Mindset and Communication Barriers in the Diffusion of Bariatric Surgery

Attitudes of primary care physicians toward bariatric surgery: a free word association networks analysis

BACKGROUND

Primary care physicians (PCPs) hold major responsibility in referring patients with obesity eligible for bariatric surgery (BS).

OBJECTIVE

The aim was to explore PCPs' mental representation of BS in order to identify barriers and catalysts of BS referral practices.

SETTING

Switzerland.

METHODS

A total of 3526 PCPs were invited to participate in an online survey. PCPs were asked to write the first 5 words that came to their mind about the term "bariatric surgery." Additionally, they had to pick 2 emotions that best described each provided association. Demographic data and obesity-related referral patterns were collected. Mental representation network was constructed based on co-occurrence of associations, using validated data-driven methodology.

RESULTS

In all, 216 PCPs completed the study (response rate: 6.13%). Respondents were aged 55 ± 9.8 years, had an equal sex distribution, and practiced mainly in urban settings. Three mental representations of BS emerged: indication-focused (most frequent associations: "obesity," "diabetes"), treatment-focused ("gastric bypass," "weight loss"), and outcome-focused ("complications," "challenging follow-up"). The emotional label "interested" was used significantly more frequently in the treatment-focused group. Comparison of PCPs among mental modules showed that those with a treatment-focused mindset referred patients for BS most frequently and were significantly more willing to follow up with postbariatric patients (χ2 = 17.8, P = .022).

CONCLUSIONS

PCPs think about BS along 3 mental representations, and the treatment-focused attitude was coupled with the highest willingness to refer eligible patients for BS. Confidence in performing postbariatric follow-up was identified as catalyst of BS referral. Access to optimal care for patients with obesity may be improved accordingly.

A study analyzing outcomes after bariatric surgery by primary language

BACKGROUND

Communication is key to success in bariatric surgery. This study aims to understand how outcomes after bariatric surgery differ between patients with a non-English primary language and those with English as their primary language.

METHODS

This retrospective, observational cohort study of bariatric surgery patients age ≥ 18 years utilized the Michigan, Maryland, and New Jersey State Inpatient Databases and State Ambulatory Surgery and Services Databases, 2016 to 2018. Patients were classified by primary spoken language: English and non-English. Primary outcome was complications. Secondary outcomes included length of stay (LOS) and cost, with cost calculated using cost-to-charge ratios provided by Healthcare Cost and Utilization Project and reported in 2019 United States dollars. Multivariable regression models (logistic, Poisson, and quantile) were used to examine associations between primary language and outcomes. Given the uneven distribution of race by primary language, interaction terms were used to examine conditional effects of race.

RESULTS

Among 69,749 bariatric surgery patients, 2811 (4.2%) spoke a non-English primary language. Covariates, notably race distribution, and unadjusted outcomes differed significantly by primary language. However, after adjustment, non-English primary language was not associated with significantly increased odds of complications (odds ratio 1.24, p = 0.389), significantly different LOS (- 0.02 days, p = 0.677), nor significantly different mean healthcare costs (- $265, p = 0.309). There were no significant conditional effects of race seen among outcomes.

CONCLUSIONS

Though non-English primary language was associated with a significantly different distribution of observable characteristics (including race, income quartile, and insurance type), after adjustment, non-English primary language was not associated with significant differential risk of adverse outcomes after bariatric surgery, and there were no significant conditional effects of race. As such, this study suggests that disparities in bariatric surgery by primary spoken language more likely related to access to care, or the pre- and post-hospital care continuum, rather than index hospitalization after surgery.

Integrated Care Model of Adiposity-Related Chronic Diseases

PURPOSE OF REVIEW

Although obesity is a disease, most patients with obesity do not undergo effective treatment nor adhere to long-term care. We examine the barriers that patients with obesity confront when searching for effective treatment and propose an integrated care model of adiposity-related chronic diseases in a cardio-renal metabolic unit.

RECENT FINDINGS

The current care of obesity is fragmented between primary care providers, medical specialists and metabolic bariatric surgeons with little or no coordination of care between these providers. The current care of obesity heavily focuses on weight loss as the primary aim of treatment thereby reenforcing the weight stigma and turning patients away from effective therapy like metabolic bariatric surgery. An interdisciplinary cardio-renal metabolic unit that, besides weight loss, emphasizes prevention/remission of adiposity-related chronic diseases may deliver thorough and rewarding care to most patients with obesity.

[Healthcare cost reimbursement without application-Experiences of a German bariatric service]

BACKGROUND

Only a small proportion of patients with morbid obesity in Germany have access to the currently most effective treatment, bariatric surgery. A major reason for this is the restrictive attitude of health insurance companies regarding the reimbursement of costs.

OBJECTIVE

To record the postoperative rate of cost coverage by health insurance companies without the currently common preoperative application for morbidly obese patients who received a guideline-indicated bariatric surgery.

METHODS

The process of postoperative reimbursement was evaluated through a prospective database over a 2-year period. Cases of primary reimbursement were correlated with respect to age, BMI, comorbidities and membership of a specific health insurance company. Rejected coverage cases were followed up for further advocacy and social court process.

RESULTS

A total of 188 patients underwent bariatric surgery as indicated in the guidelines without prior application. Primary cost coverage was achieved in 76.6% (n = 144). There was no correlation with BMI, comorbidities or health insurance affiliation. Patients over 40 years of age were significantly more likely to be covered for costs. For patients without postoperative cost coverage, an out of court settlement was reached in 7 cases, 8 cases were heard by the social courts and 29 cases were still being processed by lawyers.

CONCLUSION

Despite the relatively high rate of primary cost coverage, this analysis also shows the restrictive attitude of the health insurance companies regarding bariatric surgery with corresponding economic pressure on the service providers. The consistent implementation of application-free surgery seems necessary to increase the political pressure on health insurers and social courts.

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.

Mental and emotional representations of "weight loss": free-word association networks in members of bariatric surgery-related social media communities

BACKGROUND

Mindset and communication barriers may hinder the acceptance of bariatric surgery (BS) by the eligible patient population.

OBJECTIVES

To improve the understanding of expectations, opinions, emotions, and attitudes toward weight loss among patients with obesity.

SETTING

Switzerland, Germany, Austria.

METHODS

Survey data collected from BS-related social media communities (n = 1482). Participants were asked to write 5 words that first came to their mind about "weight loss," and to select 2 emotions, which best described their corresponding feelings. Demographic and obesity-related data were collected. Cognitive representations were constructed based on the co-occurrence network of associations, using validated data-driven methodology.

RESULTS

Respondents were Caucasian (98%), female (94%), aged 42.5 ± 10.1 years, current/highest lifetime body mass index = 36.9 ± 9/50.7 ± 8.7 kg/m². The association network analysis revealed the following 2 cognitive modules: benefit-focused (health, attractiveness, happiness, agility) and procedure-focused (effort, diet, sport, surgery). Patients willing to undergo BS were more benefit-focused (odds ratio [OR] = 2.4, P = .02) and expressed more "hope" (OR = 142, P < .001). History of BS was associated with higher adherence to the procedure-focused module (OR = 2.3, P < .001), and with increased use of the emotions "gratitude" (OR = 107, P < .001), "pride" (OR = 15, P < .001), and decreased mention of "hope" (OR = .03, P < .001).

CONCLUSION

Patients with obesity in our study tend to think about weight loss along 2 cognitive schemes, either emphasizing its expected benefits or focusing on the process of achieving it. Benefit-focused respondents were more likely to consider BS, and to express hope rather than gratitude or pride. Novel communication strategies may increase the acceptance of BS by incorporating weight loss-related cognitive and emotional content stemming from patients' free associations.