant differences in the complication rates, including surgical complications, malnutrition, and micronutrition deficiency. The parameters of bioelectrical impedance analysis and quality of life did not differ between the groups. Vitamins and minerals in serum were similar in both groups except for calcium, which was significantly higher in the interventional group (2.52 mmol/L vs. 2.35 mmol/L, p = 0.038).

CONCLUSION

Fully remote FU with a smartphone application is at least as effective as traditional in-person FU in an outpatient clinic after bariatric surgery. Through remote FU, patients can save time and medical professionals may have more resources for patients with more severe problems.

Analysis of the Lack of Follow-Up of Bariatric Surgery Patients: Experience of a Reference Center

Few studies have evaluated the association between non-clinical and clinical determinants in terms of discontinuing follow-up after bariatric surgery. This cohort study aims to assess these associations. Data were collected from a prospectively maintained database of patients who underwent laparoscopic bariatric surgery from January 2012 to December 2019. The Cox model was used to assess the influence of preoperative determinants on follow-up interruptions for more than one year. Multilevel logistic regression was used to evaluate the association between clinical factors and post-operative weight loss with the regularity of follow-up. During the study period, 9607 consultations were performed on 1549 patients. The factors associated with a follow-up interruption from more than 365 days included male gender (HR = 1.323; CI = 1.146−1.527; p = 0.001) and more recent years of intervention (HR = 1.043; CI = 1.012−1.076; p = 0.0068). Revisional bariatric surgery was associated with a lower risk of follow-up interruption (HR = 0.753; CI = 0.619−0.916; p = 0.0045). Independent risk factors of an irregular follow up were higher age (HR = 1.01; CI = 1.002−1.017; p = 0.0086); male gender (OR = 1.272; CI = 1.047−1.545; p = 0.0153); and higher %TWL (Total Weight Loss) (OR = 1.040 CI = 1.033−1.048 p < 0.0001). A higher preoperative BMI (OR = 0.985; CI = 0.972−0.998; p = 0.0263) and revisional surgery (OR = 0.707; CI = 0.543−0.922; p = 0.0106) were protective factors of irregularity. This study suggests that the male gender and most recent dates of surgery are the two independent risk factors for follow-up interruption. Older age, male gender, and higher weight loss were all independent risk factors of an irregular follow-up. Revision bariatric surgery is a protective factor against interruption and irregular follow-up with a higher preoperative BMI. Further studies are needed to obtain long-term results in these patients with discontinued follow-ups.

The Long-Term Impact of Postoperative Educational Programs on Weight Loss After Roux-en-Y Gastric Bypass

Purpose

Roux-en-Y gastric bypass (RYGB) is a well-documented treatment of severe obesity. Attending postoperative educational programs may improve the outcome. The aim of this study was to evaluate whether participation in educational programs lasting 2–3 years after RYGB influences long-term weight loss, weight regain, physical activity, and compliance to multivitamin supplements.

Materials and Methods

The Bariatric Surgery Observation Study (BAROBS) is a multicenter retrospective, cross-sectional study 10–15 years after primary RYGB. Four hundred and ninety-seven participants answered questions regarding participation in postoperative educational programs. Participants were divided into frequent attendees (FA) and infrequent attendees (IFA) at the educational programs.

Results

Ten to 15 years after surgery, a total weight loss (TWL) of 23.2 ± 11.6% were seen in the FA group vs 19.5 ± 12.6% in the IFA group, p < 0.001. Percent excess weight loss (%EWL) was 55.7 ± 28.9% vs 46.0 ± 31.1%, p < 0.001. Weight regain in percent of maximal weight loss for the FA was 32.1 ± 32.8% vs IFA 38.4 ± 40.0%, p = 0.052. No difference between the groups in compliance to multivitamin and physical activity.

Conclusion

Participants with frequent participation in group-based educational programs had better weight loss outcomes 10–15 years after RYGB and tended to have less weight regain. There was no difference between the two groups in participants compliance to recommended multivitamin supplements and physical activity.

Graphical abstract

Long-term complications after gastric bypass and sleeve gastrectomy: What information to give to patients and practitioners, and why?

Bariatric surgery is now recognized as the most effective treatment of morbid obesity, leading to durable weight loss and resolution of associated co-morbidities. Roux-en-Y gastric bypass and sleeve gastrectomy are the two most widely used operations today. However, potentially serious medical, surgical, and/or psychiatric complications can occur that raise questions regarding the benefits of this type of surgery. These complications can lead to surgical re-operations, iterative hospitalizations, severe nutritional deficiencies and psychological disorders. Indeed, death from suicide is said to be three times higher than in non-operated obese patients. These results are of concern, all the more because of the high prevalence of patients lost to follow-up (for various and multifactorial reasons) after bariatric surgery. However, better knowledge of post-surgical sequelae could improve the information provided to patients, the preoperative evaluation of the benefit/risk ratio, and, for patients undergoing surgery, the completeness and quality of follow-up as well as the detection and management of complications. The development of new strategies for postoperative follow-up such as telemedicine but also the mobilization of all the actors along the healthcare pathway can make inroads and warrant further study.