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Ehlers LH, Reinstrup NW, Olesen RH, Holm JC, McEwan P, Le Roux CW. Global barriers to decision makers for prioritizing interventions for obesity. Int J Obes (Lond) 2024:10.1038/s41366-024-01650-z. [PMID: 39414950 DOI: 10.1038/s41366-024-01650-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 10/01/2024] [Accepted: 10/04/2024] [Indexed: 10/18/2024]
Abstract
The treatment of obesity remains underprioritized. New pharmacologic options for the treatment of obesity have shown effectiveness and safety but are not widely reimbursed. Despite the unmet need and the existence of effective prevention and treatment strategies, substantial barriers exist to effectively address obesity as a disease. The purpose of this scoping review was to investigate the barriers for decision makers in prioritizing interventions for obesity and to seek out interconnection between barriers to prevention and treatment. A scoping review was conducted using a systematic search of both scientific databases and Health Technology Assessment (HTA) databases. Studies that addressed barriers to reimbursement or prioritization of obesity treatment and prevention were included. A total of 26 articles and 14 HTAs were included. Four main barriers for decision makers to prioritize new interventions for obesity were identified: perceptions, knowledge, economics, and politics. There was a high degree of interconnectedness among barriers, as well as large overlaps between barriers in relation to bariatric surgery, pharmacologic treatments, and prevention regulation. Multiple barriers exist that impact decision makers in prioritizing interventions for treating obesity. A strong interconnectedness of the barriers was found, indicating a systems approach to improve global prioritization to address the disease. This study suggests that decision makers should carefully consider all main barriers when addressing the obesity epidemic.
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Affiliation(s)
| | | | | | | | - Phil McEwan
- Health Economics and Outcomes Research Ltd, Cardiff, UK
| | - Carel W Le Roux
- University College Dublin, School of Medicine, Dublin, Ireland
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Yousefi R, Ben-Porat T, Marques Vieira A, Lavoie KL, Bacon SL. Who gains the most quality-of-life benefits from metabolic and bariatric surgery: findings from the prospective REBORN cohort study. Surg Obes Relat Dis 2024:S1550-7289(24)00787-1. [PMID: 39304457 DOI: 10.1016/j.soard.2024.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 06/22/2024] [Accepted: 08/17/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Prioritizing patients for metabolic and bariatric surgery (MBS) based on their potential postoperative benefits is essential. OBJECTIVES To examine changes in quality of life (QoL) during the initial postoperative year among patients with diverse eligibility statuses and determine which group experiences greater benefits. SETTING Center intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de- Montréal (CIUSSS-NIM), Canada. METHODS We categorized patients into 3 groups based on obesity class and the presence of comorbidities: Group 1 (obesity class II without comorbidities, n = 28); Group 2 (obesity class II with comorbidities, n = 36); and Group 3 (obesity class III, n = 460). QoL (Short-Form QoL questionnaire [SF-12]) and anthropometrics were measured at 6 months before, and 6 and 12 months after surgery. RESULTS Repeated measures mixed models revealed a significant main effect of time (P < .001) and an interaction between time and group for the physical component of QoL (P = .007). These indicated consistent improvements across time in all groups, with the greatest benefits seen in Group 3 relative to Group 1. There were no interactions between time and group for the mental components of QoL (P = .402). There were significant interaction effects for weight and BMI (P's < .001), with Group 3 losing more weight than Groups 1 or 2. CONCLUSIONS All groups that underwent MBS had improvements in the physical aspects of QoL and weight over time, even those who have traditionally not be considered eligible for MBS (i.e., Group 1). This provides a starting point to explore the importance of not excluding patients due to their weight and comorbidity status and setting comprehensive eligibility criteria encompassing all patients who might benefit from MBS, beyond just weight loss.
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Affiliation(s)
- Reyhaneh Yousefi
- Montréal Behavioural Medicine Centre (MBMC), Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal (CIUSSS-NIM), Québec, Canada; Department of Health, Kinesiology, and Applied Physiology, Concordia University, Montréal, Québec, Canada
| | - Tair Ben-Porat
- Montréal Behavioural Medicine Centre (MBMC), Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal (CIUSSS-NIM), Québec, Canada; Department of Health, Kinesiology, and Applied Physiology, Concordia University, Montréal, Québec, Canada
| | - Ariany Marques Vieira
- Montréal Behavioural Medicine Centre (MBMC), Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal (CIUSSS-NIM), Québec, Canada; Department of Health, Kinesiology, and Applied Physiology, Concordia University, Montréal, Québec, Canada
| | - Kim L Lavoie
- Montréal Behavioural Medicine Centre (MBMC), Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal (CIUSSS-NIM), Québec, Canada; Department of Psychology, Université du Québec à Montréal, Montréal, Québec, Canada
| | - Simon L Bacon
- Montréal Behavioural Medicine Centre (MBMC), Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal (CIUSSS-NIM), Québec, Canada; Department of Health, Kinesiology, and Applied Physiology, Concordia University, Montréal, Québec, Canada.
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McKechnie T, Saddik M, Doumouras A, Eskicioglu C, Parpia S, Bhandari M. PREscribing preoperative weight loss prior to major non-bariatric abdominal surgery for patients with Elevated weight: Patient and Provider Survey Protocols (PREPARE surveys). PLoS One 2024; 19:e0302482. [PMID: 38687754 PMCID: PMC11060585 DOI: 10.1371/journal.pone.0302482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 04/02/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Preoperative very low energy diet (VLED) interventions are used routinely in patients undergoing bariatric surgery, a surgical subspecialty that deals almost exclusively with patients with obesity. Yet, their use and study has been limited in non-bariatric abdominal surgery. To investigate the use of VLEDs in non-bariatric surgery, we plan on conducting a randomized controlled trial (RCT). Prior to proceeding, however, we have designed two surveys as important pre-emptive studies aimed at elucidating patient and provider perspectives regarding these interventions. METHODS The patient survey is a cross-sectional, single-center survey aimed at assessing the safety, adherence, barriers to adherence, and willingness to participate in preoperative optimization protocols with VLEDs prior to undergoing elective non-bariatric intra-abdominal surgery (S1 File). The population of interest is all adult patients with obesity undergoing elective non-bariatric intra-abdominal surgery at St. Joseph's Healthcare Hamilton who were prescribed a course of preoperative VLED. The primary outcomes will be safety and adherence. The target sample size is 35 survey responses. The provider survey is a cross-sectional national survey of practicing surgeons in Canada who perform major non-bariatric abdominal surgery aimed assessing the willingness and ability to prescribe preoperative weight loss interventions amongst practicing Canadian surgeons who perform major non-bariatric abdominal surgery (S2 File). The population of interest is independent practicing surgeons in Canada who perform major non-bariatric abdominal surgery. The primary outcome will be willingness to prescribe preoperative VLED to patients with obesity undergoing major non-bariatric abdominal surgery for both benign and malignant indications. The target sample size is 61 survey responses. Descriptive statistics will be used to characterize the sample populations. To determine variables associated with primary outcomes in the surveys, regression analyses will be performed. DISCUSSION These survey data will ultimately inform the design of an RCT evaluating the efficacy of preoperative VLEDs for patients with obesity undergoing major abdominal surgery.
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Affiliation(s)
- Tyler McKechnie
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Maisa Saddik
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Aristithes Doumouras
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Surgery, Division of General Surgery, St. Joseph Healthcare, Hamilton, Ontario, Canada
| | - Cagla Eskicioglu
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Surgery, Division of General Surgery, St. Joseph Healthcare, Hamilton, Ontario, Canada
| | - Sameer Parpia
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Mohit Bhandari
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Surgery, Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada
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Jain S, Lapointe-Gagner M, Alali N, Elhaj H, Poirier AS, Kaneva P, Alhashemi M, Lee L, Agnihotram RV, Feldman LS, Gagner M, Andalib A, Fiore JF. Prescription and consumption of opioids after bariatric surgery: a multicenter prospective cohort study. Surg Endosc 2023; 37:8006-8018. [PMID: 37460817 DOI: 10.1007/s00464-023-10265-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/27/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION In the current opioid crisis, bariatric surgical patients are at increased risk of harms related to postoperative opioid overprescribing. This study aimed to assess the extent to which opioids prescribed at discharge after bariatric surgery are consumed by patients. METHODS This multicenter prospective cohort study included adult patients (≥ 18yo) undergoing laparoscopic bariatric surgery. Preoperative assessments included demographics and patient-reported measures. Information regarding surgical and perioperative care interventions (including discharge prescriptions) was obtained from medical records. Self-reported opioid consumption was assessed weekly up to 30 days post-discharge. Number of opioid pills prescribed and consumed was compared using Wilcoxon signed-rank test. Zero-inflated negative binomial regression was used to identify predictors of post-discharge opioid consumption. RESULTS We analyzed 351 patients (mean age 44 ± 11 years, BMI 45 ± 8.0 kg/m2, 77% female, 71% sleeve gastrectomy, length of stay 1.6 ± 0.6 days). The quantity of opioids prescribed at discharge (median 15 pills [IQR 15-16], 112.5 morphine milligram equivalents (MMEs) [IQR 80-112.5]) was significantly higher than patient-reported consumption (median 1 pill [IQR 0-5], 7.5 MMEs [IQR 0-37.5]) (p < 0.001). Overall, 37% of patients did not take any opioids post-discharge and 78.5% of the opioid pills prescribed were unused. Increased post-discharge opioid consumption was associated with male sex (IRR 1.54 [95%CI 1.14 to 2.07]), higher BMI (1.03 [95%CI 1.01 to 1.05]), preoperative opioid use (1.48 [95%CI 1.04 to 2.10]), current smoking (2.32 [95%CI 1.44 to 3.72]), higher PROMIS-29 depression score (1.03 [95% CI 1.01 to 1.04]), anastomotic procedures (1.33 [95%CI 1.01 to 1.75]), and number of pills prescribed (1.04 [95%CI 1.01 to 1.06]). CONCLUSION This study supports that most opioid pills prescribed to bariatric surgery patients at discharge are not consumed. Patient and procedure-related factors may predict opioid consumption. Individualized post-discharge analgesia strategies with minimal or no opioids may be feasible and should be further investigated in future research.
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Affiliation(s)
- Shrieda Jain
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Maxime Lapointe-Gagner
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Naser Alali
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Hiba Elhaj
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Anne-Sophie Poirier
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Pepa Kaneva
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - Mohsen Alhashemi
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Lawrence Lee
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Ramanakumar V Agnihotram
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Liane S Feldman
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Michel Gagner
- Clinique Michel Gagner (Westmount Square Surgical Center), Westmount, QC, Canada
| | - Amin Andalib
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
- Center for Bariatric Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Julio F Fiore
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada.
- Division of General Surgery, Department of Surgery, McGill University, Montreal, QC, Canada.
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada.
- Montreal General Hospital, 1650 Cedar Ave, R2-104, Montreal, QC, H3G 1A4, Canada.
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O’Moore-Sullivan T, Paxton J, Cross M, Teppala S, Chikani V, Hopkins G, Wykes K, Scuffham PA. Health outcomes of patients with type 2 diabetes following bariatric surgery: Results from a publicly funded initiative. PLoS One 2023; 18:e0279923. [PMID: 36827391 PMCID: PMC9955585 DOI: 10.1371/journal.pone.0279923] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 12/16/2022] [Indexed: 02/26/2023] Open
Abstract
OBJECTIVE Bariatric surgery is an effective treatment for type 2 diabetes and morbid obesity. This paper analyses the clinical and patient-reported outcomes of patients treated through the Bariatric Surgery Initiative, a health system collaboration providing bariatric surgery as a state-wide public service in Queensland, Australia. RESEARCH DESIGN AND METHODS A longitudinal prospective cohort study was undertaken. Eligible patients had type 2 diabetes and morbid obesity (BMI ≥ 35 kg/m2). Following referral by specialist outpatient clinics, 212 patients underwent Roux-en-Y gastric bypass or sleeve gastrectomy. Outcomes were tracked for a follow-up of 12-months and included body weight, BMI, HbA1c, comorbidities, health-related quality of life, eating behaviour, and patient satisfaction. RESULTS Following surgery, patients' average body weight decreased by 23.6%. Average HbA1c improved by 24.4% and 48.8% of patients were able to discontinue diabetes-related treatment. The incidence of hypertension, non-alcoholic steatohepatitis, and renal impairment decreased by 37.1%, 66.4%, and 62.3%, respectively. Patients' emotional eating scores, uncontrolled eating and cognitive restraint improved by 32.5%, 20.7%, and 6.9%, respectively. Quality of life increased by 18.8% and patients' overall satisfaction with the treatment remained above 97.5% throughout the recovery period. CONCLUSIONS This study confirmed previous work demonstrating the efficacy of publicly funded bariatric surgery in treating obesity, type 2 diabetes and related comorbidities, and improving patients' quality of life and eating behaviour. Despite the short follow-up period, the results bode well for future weight maintenance in this cohort.
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Affiliation(s)
| | - Jody Paxton
- Healthcare Improvement Unit, Clinical Excellence Queensland, Queensland Health, Brisbane, Queensland, Australia
| | - Megan Cross
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Srinivas Teppala
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Viral Chikani
- Department of Diabetes and Endocrinology, The Princess Alexandra Hospital, Brisbane & Senior Lecturer, University of Queensland, Brisbane, Queensland, Australia
| | - George Hopkins
- Royal Brisbane and Womens Hospital, Queensland Health, Brisbane, Queensland, Australia
| | - Katie Wykes
- Healthcare Improvement Unit, Clinical Excellence Queensland, Queensland Health, Brisbane, Queensland, Australia
| | - Paul A. Scuffham
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- * E-mail:
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Xia Q, Campbell JA, Ahmad H, de Graaff B, Si L, Otahal P, Ratcliffe K, Turtle J, Marrone J, Huque M, Hagan B, Green M, Palmer AJ. Resource utilization and disaggregated cost analysis of bariatric surgery in the Australian public healthcare system. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:941-952. [PMID: 34767114 PMCID: PMC8586836 DOI: 10.1007/s10198-021-01405-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/28/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To present a comprehensive real-world micro-costing analysis of bariatric surgery. METHODS Patients were included if they underwent primary bariatric surgery (gastric banding [GB], gastric bypass [GBP] and sleeve gastrectomy [SG]) between 2013 and 2019. Costs were disaggregated into cost items and average-per-patient costs from the Australian healthcare systems perspective were expressed in constant 2019 Australian dollars for the entire cohort and subgroup analysis. Annual population-based costs were calculated to capture longitudinal trends. A generalized linear model (GLM) predicted the overall bariatric-related costs. RESULTS N = 240 publicly funded patients were included, with the waitlist times of ≤ 10.7 years. The mean direct costs were $11,269. The operating theatre constituted the largest component of bariatric-related costs, followed by medical supplies, salaries, critical care use, and labour on-costs. Average cost for SG ($12,632) and GBP ($15,041) was higher than that for GB ($10,049). Operating theatre accounted for the largest component for SG/GBP costs, whilst medical supplies were the largest for GB. We observed an increase in SG and a decrease in GB procedures over time. Correspondingly, the main cost driver changed from medical supplies in 2014-2015 for GB procedures to operating theatre for SG thereafter. GLM model estimates of bariatric average cost ranged from $7,580 to $36,633. CONCLUSIONS We presented the first detailed characterization of the scale, disaggregated profile and determinants of bariatric-related costs, and examined the evolution of resource utilization patterns and costs, reflecting the shift in the Australian bariatric landscape over time. Understanding these patterns and forecasting of future changes are critical for efficient resource allocation.
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Affiliation(s)
- Qing Xia
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool St, Hobart, TAS, 7000, Australia.
| | - Julie A Campbell
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool St, Hobart, TAS, 7000, Australia
| | - Hasnat Ahmad
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool St, Hobart, TAS, 7000, Australia
| | - Barbara de Graaff
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool St, Hobart, TAS, 7000, Australia
| | - Lei Si
- The George Institute for Global Health, University of New South Wales, Kensington, NSW, 2042, Australia
| | - Petr Otahal
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool St, Hobart, TAS, 7000, Australia
| | - Kevin Ratcliffe
- Tasmanian Department of Health, Tasmanian State Government, 22 Elizabeth Street, Hobart, TAS, 7000, Australia
| | - Julie Turtle
- Tasmanian Department of Health, Tasmanian State Government, 22 Elizabeth Street, Hobart, TAS, 7000, Australia
| | - John Marrone
- Tasmanian Department of Health, Tasmanian State Government, 22 Elizabeth Street, Hobart, TAS, 7000, Australia
| | - Mohammed Huque
- Tasmanian Department of Health, Tasmanian State Government, 22 Elizabeth Street, Hobart, TAS, 7000, Australia
| | - Barry Hagan
- Tasmanian Department of Health, Tasmanian State Government, 22 Elizabeth Street, Hobart, TAS, 7000, Australia
| | - Matthew Green
- Tasmanian Department of Health, Tasmanian State Government, 22 Elizabeth Street, Hobart, TAS, 7000, Australia
| | - Andrew J Palmer
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool St, Hobart, TAS, 7000, Australia.
- Centre for Health Economics, School of Population and Global Health, University of Melbourne, 207 Bouverie Street, Carlton 3000, Victoria, Australia.
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Sinclair P, Vijgen GHEJ, Aarts EO, Van Nieuwenhove Y, Maleckas A. First Inventory of Access and Quality of Metabolic Surgery Across Europe. Obes Surg 2021; 31:5196-5206. [PMID: 34508296 PMCID: PMC8595173 DOI: 10.1007/s11695-021-05633-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 07/22/2021] [Accepted: 07/23/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Europe consists of 51 independent countries. Variation in healthcare regulations results in differing challenges faced by patients and professionals. This study aimed to gain more insight into the accessibility, patient pathway and quality indicators of metabolic and body contouring surgery. METHODS AND MATERIALS Expert representatives in the metabolic field from all 51 countries were sent an electronic self-administered online questionnaire on their data and experiences from the previous year exploring accessibility to and quality indicators for metabolic surgery and plastic surgery after weight loss. RESULTS Forty-five responses were collected. Sixty-eight percent of countries had eligibility criteria for metabolic surgery; 59% adhered to the guidelines. Forty-six percent had reimbursement criteria for metabolic surgery. Forty-one percent had eligibility criteria for plastic surgery and 31% reimbursement criteria. Average tariffs for a metabolic procedure varied € 800 to 16,000. MDTs were mandated in 78%, with team members varying significantly. Referral practices differed. In 45%, metabolic surgery is performed by pure metabolic surgeons, whilst re-operations were performed by a metabolic surgeon in 28%. A metabolic training programme was available in 23%. Access to metabolic surgery was rated poor to very poor in 33%. Thirty-five percent had a bariatric registry. Procedure numbers and numbers of hospitals performing metabolic surgery varied significantly. Twenty-four percent of countries required a minimum procedure number for metabolic centres, which varied from 25 to 200 procedures. CONCLUSION There are myriad differences between European countries in terms of accessibility to and quality indicators of metabolic surgery. Lack of funding, education and structure fuels this disparity. Criteria should be standardised across Europe with clear guidelines.
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Affiliation(s)
- Piriyah Sinclair
- Department of Surgery, Broomfield Hospital, Chelmsford, UK.
- Department of Metabolic Medicine, University College Dublin, Belfield, Ireland.
| | - Guy H E J Vijgen
- Department of Surgery, Franciscus Gasthuis, Rotterdam, the Netherlands
| | - Edo O Aarts
- WeightWorks Clinics, Amersfoort, the Netherlands
- Allurion Kliniek, Amersfoort, The Netherlands
| | | | - Almantas Maleckas
- Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Department of Gastrosurgical Research and Education, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Stogryn S, Johnson GGRJ, Okrainec A, Jackson T, Vergis A. Outcomes from Explantation of Laparoscopic Adjustable Gastric Band: Experience from a Canadian Bariatric Center of Excellence. Obes Surg 2021; 31:4933-4938. [PMID: 34427867 DOI: 10.1007/s11695-021-05676-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/13/2021] [Accepted: 08/19/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Laparoscopic adjustable gastric banding (LAGB) has declined in popularity due to poor weight loss and high revision rates. The study aim was to evaluate complication rates following LAGB removals, including conversions to other bariatric procedures. MATERIALS AND METHODS This was a retrospective cohort study of patients who underwent LAGB removal, identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database from the Toronto Western Hospital site. Patients were filtered using principal procedure and concurrent procedural terminology (CPT) codes. Patients converted to other bariatric procedures were also included. Outcomes were evaluated for 30-day morbidity, mortality, readmissions, and costs. RESULTS From 2012 to 2018, 93 patients met inclusion. 96.77% had elective surgery, and 3.23% were emergent. Thirty-day postoperative complication rate was 11.83%, with 4.30% readmissions and no deaths. Surgical site infections accounted for 81.82% of complications (54.55% superficial, 27.27% deep). Thirty-day complication rate for LAGB removal alone was 17.50% and 33.33% following emergent explantation. 56.99% LAGBs were converted to other bariatric procedures: 48.39% laparoscopic Roux-en-Y gastric bypass (LRYGB) and 8.6% sleeve gastrectomy (LSG). Conversion to LSG had a significantly higher 30-day complication rate (all Clavien-Dindo class I-II) compared to conversion to LRYGB (37.50% versus 2.22%, p < 0.009). Direct costs of LAGB explantation to the healthcare system were $665,443, amounting to $7,155 per patient. CONCLUSION Thirty-day complication rates for LAGB explantation and conversion to other bariatric procedures are significant and may be higher than previously reported for LAGB removal alone. Conversion to LSG may have the highest complication rate, amounting to significant costs.
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Affiliation(s)
- Shannon Stogryn
- Department of Surgery, University of Toronto, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Garrett G R J Johnson
- Department of Surgery, Section of General Surgery, University of Manitoba, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada.,Clinician Investigator Program, University of Manitoba, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada
| | - Allan Okrainec
- Department of Surgery, University of Toronto, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Timothy Jackson
- Department of Surgery, University of Toronto, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Ashley Vergis
- Department of Surgery, Section of General Surgery, University of Manitoba, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada. .,St. Boniface General Hospital, Z3039-409 Tache Avenue, Winnipeg, Manitoba, R2H 2A6, Canada.
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Mierzwa AS, Mocanu V, Marcil G, Dang J, Switzer NJ, Birch DW, Karmali S. Characterizing Timing of Postoperative Complications Following Elective Roux-en-Y gastric Bypass and Sleeve Gastrectomy. Obes Surg 2021; 31:4492-4501. [PMID: 34374931 PMCID: PMC8353221 DOI: 10.1007/s11695-021-05638-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/25/2021] [Accepted: 07/27/2021] [Indexed: 11/30/2022]
Abstract
Purpose With the growing prevalence of bariatric procedures performed worldwide, it is important to understand the timing of postoperative complications following bariatric surgery and the differences which may exist between procedures. Methods This retrospective study was conducted using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2017 to 2018. All patients with primary elective Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) procedures were included. The primary outcome was to characterize the timing of postoperative complications for RYGB and SG. Results A total of 316,314 patients were identified with 237,066 (74.9%) in the SG cohort and 79,248 (25.1%) in the RYGB cohort. Early complications included myocardial infarction (4.7 ± 6.4 days), cardiac arrest (6.4 ± 8.5 days), pneumonia (6.9 ± 6.9 days), progressive renal insufficiency (8.1 ± 8.1 days), and acute renal failure (8.2 ± 7.6 days). Late complications included Clostridioides difficile infection (11.3 ± 7.8 days), organ space infections (11.7 ± 7.9 days), deep incisional infections (12.4 ± 6.6 days), superficial incisional infections (13.2 ± 6.9 days), and urinary tract infections (14.0 ± 8.4 days). SG patients were more likely to be diagnosed later than RYGB patients with regard to superficial incisional infections (14.0 ± 7.4 days vs 12.5 ± 6.3 days; p = 0.002), organ space infections (12.6 ± 7.8 days vs 10.8 ± 7.9 days; p = 0.001), acute renal failure (9.3 ± 8.1 days vs 6.8 ± 6.8 days; p = 0.03), and pulmonary embolism (13.7 ± 7.5 days vs 11.3 ± 8.0 days; p = 0.003). No significant difference in timing was observed for any other complication by procedures. Conclusion We demonstrate that significant differences in timing exist between complications and that these differences also vary by surgical procedure. Graphical abstract ![]()
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Affiliation(s)
- Anna S. Mierzwa
- Department of Surgery, University of Alberta, Edmonton, AB Canada
| | - Valentin Mocanu
- Department of Surgery, University of Alberta, Edmonton, AB Canada
| | - Gabriel Marcil
- Department of Surgery, University of Alberta, Edmonton, AB Canada
| | - Jerry Dang
- Department of Surgery, University of Alberta, Edmonton, AB Canada
| | - Noah J. Switzer
- Department of Surgery, University of Alberta, Edmonton, AB Canada
| | - Daniel W. Birch
- Department of Surgery, University of Alberta, Edmonton, AB Canada
| | - Shahzeer Karmali
- Department of Surgery, University of Alberta, Edmonton, AB Canada
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Barber D, Morkem R, Dalgarno N, Houlden R, Smith K, Anvari M, Zevin B. Patients eligible and referred for bariatric surgery in southeastern Ontario: Retrospective cohort study. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2021; 67:e31-e40. [PMID: 33483411 DOI: 10.46747/cfp.6701e31] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the proportion of eligible individuals, within one health region in Ontario, who were referred for publicly funded medical and surgical weight-loss interventions (MSWLI). DESIGN A retrospective cohort study that used primary care data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) and referral data from the Ontario Bariatric Network (OBN). SETTING Primary care practices within southeastern Ontario that contribute data to CPCSSN. PARTICIPANTS Patients with class II (body mass index [BMI] 35.0 to 39.9 kg/m2) or III (BMI ≥ 40 kg/m2) obesity who were eligible for referral to the OBN for MSWLI. MAIN OUTCOME MEASURES Primary care data about patients within the CPCSSN database were linked to referral records within the OBN database using 3 indirect identifiers to determine the proportion of patients with class II and III obesity who were referred to the OBN for MSWLI. An adjusted multivariate logistic regression model was used to determine the most significant predictors of referral. RESULTS Of the 87 276 patients within one health region in Ontario, 15 526 (17.8%) patients had class II or III obesity and were eligible for referral for MSWLI. Only 966 out of those 15 526 (6.2%) patients were actually referred for MSWLI. In the multivariate regression analysis, BMI had the strongest association with referral in terms of adjusted odds ratio (AOR), varying from 2.50 (95% CI 2.04 to 3.06) for a BMI of 40.0 to 44.9 kg/m2, to 5.15 (95% CI 4.21 to 6.30) for a BMI of 50.0 kg/m2 or greater. Referral was more likely for female than male patients (AOR = 2.18; 95% CI 1.86 to 2.57), those living rurally than for urban dwellers (AOR = 1.39; 95% CI 1.20 to 1.60), and those aged 30 to 39 (AOR = 1.61; 95% CI 1.24 to 2.09) and 40 to 49 (AOR = 1.53; 95% CI 1.18 to 1.98) compared with other age groups. CONCLUSION Within one health region in Ontario, the referral rate of patients with class II and III obesity for MSWLI was low. Our findings highlight the need for further research to understand and address the barriers to referral of patients with class II and III obesity for MSWLI.
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Affiliation(s)
- David Barber
- Network Director and Assistant Professor in the Centre for Studies in Primary Care at Queen's University in Kingston, Ont
| | - Rachael Morkem
- Research associate with the Centre for Studies in Primary Care at Queen's University
| | - Nancy Dalgarno
- Education Researcher and Consultant in the Office of Health Sciences Education at Queen's University
| | - Robyn Houlden
- Professor and Chair of the Division of Endocrinology at Queen's University
| | - Karen Smith
- Professor in the Office of Health Sciences Education at Queen's University
| | - Mehran Anvari
- Professor of Surgery in the Faculty of Health Sciences at McMaster University and Chair and Clinic Lead of the Ontario Bariatric Network
| | - Boris Zevin
- Assistant Professor in the Department of Surgery at Queen's University.
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Davis JA, Saunders R. Earlier Provision of Gastric Bypass Surgery in Canada Enhances Surgical Benefit and Leads to Cost and Comorbidity Reduction. Front Public Health 2020; 8:515. [PMID: 33102415 PMCID: PMC7554569 DOI: 10.3389/fpubh.2020.00515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/10/2020] [Indexed: 12/04/2022] Open
Abstract
Background: Effective provision of bariatric surgery for patients with obesity may be impeded by concerns of payers regarding costs or perceptions of patients who drop out of surgical programs after referral. Estimates of the cost and comorbidity impact of these inefficiencies in gastric bypass surgery in Canada are lacking but would aid in informing healthcare investment and resource allocation. Objectives: To estimate total and relative public payer costs for surgery and comorbidities (diabetes, hypertension, and dyslipidemia) in a bariatric surgery population. Methods: A decision analytic model for a 100-patient cohort in Canada (91% female, mean body mass index 49.2 kg/m2, 50% diabetes, 66% hypertension, 59% dyslipidemia). Costs include surgery, surgical complications, and comorbidities over the 10-year post-referral period. Results are calculated as medians and 95% credibility intervals (CrIs) for a pathway with surgery at 1 year (“improved”) compared with surgery at 3.5 years (“standard”). Sensitivity analyses were performed to test independent contributions to results of shorter wait time, better post-surgical weight loss, and randomly sampled cohort demographics. Results: Compared to standard care, the improved path was associated with reduction in patient-years of treatment for each of the three comorbidities, corresponding to a reduction of $1.1 (0.68–1.6) million, or 34% (26-41%) of total costs. Comorbidity treatment costs were 9.0- and 4.7-fold greater than surgical costs for the standard and improved pathways, respectively. Relative to non-surgical bariatric care, earlier surgery was associated with earlier return on surgical investment and 2-fold reduction in risk of prevalence of each comorbidity compared to delayed surgery. Conclusions: Comorbidity costs represent a greater burden to payers than the costs of gastric bypass surgery. Investments may be worthwhile to reduce wait times and dropout rates and improve post-surgical weight loss outcomes to save overall costs and reduce patient comorbidity prevalence.
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Davis JA, Saunders R. Impact of weight trajectory after bariatric surgery on co-morbidity evolution and burden. BMC Health Serv Res 2020; 20:278. [PMID: 32245378 PMCID: PMC7119002 DOI: 10.1186/s12913-020-5042-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 02/26/2020] [Indexed: 01/06/2023] Open
Abstract
Background Bariatric surgery, such as Roux-en-Y gastric bypass [RYGB] has been shown to be an effective intervention for weight management in select patients. After surgery, different patients respond differently even to the same surgery and have differing weight-change trajectories. The present analysis explores how improving a patient’s post-surgical weight change could impact co-morbidity prevalence, treatment and associated costs in the Canadian setting. Methods Published data were used to derive statistical models to predict weight loss and co-morbidity evolution after RYGB. Burden in the form of patient-years of co-morbidity treatment and associated costs was estimated for a 100-patient cohort on one of 6 weight trajectories, and for real-world simulations of mixed patient cohorts where patients experience multiple weight loss outcomes over a 10-year time horizon after RYGB surgery. Costs (2018 Canadian dollars) were considered from the Canadian public payer perspective for diabetes, hypertension and dyslipidaemia. Robustness of results was assessed using probabilistic sensitivity analyses using the R language. Results Models fitted to patient data for total weight loss and co-morbidity evolution (resolution and new onset) demonstrated good fitting. Improvement of 100 patients from the worst to the best weight loss trajectory was associated with a 50% reduction in 10-year co-morbidity treatment costs, decreasing to a 27% reduction for an intermediate improvement. Results applied to mixed trajectory cohorts revealed that broad improvements by one trajectory group for all patients were associated with 602, 1710 and 966 patient-years of treatment of type 2 diabetes, hypertension and dyslipidaemia respectively in Ontario, the province of highest RYGB volume, corresponding to a cost difference of $3.9 million. Conclusions Post-surgical weight trajectory, even for patients receiving the same surgery, can have a considerable impact on subsequent co-morbidity burden. Given the potential for alleviated burden associated with improving patient trajectory after RYGB, health care systems may wish to consider investments based on local needs and available resources to ensure that more patients achieve a good long-term weight trajectory.
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Affiliation(s)
- Jason A Davis
- Coreva Scientific GmbH & Co KG, Im Muehlenbruch 1, 3rd Floor, 53639, Koenigswinter, Germany.
| | - Rhodri Saunders
- Coreva Scientific GmbH & Co KG, Im Muehlenbruch 1, 3rd Floor, 53639, Koenigswinter, Germany
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Davis JA, Saunders R. Comparison of Comorbidity Treatment and Costs Associated With Bariatric Surgery Among Adults With Obesity in Canada. JAMA Netw Open 2020; 3:e1919545. [PMID: 31951277 PMCID: PMC6991282 DOI: 10.1001/jamanetworkopen.2019.19545] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Information on the associations between barriers to delivery of bariatric surgery and poor weight trajectory afterward is lacking. Estimates are needed to inform decisions by administrators and clinicians to improve care. OBJECTIVE To estimate the difference in patient-years of treatment for diabetes, hypertension, and dyslipidemia and public-payer cost between the Canadian standard and an improved bariatric surgery care pathway. DESIGN, SETTING, AND PARTICIPANTS Economic evaluation of a decision analytic model comparing the outcomes of the standard care in Canada with an improved bariatric care pathway with earlier sleeve gastrectomy delivery and better postsurgical weight trajectory. The model was informed by published clinical data (101 studies) and meta-analyses (11 studies) between January and May 2019. Participants were a hypothetical 100-patient cohort with demographic characteristics derived from a Canadian study. INTERVENTIONS Reduction of Canadian mean bariatric surgery wait time by 2.5 years following referral and improvement of patient postsurgery weight trajectory to levels observed in other countries. MAIN OUTCOMES AND MEASURES Modeling weight trajectory after sleeve gastrectomy and resolution rates for comorbidities in Canada in comparison with an improved care pathway to estimate differences in patient-years of comorbidity treatment over 10 years following referral and the associated costs. RESULTS For the 100-patient cohort (mean [SD] 88.2% [1.4%] female; mean [SD] age, 43.6 [9.2] years; mean [SD] body mass index, 49.4 [8.2]; and mean [SD] comorbidity prevalence of 50.0% [4.1%], 66.0% [3.9%], and 59.3% [4.0%] for diabetes, hypertension, and dyslipidemia, respectively) over 10 years following referral, the improved vs standard care pathway was associated with median reduction in patient-years of treatment of 324 (95% credibility interval [CrI], 249-396) for diabetes, 245 (95% CrI, 163-356) for hypertension, and 255 (95% CrI, 169-352) for dyslipidemia, corresponding to total savings of $900 000 (95% CrI, $630 000 to $1.2 million) for public payers in the base case. Relative to standard of care, the associated reduction in costs was approximately 29% (95% CrI, 20%-42%) in the improved pathway. Sensitivity analyses demonstrated independent associations of earlier surgical delivery and various levels of postsurgical weight trajectory improvements with overall savings. CONCLUSIONS AND RELEVANCE This study suggests that health care burden may be decreased through improvements to delivery and management of patients undergoing sleeve gastrectomy. More data are needed on long-term patient experience with bariatric surgery in Canada to inform better estimates.
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