Bariatric surgery barriers: a review using Andersen's Model of Health Services Use

Randomized Controlled Trial Based US Commercial Payor Cost-Effectiveness Analysis of Endoscopic Sleeve Gastroplasty Versus Lifestyle Modification Alone for Adults With Class I/II Obesity

PURPOSE

Endoscopic sleeve gastroplasty (ESG) is a minimally invasive day procedure that the MERIT randomized controlled trial (RCT) has demonstrated to be an effective and safe method of weight loss versus lifestyle modification alone. We sought to evaluate the cost-effectiveness of ESG from the perspective of a US commercial payer in a cohort of adults with class II and class I obesity with diabetes based on this RCT.

MATERIALS

We used a Markov modelling approach with BMI group health states and an absorbing death state. Baseline characteristics, utilities, BMI group transition probabilities, and adverse events (AEs) were informed by patient-level data from the MERIT RCT. Mortality was estimated by applying BMI-specific hazard ratios to US general population mortality rates. We used BMI-based health state utilities to reflect the impact of obesity comorbidities and applied disutilities due to ESG AEs. Costs included intervention costs, AE costs, and BMI-based annual direct healthcare costs to account for costs associated with obesity comorbidities. A willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY) was assumed.

RESULTS

In our base-case analysis over a 5-year time horizon, ESG was cost-effective versus lifestyle modification alone with an incremental cost-effectiveness ratio of $23,432/QALY. ESG remained cost-effective in all sensitivity analyses we conducted and was dominant in analyses with longer time horizons.

CONCLUSION

ESG is a cost-effective treatment option for people living with obesity and should be considered in commercial health plans as an additional treatment option for clinically eligible patients.

Pediatric metabolic and bariatric surgery: indications and preoperative multidisciplinary evaluation

The standard of care for pediatric patients with severe obesity considering metabolic and bariatric surgery is a preoperative multidisciplinary evaluation. A multidisciplinary team allows for the efficient use of variable personnel expertise to evaluate, manage, and support a pediatric patient and family through metabolic and bariatric surgery. This review discusses the purpose, recommended team members, patient selection, content, and benefits of the multidisciplinary preoperative evaluation. This evaluation should reduce barriers to care and optimize patient safety and outcomes while taking into consideration the unique developmental needs of this age group.

From Early to Mid-Term Results of Endoscopic Sleeve Gastroplasty: A Retrospective Analysis of a Bariatric Center

PURPOSE

Global obesity rates have surged, necessitating effective interventions beyond traditional bariatric and metabolic surgery (BMS). Endoscopic Sleeve Gastroplasty (ESG) has emerged as a minimally invasive alternative, addressing limitations of eligibility criteria and patient reluctance associated with BMS. This study aims to present a 3-year experience with ESG, focusing on its mid-term efficacy in weight loss.

MATERIALS AND METHODS

A retrospective, single-center study included 143 consecutive ESG patients (BMI > 30 kg/m2 or > 25 kg/m2 with obesity associated-diseases) from February 2019 to March 2023. Data on demographics, comorbidities, operative details, and follow-up outcomes were collected. The primary outcome was %TWL ≥ 15% at 12 months. Secondary outcomes were an optimal clinical response (OCR) at 24 and 36 months defined by %TWL ≥ 10% or %EWL ≥ 25%.

RESULTS

ESG demonstrated a mean %TWL of 14.37% at 12 months, aligning with previous studies. Early postoperative complications were minimal (2.1%), with no mortality. Follow-up revealed a peak in weight loss at 9 months, but mid-term OCR was achieved in 41.2% at 3 years. The learning curve showed efficiency improvements after 26 procedures.

CONCLUSION

ESG proves effective at one year, with a %TWL of 14.37%. However, mid-term efficacy beyond 12 months remains challenging, raising questions about the durability of weight loss. Despite a low complication rate, strategies for maintaining a long-term OCR, including potential repeat ESG, warrant further investigation.

Bariatric surgery stigma from the perspective of patients: A scoping review

AIMS

To explore the experiences and consequences of bariatric surgery stigma from the perspective of bariatric surgery patients and to identify knowledge gaps in the literature.

DESIGN

A scoping review.

DATA SOURCES

Studies published between December 2002 and January 2022 were identified from the following databases: PubMed, Web of Science, PsycINFO and MEDLINE.

REVIEW METHODS

We screened 3092 records and included 28 studies. Findings were grouped thematically using the health stigma discrimination framework.

RESULTS

Patients experienced several types of stigmas, including perceived, experienced, anticipated and internalized stigma, related to undergoing bariatric surgery. Patients were confronted with negative comments and judgement from others when they disclosed their decision to have surgery or when they revealed that they had undergone surgery. These experiences led to conflicts in the decision-making process, such as delaying the choice for surgery, seeking surgery abroad or opting out. Patients who internalized stigma often reported feelings of shame and embarrassment for choosing surgery and felt the need for secrecy or selective disclosure. Stigma experiences were influenced by gender and differed between different subgroups of patients.

CONCLUSION

The stigma surrounding bariatric surgery has detrimental consequences for eligible individuals and bariatric surgery patients. However, the evidence from patients' perspective remains limited. More research into patient's experiences is needed to improve patient care and further educate healthcare professionals. In addition, to better understand the nature and implications of bariatric surgery stigma, future research should be founded on stigma theories and distinguish between the different types of stigmas.

IMPACT

This scoping review contributes to a better understanding of the implications the stigma surrounding bariatric surgery has for bariatric surgery patients before and after surgery. The knowledge generated by this review can inform improvements in the education and management of people living with obesity and bariatric surgery patients.

REPORTING METHOD

The scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews checklist.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

PROTOCOL REGISTRATION

A protocol was not registered for this scoping review.

How to establish an endoscopic bariatric practice

Obesity is a chronic, progressive, and relapsing disease of excess adiposity that contributes to more than two hundred medical conditions and is projected to affect more than half the adult population of the United States by the year 2030. Given the limited penetrance of traditional bariatric surgery, as well as the cost and adherence barriers to anti-obesity medications, there is growing interest in the rapidly evolving field of endoscopic bariatric therapies (EBTs). EBTs are minimally invasive, same-day, per-oral endoscopic procedures and include endoscopic sleeve gastroplasty, intragastric balloons, and endoscopic bariatric revisional procedures. This field represents an exciting and innovative subspecialty within gastroenterology. However, building a successful endoscopic bariatric practice requires intentional, coordinated, and sustained efforts to overcome the numerous obstacles to entry. Common barriers include acquisition of the technical and cognitive skillset, practice limitations including the availability of nutrition counseling, facility capabilities, direct-to-consumer marketing, and financial pressures such as facility and anesthesia fees. As the highest-volume center for metabolic and bariatric endoscopy in the United States, we provide insights into successfully establishing an endoscopic bariatric program.

What matters to adolescents with obesity, and their caregivers, when considering bariatric surgery or weight loss devices? A qualitative evidence synthesis

BACKGROUND

Bariatric surgery and weight loss devices have been considered as a therapeutic option in some settings for adolescents with severe obesity. We conducted a systematic review and qualitative evidence synthesis of factors affecting adolescent and caregiver decision-making processes around such interventions, as well as post-surgery demands and challenges, so that their experiences might be better understood and improved support given. No previous qualitative evidence synthesis has been published on this topic.

METHODS AND FINDINGS

We searched 10 bibliographic databases and followed-up gray literature and citations sources. We performed a qualitative evidence synthesis on 19 primary qualitative research studies in adolescents aged 13 years or older. They reported diverse motivations and incentives for considering these interventions, including the physical and social problems resulting from living with obesity, and an awareness of the benefits and limitations of interventions. They reported that they need: information, physical and emotional support and, in some cases, financial assistance. There was high confidence in a majority of these findings (GRADE CERQual).

CONCLUSIONS

We found that supportive interventions accompanying bariatric surgery should be in place to offer: practical help; address anxieties and uncertainties; and facilitate both appropriate decision-making and the achievement of young people's desired outcomes.

Association of program-specific variation in bariatric surgery volume for Medicaid patients and access to care: a tale of inequality?

BACKGROUND

Although patients with lower socioeconomic status are at higher risk of obesity, bariatric surgery utilization among patients with Medicaid is low and may be due to program-specific variation in access. Our goal was to compare bariatric surgery programs by percentage of Medicaid cases and to determine if variation in distribution of patients with Medicaid could be linked to adverse outcomes.

METHODS

Using a state-wide bariatric-specific data registry that included 43 programs performing 97,207 cases between 2006 and 2020, we identified all patients with Medicaid insurance (n = 4780, 4.9%). Bariatric surgery programs were stratified into quartiles according to the percentage of Medicaid cases performed and we compared program-specific characteristics as well as baseline patient characteristics, risk-adjusted complication rates and wait times between top and bottom quartiles.

RESULTS

Program-specific distribution of Medicaid cases varied between 0.69 and 22.4%. Programs in the top quartile (n = 11) performed 18,885 cases in total, with a mean of 13% for Medicaid patients, while programs in the bottom quartile (n = 11) performed 32,447 cases in total, with a mean of 1%. Patients undergoing surgery at programs in the top quartile were more likely to be Black (20.2% vs 13.5%, p < 0.0001), have diabetes (35.1% vs 29.5%, p < 0.0001), hypertension (55.1% vs 49.6%, p < 0.0001) and hyperlipidemia (47.6% vs 45.2%, p < 0.0001). Top quartile programs also had higher complication rates (8.4% vs 6.6%, p < 0.0001), extended length of stay (5.6% vs 4.0%, p < 0.0001), Emergency Department visits (8.1% vs 6.5%, p < 0.0001) and readmissions (4.7% vs 3.9%, p < 0.0001). Median time from initial evaluation to surgery date was also significantly longer among top quartile programs (200 vs 122 days, p < 0.0001).

CONCLUSIONS

Bariatric surgery programs that perform a higher proportion of Medicaid cases tend to care for patients with greater disease severity who experience delays in care and also require more resource utilization. Improving bariatric surgery utilization among patients with lower socioeconomic status may benefit from insurance standardization and program-centered incentives to improve access and equitable distribution of care.

A machine learning framework for optimizing obesity care by simulating clinical trajectories and targeted interventions

OBJECTIVE

This study aimed to determine the important clinical management bottlenecks that contribute to underuse of weight loss surgery (WLS) and assess risk factors for attrition at each of them.

METHODS

A multistate conceptual model of progression from primary care to WLS was developed and used to study all adults who were seen by a primary care provider (PCP) and eligible for WLS from 2016 to 2017 at a large institution. Outcomes were progression from each state to each subsequent state in the model: PCP visit, endocrine weight management referral, endocrine weight management visit, WLS referral, WLS visit, and WLS.

RESULTS

Beginning with an initial PCP visit, the respective 2-year Kaplan-Meier estimate for each outcome was 35% (n = 2063), 15.6% (n = 930), 6.3% (n = 400), 4.7% (n = 298), and 1.0% (n = 69) among 5876 eligible patients. Individual providers and clinics differed significantly in their referral practices. Female patients, younger patients, those with higher BMI, and those seen by trainees were more likely to progress. A simulated intervention to increase referrals among PCPs would generate about 49 additional WLS procedures over 3 years.

CONCLUSIONS

This study discovered novel insights into the specific dynamics underlying low WLS use rates. This methodology permits in silico testing of interventions designed to optimize obesity care prior to implementation.

Patient and Provider Perceptions About Communication After Bariatric Surgery: A Qualitative Analysis

INTRODUCTION

Communication between patients and providers can strongly influence patient behavior after surgery. The objective of this study was to assess patient and provider perceptions of how communication affected weight-related behaviors after bariatric surgery.

MATERIALS AND METHODS

Semistructured interviews with bariatric surgery patients and providers were conducted from April-November 2020. Patients who had Medicaid within 3 y of surgery were defined as socioeconomically disadvantaged. Interview guides were derived from Andersen's Behavioral Model of Health Services and Torain's Framework for Surgical Disparities. Participants described postoperative experiences regarding diet, physical activity, and follow-up care. A codebook was developed deductively based on the two theories. Directed content analysis identified themes pertaining to patient-provider communication.

RESULTS

Forty-five participants were interviewed, including 24 patients (83% female; 79% White), six primary care providers, four health psychologists, five registered dietitians, and six bariatric surgeons. Four themes regarding communication emerged: (1) Patients experiencing weight regain did not want to follow-up with providers to discuss their weight; (2) Patients from socioeconomically disadvantaged backgrounds had less trust and required more rapport-building from providers to enhance trust; (3) Patients felt that providers did not get to know them personally, which was perceived as a lack of personalized communication; and (4) Providers often changed their language to be simpler, so patients could understand them.

CONCLUSIONS

Patient-provider communication after bariatric surgery is essential, but perceptions about the elements of communication differ between patients and providers. Reassuring patients who have attained less weight loss than expected and establishing trust with socioeconomically vulnerable patients could strengthen care after bariatric surgery.

Obesity management for cardiovascular disease prevention

Background

Obesity is a complex disease that leads to higher morbidity and mortality and its rate in the United States is rapidly rising. Targeting obesity management is one of the cornerstones of preventive medicine. Early intervention can significantly reduce the risk of developing cardiovascular disease. While it is well known that lifestyle interventions such as healthful nutrition and routine physical activity are the first and most important step in management, some do not achieve the desired results and require further therapies.

Methods

A literature review was conducted, that included clinical documents, public scientific citations and peer review articles to evaluate anti-obesity medications, endoscopic procedures and bariatric surgeries in the management of obesity. We also included effects of these interventions on weight loss, cardiovascular disease risk reduction and side effects.

Results

This clinical review summarizes recent evidence for the different approaches in obesity management including medications, common endoscopic procedures and bariatric surgeries. For more detailed review on the different management options discussed, we recommend reviewing Obesity Medicine Association Clinical Practice Statement [1].

Conclusion

Management of obesity reduces cardiovascular risk, improves metabolic parameters and other important health outcomes. Different management approaches are available, hence, a high level of awareness of the growing epidemic of obesity is needed to ensure timely referrals to obesity medicine specialists.

Performance Characteristics of Endoscopic Sleeve Gastroplasty in Patients with Prior Intragastric Balloon: Results of a Propensity Score Matched Study

INTRODUCTION

The performance characteristics of endoscopic sleeve gastroplasty (ESG) for weight recurrence after intragastric balloon (IGB) are unknown.

METHODS

This is a retrospective propensity score matched study of ESG after IGB (IGB-to-ESG) vs ESG without prior IGB (ESG-only). The primary outcome was total weight loss (TWL) at 12 months. Secondary outcomes included TWL at 3 and 6 months, 12-month excess weight loss (EWL), procedural characteristics, and safety.

RESULTS

Thirty-nine adults underwent ESG from August 2020 to September 2022 after IGB explantation a median of 24 months (range 2-56 months) prior and a median post-IGB nadir weight increase of 100.0% (range 0 to 3200%). An ESG-only 2:1 age- sex- and BMI- propensity score matched cohort was derived from 649 patients (Pearson's goodness-of-fit: 0.86). TWL for IGB-to-ESG vs. ESG-only was 12.3 ± 13.5% vs. 12.4 ± 3.7% at 3 months (p = 0.97), 10.1 ± 7.1% vs. 15.4 ± 4.6% at 6 months (p < 0.001), and 8.7 ± 7.7% vs. 17.1 ± 5.7% at 12 months (p < 0.001). Twelve-month EWL for IGB-to-ESG vs ESG-only was 27.8 ± 46.9% vs 62.0 ± 21.0% (p < 0.001). There was no difference in mean procedural duration of ESG; however, more sutures were used with IGB-to-ESG vs. ESG-only (7 vs. 6, p < 0.0002). There were no serious adverse events in either cohort.

CONCLUSION

ESG after IGB produces safe, acceptable weight loss but with an attenuated effect compared to ESG alone. Further study is required to understand the factors driving this discrepancy.

Endoluminal bariatric and metabolic therapies: state-of-the-art

PURPOSE OF REVIEW

The aim of this review is to present the current state of the field, highlight recent developments, and describe the clinical outcomes of these endoluminal bariatric and metabolic procedures.

RECENT FINDINGS

The landscape of endoluminal devices and techniques for treating obesity has expanded significantly, with FDA-approved therapies currently available to patients with a body mass index values as high as 50 kg/m2. Although notable advancements have been made in this area, there is a need for further emphasis to be placed on the metabolic improvements resulting from these therapies, in addition to the conventional focus on weight loss outcomes. Some of these procedures are now FDA approved for the treatment of metabolic disease as opposed to weight loss. To achieve the most favorable results, it is imperative that all endoluminal interventions are combined with a moderately intensive diet and lifestyle program lasting at least 12 months.

SUMMARY

Endoluminal metabolic and bariatric therapy represents a bridge between lifestyle counseling, pharmaceutical interventions, and the most efficacious treatment for obesity, bariatric surgery. By virtue of its minimally invasive approach, this therapy may be an appealing option for patients who are ineligible for, or averse to, bariatric surgery and who have experienced suboptimal outcomes or unable to afford medical treatments. Furthermore, these interventions may be particularly beneficial in the early stages of obesity.

Depression and Anxiety as Predictors of Metabolic and Bariatric Surgery Completion Among Ethnically Diverse Patients

BACKGROUND

Mental health conditions including depression and anxiety are often prevalent among metabolic and bariatric surgery (MBS) patients, but it is not known if these conditions predict the decision to complete the procedure and if this varies by race and ethnicity. This study aimed to determine if depression and anxiety are associated with MBS completion among a race/ethnically diverse sample of patients.

METHODS

This prospective cohort study included participants who were referred to an obesity program or two MBS practices between August 2019 and October 2022. Participants completed the Mini International Neuropsychiatric Interview (MINI) instrument to determine history of anxiety and/or depression, as well as MBS completion status (Y/N). Multivariable logistic regression models determined the odds of MBS completion by depression and anxiety status adjusting for age, sex, body mass index, and race/ethnicity.

RESULTS

The sample consisted of 413 study participants (87 % women, 40% non-Hispanic White, 39% non-Hispanic Black, and 18% Hispanic). Participants with a history of anxiety were less likely to complete MBS (aOR = 0.52, 95% CI = 0.30-0.90, p = 0.020). Women had increased odds of a history of anxiety (aOR = 5.65, 95% CI = 1.64-19.49, p = 0.006) and of concurrent anxiety and depression (aOR = 3.07, 95% CI = 1.39-6.79, p = 0.005) compared to men.

CONCLUSIONS

Results showed that participants with anxiety were 48% less likely to complete MBS compared to those without anxiety. Additionally, women were more likely to report a history of anxiety with and without depression versus men. These findings can inform pre-MBS programs about risk factors for non-completion.

Endoscopic sleeve gastroplasty in class III obesity: Efficacy, safety, and durability outcomes in 404 consecutive patients

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is an effective therapy for class I-II obesity, but there are knowledge gaps in the published literature about its implementation in patients with class III obesity [body mass index (BMI) ≥ 40 kg/m²].

AIM

To evaluate the safety, clinical efficacy, and durability of ESG in adults with class III obesity.

METHODS

This was a retrospective cohort study that used prospectively collected data on adults with BMI ≥ 40 kg/m² who underwent ESG and longitudinal lifestyle counseling at two centers with expertise in endobariatric therapies from May 2018-March 2022. The primary outcome was total body weight loss (TBWL) at 12 mo. Secondary outcomes included changes in TBWL, excess weight loss (EWL) and BMI at various time points up to 36 mo, clinical responder rates at 12 and 24 mo, and comorbidity improvement. Safety outcomes were reported through the study duration. One-way ANOVA test was performed with multiple Tukey pairwise comparisons for TBWL, EWL, and BMI over the study duration.

RESULTS

404 consecutive patients (78.5% female, mean age 42.9 years, mean BMI 44.8 ± 4.7 kg/m²) were enrolled. ESGs were performed using an average of 7 sutures, over 42 ± 9 min, and with 100% technical success. TBWL was 20.9 ± 6.2% at 12 mo, 20.5 ± 6.9% at 24 mo, and 20.3 ± 9.5% at 36 mo. EWL was 49.6 ± 15.1% at 12 mo, 49.4 ± 16.7% at 24 mo, and 47.1 ± 23.5% at 36 mo. There was no difference in TBWL at 12, 15, 24, and 36 mo from ESG. TBWL exceeding 10%, 15%, and 20% was achieved by 96.7%, 87.4%, and 55.6% of the cohort at 12 mo, respectively. Of the cohort with the relevant comorbidity at time of ESG, 66.1% had improvement in hypertension, 61.7% had improvement in type II diabetes, and 45.1% had improvement in hyperlipidemia over study duration. There was one instance of dehydration requiring hospitalization (0.2% serious adverse event rate).

CONCLUSION

When combined with longitudinal nutritional support, ESG induces effective and durable weight loss in adults with class III obesity, with improvement in comorbidities and an acceptable safety profile.

Doctors' Perception Regarding Bariatric Surgery and Major Barriers in Referral of Morbidly Obese Patients for Surgery in Khyber Pakhtunkhwa

INTRODUCTION

Obesity is on the rise worldwide and has emerged as a global health concern. It has presented itself as the leading cause of morbidity, disability, and healthcare utilization. Bariatric surgery is a viable treatment option that offers sustained weight loss and improvement in comorbidities. The aim of this study is to determine the perception of doctors regarding bariatric surgery and the major barriers to the referral of morbidly obese for surgery.

METHOD

This study is a cross-sectional descriptive study conducted from November 1, 2022, to December 31, 2022. It involved prospective data collection through online questionnaires filled by doctors practicing in Peshawar. The sampling technique was non-probability convenience-based sampling. The sample size was 152. Doctors from all age groups and both genders were included in our study. Non-consenting doctors and those who were practicing bariatric surgery were excluded. Data were analyzed using a statistical package for social sciences (SPSS) version 25.0 (IBM Inc., Armonk, NY). Categorical variables have been presented as frequencies and percentages. Numerical variables have been presented as mean ± SD.

RESULTS

A total of 152 doctors participated in our research study; 92 were physicians and 60 were surgeons. The majority of our study participants' patient load per week was >75. Around 47% believed bariatric surgery was a valuable tool in the treatment of morbid obesity. The most commonly reported barrier to referral was surgical complications or side effects (28.9%).

CONCLUSION

The study concluded that the awareness regarding bariatric and metabolic surgery remains flimsy among the doctor community. Most of the physicians were unaware of the benefits of the surgical management of obesity. They also had doubts regarding the safety of the procedure. We need proper utilization of awareness strategies to overcome these barriers.

Impact of COVID-19 on the Postoperative Bariatric Surgery Patient Experience

OBJECTIVE

To characterize patient and provider perceptions of the impact of coronavirus disease 2019 (COVID-19) on weight loss following bariatric surgery.

BACKGROUND

COVID-19 has disrupted routines and healthcare throughout the United States, but its impact on bariatric surgery patients' postoperative experience is unknown.

METHODS

Semistructured interviews with bariatric surgery patients, primary care providers, and health psychologists were conducted from April to November 2020. As part of a secondary analysis, patients and providers described how the COVID-19 pandemic affected the postoperative experience within 3 domains: dietary habits, physical activity, and follow-up care. Interview guides were created from 2 conceptual models: Torain's Surgical Disparities Model and Andersen's Behavioral Model of Health Services Use. Study team members derived codes, which were grouped into themes using conventional content analysis.

RESULTS

Thirty-four participants were interviewed: 24 patients (12 Roux-en-Y gastric bypass and 12 sleeve gastrectomy), 6 primary care providers, and 4 health psychologists. Patients were predominately female (83%) and White (79%). Providers were predominately female (90%) and White (100%). COVID-19 affected the postoperative bariatric surgery patient experience via 3 mechanisms: (1) it disrupted dietary and physical activity routines due to facility closures and fear of COVID-19 exposure; (2) it required patients to transition their follow-up care to telemedicine delivery; and (3) it increased stress due to financial and psychosocial challenges.

CONCLUSIONS

COVID-19 has exacerbated patient vulnerability. The pandemic is not over, thus bariatric surgery patients need ongoing support to access mental health professionals, develop new physical activity routines, and counteract increased food insecurity.

Socioeconomic disparities and bariatric surgery outcomes: A qualitative analysis

BACKGROUND

Disparities in socioeconomic status (SES) have been associated with less weight loss after bariatric surgery. The objective of this study was to identify socioeconomic barriers to weight loss after bariatric surgery.

METHODS

We performed semi-structured interviews with bariatric surgery patients and providers from April-November 2020. Participants were asked to describe their post-operative experiences regarding dietary habits, physical activity, and follow-up care. Interview data were coded using Directed Content Analysis based on domains in Andersen's Behavioral Model of Health Services Use and Torain's Surgical Disparities Model.

RESULTS

24 patients (median of 4.1 years post-operatively; mean age 50.6 ± 10.7 years; 12 bypass and 12 sleeve; 83% female) and 21 providers (6 bariatric surgeons, 5 registered dietitians, 4 health psychologists, and 6 primary care providers) were interviewed. Barriers to weight loss included: 1) challenging employment situations; 2) limited income; 3) unreliable transportation; 4) unsafe/inconvenient neighborhoods; and 5) limited health literacy.

CONCLUSIONS

Interventions targeting socioeconomic barriers to weight loss are needed to support patients, particularly those who are socioeconomically disadvantaged.

Identifying barriers to shared decision-making about bariatric surgery in two large health systems

OBJECTIVE

Prior research suggests shared decision-making (SDM) could improve patient and health care provider communication about bariatric surgery. The aim of this work was to identify and prioritize barriers to SDM around bariatric surgery to help guide implementation of SDM.

METHODS

Two large US health care systems formed multidisciplinary teams to facilitate the implementation of SDM around bariatric surgery. The teams used a nominal group process approach involving (1) generation of multilevel barriers, (2) round-robin recording of barriers, (3) facilitated discussion, and (4) selection and ranking of barriers according to importance and feasibility to address.

RESULTS

One health system identified 13 barriers and prioritized 5 as the most important and feasible to address. The second health system identified 14 barriers and prioritized 6. Both health systems commonly prioritized six barriers: lack of insurance coverage; lack of understanding of insurance coverage; lack of organizational prioritization of SDM; lack of knowledge about bariatric surgery; lack of interdepartmental clarity between primary and specialty care; and limited training on SDM conversations and tools.

CONCLUSIONS

Health systems face numerous barriers to SDM around bariatric surgery, and these can be easily identified and prioritized by multistakeholder teams. Future research should seek to identify effective strategies to address these common barriers.

Pandemic Recovery: Persistent Disparities in Access to Elective Surgical Procedures

OBJECTIVE

To examine potential disparities in patient access to elective procedures during the recovery phase of the COVID-19 pandemic.

SUMMARY OF BACKGROUND DATA

Elective surgeries during the pandemic were limited acutely. Access to surgical care was restored in a recovery phase but backlogs and societal shifts are hypothesized to impact surgical access.

METHODS

Adults with electronic health record orders for procedures ("procedure requests"), from March 16 to August 25, 2019 and March 16 to August 25, 2020, were included. Logistic regression was performed for requested procedures that were not scheduled. Linear regression was performed for wait time from request to scheduled or completed procedure.

RESULTS

The number of patients with procedure requests decreased 20.8%, from 26,789 in 2019 to 21,162 in 2020. Patients aged 36-50 and >65 years, those speaking non-English languages, those with Medicare or no insurance, and those living >100 miles away had disproportionately larger decreases. Requested procedures had significantly increased adjusted odds ratios (aORs) of not being scheduled for patients with primary languages other than English, Spanish, or Cantonese [aOR 1.60, 95% confidence interval (CI) 1.12-2.28]; unpartnered marital status (aOR 1.21, 95% CI 1.07-1.37); uninsured or self-pay (aOR 2.03, 95% CI 1.53-2.70). Significantly longer wait times were seen for patients aged 36-65 years; with Medi-Cal insurance; from ZIP codes with lower incomes; and from ZIP codes >100 miles away.

CONCLUSIONS

Patient access to elective surgeries decreased during the pandemic recovery phase with disparities based on patient age, language, marital status, insurance, socioeconomic status, and distance from care. Steps to address modifiable disparities have been taken.

Endoscopic revision of one-anastomosis gastric bypass (ER-OAGB) for weight recurrence: a case series of 17 adults

Weight recurrence after one-anastomosis gastric bypass (OAGB), the third most common metabolic and bariatric surgery performed worldwide, is observed in a subset of patients due to the chronic, progressive nature of obesity. Endoscopic revision of the OAGB (ER-OAGB) through full-thickness suturing to reduce the gastrojejunal anastomosis and gastric pouch is a potential alternative to surgical revision. Here, we present a case series of ER-OAGB and long-term nutritional support at two international centers with expertise in bariatric endoscopy. Data were retrospectively evaluated from a prospectively maintained database. The primary outcome was total body weight loss (TBWL) at 12 months. Secondary outcomes included TBWL at 3, 6, and 15 months; excess weight loss (EWL) at 3, 6, 12, and 15 months; frequency of new/worsening symptoms of gastroesophageal reflux disease (GERD); and the frequency of serious adverse events. In this series, 17 adults (70.6% female, mean age 46.8 years, mean BMI 39.1 kg/m2) successfully underwent ER-OAGB an average of 8 years (range 2-21 years) after OAGB for a mean weight recurrence of 43.2% (range 10.9-86.9%). TBWL from ER-OAGB was 9.7 ± 1.8% at 3 months, 13.4 ± 3.5% at 6 months, 18.5 ± 2.1% at 12 months, and 18.1 ± 2.2% at 15 months. EWL from ER-OAGB was 30.5 ± 14.7% at 3 months, 42.6 ± 16.2% at 6 months, 54.2 ± 11.3% at 12 months, and 54.2 ± 11.7% at 15 months. There were no instances of new/worsening GERD symptoms or serious adverse events. In this small series of adults who experienced weight recurrence after OAGB, ER-OAGB facilitated safe and clinically meaningful weight loss, without new or worsening GERD symptoms, when performed by experienced bariatric endoscopists in concert with longitudinal nutritional support.

Exploring healthcare-seeking behavior of most vulnerable groups amid the COVID-19 pandemic in the humanitarian context in Cox's Bazar, Bangladesh: Findings from an exploratory qualitative study

The COVID-19 pandemic has raised new concerns about healthcare service availability, accessibility, and affordability in complex humanitarian settings where heterogeneous populations reside, such as Rohingya refugees in Bangladesh. This study was conducted in ten Rohingya camps and four wards of the adjacent host communities in Cox's Bazar to understand the factors influencing healthcare-seeking behavior of the most vulnerable groups (MVGs) during COVID-19 pandemic. Data were extracted from 48 in-depth interviews (24 in each community) conducted from November 2020 to March 2021 with pregnant and lactating mothers, adolescent boys and girls, persons with disabilities, elderly people, and single female-household heads. This study adopted Andersen's behavioral model of healthcare-seeking for data analysis. Findings suggest that the healthcare-seeking behavior of the participants amid COVID-19 pandemic in the humanitarian context of Cox's Bazar was influenced by several factors ranging from socioeconomic and demographic, existing gender, cultural and social norms, health beliefs, and various institutional factors. Lack of household-level support, reduced number of healthcare providers at health facilities, and movement restrictions at community level hampered the ability of many participants to seek healthcare services in both Rohingya and host communities. Most of the female participants from both communities required permission and money from their male family members to visit healthcare facilities resulting in less access to healthcare. In both communities, the fear of contracting COVID-19 from healthcare facilities disproportionately affected pregnant mothers, elderly people, and persons with disabilities accessing health services. Additionally, the economic uncertainty had a significant impact on the host communities' ability to pay for healthcare costs. These findings have the potential to influence policies and programs that can improve pandemic preparedness and health system resilience in humanitarian contexts.

Association between neighborhood food environments and bariatric surgery outcomes

BACKGROUND

Individual characteristics associated with weight loss after bariatric surgery are well established, but the neighborhood characteristics that influence outcomes are unknown.

OBJECTIVES

The objective of this study was to determine if neighborhood characteristics, including social determinants and lifestyle characteristics, were associated with weight loss after bariatric surgery.

SETTING

Single university healthcare system, United States.

METHODS

In this retrospective cohort study, all patients who underwent primary bariatric surgery from 2008 to 2017 and had at least 1 year of follow-up data were included. Patient-level demographics and neighborhood-level social determinants (area deprivation index, urbanicity, and walkability) and lifestyle factors (organic food use, fresh fruit/vegetable consumption, diet to maintain weight, soda consumption, and exercise) were analyzed. Median regression with percent total body weight (%TBW) loss as the outcome was applied to examine factors associated with weight loss after surgery.

RESULTS

Of the 647 patients who met inclusion criteria, the average follow-up period was 3.1 years, and the mean %TBW loss at the follow-up was 22%. In adjusted median regression analyses, Roux-en-Y gastric bypass was associated with greater %TBW loss (11.22%, 95% confidence interval [8.96, 13.48]) compared to sleeve, while longer follow-up time (-2.42% TBW loss per year, 95% confidence interval [-4.63, -0.20]) and a preoperative diagnosis of diabetes (-1.00% TBW loss, 95% confidence interval [-1.55, -0.44]) were associated with less. None of the 8 neighborhood level characteristics was associated with weight loss.

CONCLUSIONS

Patient characteristics rather than neighborhood-level social determinants and lifestyle factors were associated with weight loss after bariatric surgery in our cohort of bariatric surgery patients. Patients from socioeconomically deprived neighborhoods can achieve excellent weight loss after bariatric surgery.

Primary Care Physicians' Knowledge, Attitude, and Potential Referral Barriers towards Bariatric Surgery: A Northern Saudi Study

Introduction: Bariatric surgery is the most effective procedure for sustained weight loss and control of obesity-associated comorbidities among morbidly obese patients. Successful bariatric surgery depends on a multidisciplinary approach involving all healthcare workers, including the primary care physicians, from the referral of patients to long-term follow-up. The present study assessed the knowledge, attitude, and potential referral barriers of primary care physicians to bariatric surgery and associated sociodemographic factors. Materials and methods: The present analytical cross-sectional study was conducted among 280 randomly selected primary care physicians using a standard and validated data collection tool. We performed an independent t-test and one-way ANOVA to find the association between sociodemographic characteristics and knowledge, attitude, and referral barrier scores. Furthermore, multilinear regression analysis was executed to determine the association among knowledge, attitude, and barriers. Results: The current study found that 52.9%, 19.3%, and 59.3% had a low score in the knowledge, attitude, and barriers categories. The attitude scores were significantly associated with the education status (p = 0.005) and current position at primary health centers (p = 0.012), and the referral barriers score was significantly associated with the work experience duration (p = 0.004). We found a positive relationship between knowledge and attitude (regression coefficient (β) [95% CI]:0.389 [0.154 to 0.585], p = 0.001) and a negative relationship between knowledge and referral barriers (β [95% CI]: -0.291 [-0.127 to -0.058], p = 0.007). Conclusions: Our survey findings suggest that a lack of knowledge regarding bariatric surgery led to several concerns and referral barriers among the physicians. Therefore, the recommendation is to improve the primary care physicians' knowledge through continuing medical education, symposium, and other suitable training methods with a special focus on obesity care in the curriculum. Furthermore, a mixed-method survey involving other provinces of the KSA is warranted to formulate the region-specific training needs.

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.

Questioning the legitimacy of bariatric surgery: a qualitative analysis of individuals from the community who qualify for bariatric surgery

BACKGROUND

Little is known about how individuals in the community who qualify for bariatric surgery perceive it and how this affects their likelihood to consider it for themselves. This study is the first qualitative study of a racially and ethnically diverse cohort to understand perceptions of bariatric surgery.

METHODS

We designed a descriptive study to understand attitudes about bariatric surgery. We interviewed 32 individuals who met NIH criteria for bariatric surgery but have never considered bariatric surgery. We purposively sampled to ensure the majority of participants were non-white. Using an Interpretive Description framework, an exploratory, iterative method was used to code interviews and arrive at final themes.

RESULTS

Participants self-identified as 88% female, 75% Black, 3% Hispanic, 3% Pacific Islander, and 19% white. Three major themes emerged from our data regarding legitimacy of bariatric surgery. First, participants perceived bariatric surgery to be something commercialized rather than needed treatment. They equated bariatric surgery with "botulism of the lips" or "cool sculpting." Second, an important contributor to the lack of legitimacy as a medical treatment was that many had not heard about bariatric surgery before from their doctors. Doctors were trusted sources for legitimate information about health. Lastly, conflicting information over bariatric surgery-related diet and weight loss further diminished the legitimacy of bariatric surgery. As one participant reflected about pre-operative weight loss requirements, "[If] I'm going to do that, I might as well just keep losing the weight. Why even go do the surgery?".

CONCLUSION

Though bariatric surgery is a safe, effective, and durable therapy for patients with obesity, the majority of individuals we interviewed had concerns over the legitimacy of bariatric surgery as a medical treatment. Moving forward in reaching out to communities about bariatric surgery, healthcare providers and systems should consider the presentation of information to attenuate these concerns.

Racial Differences in Bariatric Surgical Approach: a Cross-Sectional National Inpatient Sample Analysis

PURPOSE

Although racial inequalities in referral and access to bariatric surgical care have been well reported, racial difference in the selection of surgical techniques is understudied. This study examined factors associated with the utilization of the two main bariatric surgical techniques: laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB).

MATERIALS AND METHODS

The National Inpatient Sample database was queried for patients who underwent elective LSG or LRYGB for the treatment of severe obesity. Chi-square tests and multivariable logistic regression assessed associations of surgical approach with patient and facility characteristics. Sensitivity analyses examined the following body mass index (BMI) subgroups: < 40.0 kg/m², 40.0-44.9 kg/m², 45.0-49.9 kg/m², and ≥ 50.0 kg/m².

RESULTS

Within the final cohort (N = 86,053), 73.0% (N = 62,779) underwent LSG, and 27.0% (N = 23,274) underwent LRYGB. Patients with BMI 45.0-49.9 kg/m² (OR = 0.85) and BMI ≥ 50.0 kg/m² (OR = 0.80) were less likely to undergo LSG than patients with BMI 40.0-45.0 kg/m² (all p < 0.001). However, Black (OR = 1.74) and White Hispanic patients (OR = 1.30) were more likely to undergo LSG than White non-Hispanic patients (all p < 0.005). In the BMI ≥ 50.0 kg/m² group, Black patients were still more likely to undergo LSG compared to White non-Hispanic patients (OR = 1.69, p < 0.001), while Asians/Pacific Islanders were less likely to receive LSG than White non-Hispanic patients (OR = 0.41, p < 0.05).

CONCLUSION

In this observational study, we identified racial differences in the selection of common bariatric surgical approaches across various BMI categories. Future investigations are warranted to study and to promote awareness of the racial/ethnic influence in attitudes on obesity, weight loss, financial support, and surgical risks during bariatric discussions with minorities.

Service Demand for and Awareness of a Primary Healthcare Pilot Project for People With Disabilities

BACKGROUND

This study investigated the demand for and awareness of a primary healthcare pilot project for people with disabilities; it also sought to identify relevant determinants for demand and awareness using Andersen's behavioral model of health service use.

METHODS

This study is a secondary analysis of data from the population-based survey conducted in Gyeonggi Regional Health & Medical Center for People with Disabilities. The data was designed with quota random sampling based on the population with disabilities in each district (city [si] and county [gun]) across the Gyeonggi province (do) to evaluate the health and healthcare accessibility of the disabled people living in the Gyeonggi province. The data was collected through the mobile-based survey of 1,140 people with disabilities living in Gyeonggi-do between March 2021 and June 2021.

RESULTS

Awareness of the service (12.1%) was remarkably low, while the demand (80.5%) was high. The gap between respondents who needed the service but were unaware of it differed according to age, education, activities of daily living, health information sources, chronic disease, depression, subjective health status, and unmet healthcare needs. Chronic disease (odds ratio [OR], 1.86; P = 0.001) and an unmet need for medical care (OR, 2.30; P = 0.002) had significant influences on demand for the service. Furthermore, living alone (OR, 0.42; P = 0.023), medical aid program beneficiary status (OR, 2.10; P = 0.020), access to health information from health service centers (OR, 4.00; P = 0.002), chronic disease (OR, 1.68; P = 0.043), severity of disability (OR, 1.78; P = 0.025), and subjective health status (OR, 4.51; P < 0.001) significantly affected awareness of the program.

CONCLUSION

Chronic disease and an unmet need for medical care were key determinants of service demand, while the severity of disability was not. Thus, there is a need to review the initiative that defines service beneficiaries as people with severe disabilities. Policy makers should consider advertising programs to improve service awareness among people with disabilities.

Pharmacological profile of once-weekly injectable semaglutide for chronic weight management

INTRODUCTION

The recent approval in the USA (Food and Drug Administration), Canada (Health Canada), UK (Medicines and Healthcare products Regulatory Agency), and EU (European Medicines Agency) of once-weekly injectable semaglutide 2.4 mg, as an adjunct to a calorie-controlled diet and increased physical activity, for chronic weight management provides health-care practitioners with an additional option when prescribing weight-loss medication.

AREAS COVERED

We describe the chemistry, mechanism of action, and pharmacological properties of semaglutide (a glucagon-like peptide 1 receptor agonist [GLP-1 RA]) and discuss clinical data and considerations for using once-weekly subcutaneous semaglutide 2.4 mg as treatment for overweight and obesity among patients with and without type 2 diabetes (T2D).

EXPERT OPINION

Once-weekly subcutaneous semaglutide 2.4 mg is the most efficacious medication approved for chronic weight management among patients with overweight and obesity, with and without T2D, and is the first drug to induce sustained double-digit reductions in percentage body weight over 1- to 2-year treatment periods. It demonstrates a similar safety and tolerability profile to other GLP-1 RAs. Semaglutide 2.4 mg treatment could dramatically improve clinical approaches to weight management, but the relatively high cost might prevent patients accessing treatment. Further research exploring the cost-effectiveness of subcutaneous semaglutide 2.4 mg is required.

Endoscopic bariatrics: current therapies and future directions

Endoscopic bariatric therapies (EBTs) are endoscopic procedures indicated for weight loss in the obese population. They are shown to be safe and effective for patients who do not quality for bariatric surgery. There are currently no randomized controlled studies comparing bariatric surgery with EBTs. However, EBTs are more cost effective and have fewer complications. This review will examine currently available EBTs with published data.

Online survey on factors influencing patients' motivation to undergo bariatric surgery

Given the worldwide increasing prevalence of severe obesity and considering the amount of scientific evidence demonstrating the beneficial effects of bariatric surgery (BS), it is surprising that only a fraction of patients with obesity undergo BS. We therefore conducted an anonymized online survey among individuals with a history of BS to understand factors influencing the deciding process leading to BS. Respondents were recruited on a voluntary basis from obesity-related social media groups between April and June 2020. The self-designed, non-validated questionnaire consisted of 20 questions and was open to any participants with a history of BS. Of 851 participants who started the survey, 665 completed the questionnaire (completion rate of 78.1%). Five years after BS, still 70% of the survey-participants were very satisfied or satisfied with the surgical result. However, the majority (73.3%) would have undergone BS earlier. The main motivation to choose BS was related to health status or quality of life. Important characteristics for a bariatric surgeon to obtain patients' trust are "taking time and listen" (74.7%), empathy (64%) and sympathy (56%). Post-operative satisfaction with the surgical outcome was high and long-lasting in this large cohort of BS patients. However, most participants would retrospectively have undergone BS earlier. The main reason to choose BS as treatment for their obesity were impaired physical health or reduced quality of life. Nearby location to patients' residence and availability of surgeons with empathy were decisive motives for bariatric centre selection.

Health care use by adults with obesity: A French cohort study

OBJECTIVE

Studies on obesity costs have focused on global costs of people with obesity but scarcely investigated their precise use of health care. The aim of this study is to document real-life health care use across obesity classes.

METHODS

Data of participants with obesity and enrolled in the CONSTANCES cohort were analyzed. Health care use was defined as ≥1 visit to general practitioners, specialists, emergency departments, and inpatient hospital admissions versus none over a 3-year period prior to enrollment and was obtained from the Universal Health Insurance database. Multivariate regression models were conducted and adjusted for comorbidities and social deprivation markers with medical visits as the outcome variables and compared people with class II and III obesity versus class I obesity.

RESULTS

Out of the 10,774 participants with obesity, 613 (5.7%) had class III obesity, and 2,076 (19.3%) had class II obesity. Compared with participants with class I obesity, class III obesity participants had higher odds of visiting emergency departments (OR = 1.31; 95% CI: 1.07-1.61) and various specialist physicians (pneumologists, endocrinologists, cardiologists) but lower odds of visiting gynecologists (OR = 0.69; 95% CI 0.55-0.87). Participants with class II obesity had lower odds of visiting general practitioners, dentists, and psychiatrists. There was no difference with regard to hospital admissions.

CONCLUSION

Health care use by people with obesity differs across classes.

Understanding Racially Diverse Community Member Views of Obesity Stigma and Bariatric Surgery

Purpose

The obesity epidemic poses serious challenges to health equity. Despite bariatric surgery being one of the most effective obesity treatments, utilization remains low. In this context, we explored public perceptions of bariatric surgery, centering voices of Black individuals.

Materials and Methods

Semi-structured interviews with individuals who have never considered bariatric surgery with purposive sampling to ensure the majority of participants were Black. Transcripts were iteratively analyzed. We employed an Interpretive Description framework to arrive at a collective description of perceptions of bariatric surgery.

Results

Thirty-two participants self-identified as 88% female, 72% Black, 3% Hispanic, 3% Pacific Islander, 3% Mixed Race, and 19% White. Participants reported a complex interplay of deeply held, stigmatized beliefs about identity. According to the stigma, persons with obesity lacked willpower and thus were considered devalued. Participants internalized this stigma, describing themselves with words like “glutton,” “lazy,” and “slack off.” Because stigma caused participants to view obesity as resulting from personal failings alone, socially acceptable ways to lose weight were discipline through diet and exercise. Working for weight loss was “self-love, self-discipline, and determination.” Thus, bariatric surgery was illegitimate, a “shortcut to weight loss” or “easy way out,” since it was outside acceptable methods of effort.

Conclusion

This qualitative study of community members who qualify for bariatric surgery shows obesity stigma was the main reason individuals rejected bariatric surgery. Obesity was stigmatizing, but undergoing bariatric surgery would further stigmatize individuals. Thus, healthcare providers may be instrumental in increasing bariatric surgery uptake by shifting social discourse from stigmatized notions of obesity towards one focusing on health.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-022-05928-x.

Perceptions and Attitudes Toward Obesity and its Management in Migrants and Rural Residents in China: a Cross-sectional Pilot Study

BACKGROUND

The incidence of overweight and obesity in rural-to-urban migrants and rural residents is increasing rapidly. This study aims to explore the perceptions and attitudes toward obesity and its management among rural-urban migrants and rural residents who are left in rural regions, China.

METHODS

We performed a cross-sectional survey investigating migrants and rural residents aged 18-45 in China from October to November 2020. We created a questionnaire. Two hundred five questionnaires were completed.

RESULTS

Finally, 184 were included, of which 102 were migrants and 82 were non-migrants. More respondents were male (62%). There was no significant difference in BMI between the two groups. The migrants had good knowledge about obesity as a disease (75.5%) and agreed that obesity seriously threatens health (93.1%). It is worth noting that more non-migrant group believed that obesity was due to a lack of willpower (87.3% vs. 54.9%, p = 0.000) than the migrant group. More than half in both groups believed that obesity was caused by a bad lifestyle (69.6%) or addiction to food (58.7%). Half of the participants believed that biological factors caused obesity. Most participants in both groups still believed weight loss modalities were limited to exercise and diet while having extremely poor acceptance of pharmacotherapy and bariatric surgery.

CONCLUSIONS

This study found that the migrants and rural residents had a good understanding of obesity as a disease, and better among migrants than rural residents. However, they showed significant uncertainty and misconceptions about the efficacy and safety of pharmacotherapy and bariatric surgery.

A Qualitative Study of the System-level Barriers to Bariatric Surgery Within the Veterans Health Administration

OBJECTIVE

To characterize system-level barriers to bariatric surgery from the perspectives of Veterans with severe obesity and obesity care providers.

SUMMARY OF BACKGROUND DATA

Bariatric surgery is the most effective weight loss option for Veterans with severe obesity, but fewer than 0.1% of Veterans with severe obesity undergo it. Addressing low utilization of bariatric surgery and weight management services is a priority for the veterans health administration.

METHODS

We conducted semi-structured interviews with Veterans with severe obesity who were referred for or underwent bariatric surgery, and providers who delivered care to veterans with severe obesity, including bariatric surgeons, primary care providers, registered dietitians, and health psychologists. We asked study participants to describe their experiences with the bariatric surgery delivery process in the VA system. All interviews were audio-recorded and transcribed. Four coders iteratively developed a codebook and used conventional content analysis to identify relevant systems or "contextual" barriers within Andersen Behavioral Model of Health Services Use.

RESULTS

Seventy-three semi-structured interviews with veterans (n = 33) and providers (n = 40) throughout the veterans health administration system were completed. More than three-fourths of Veterans were male, whereas nearly three-fourths of the providers were female. Eight themes were mapped onto Andersen model as barriers to bariatric surgery: poor care coordination, lack of bariatric surgery guidelines, limited primary care providers and referring provider knowledge about bariatric surgery, long travel distances, delayed referrals, limited access to healthy foods, difficulties meetings preoperative requirements, and lack of provider availability and/or time.

CONCLUSIONS

Addressing system-level barriers by improving coordination of care and standardizing some aspects of bariatric surgery care may improve access to evidence-based severe obesity care within VA.

Individual-level barriers to bariatric surgery from patient and provider perspectives: A qualitative study

BACKGROUND

Less than 1% adults in the United States who meet body mass index criteria undergo bariatric surgery. Our objective was to identify patient and provider perceptions of individual-level barriers to undergoing bariatric surgery.

METHODS

Adults with severe obesity and obesity care providers described their experiences with the bariatric surgery care process in semi-structured interviews. Using conventional content analysis, individual-level barriers were identified within Andersen's Behavioral Model of Health Services Use.

RESULTS

Of the 73 individuals interviewed, 36 (49%) were female, and 15 (21%) were non-white. Six individual-level barriers were identified: fear of surgery, fear of lifestyle change, perception that weight had not reached its "tipping point," concerns about dietary changes, lack of social support, and patient characteristics influencing referral.

CONCLUSIONS

Patient and provider education should address patient fears of surgery and the belief that surgery is a "last resort." Bariatric surgery programs should strengthen social support networks for patients.

First Inventory of Access and Quality of Metabolic Surgery Across Europe

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.

Health service utilisation among African migrants in China: a nationwide cross-sectional study

OBJECTIVES

To assess the health utilisation status and associated factors among African migrants in China.

DESIGN

A national cross-sectional study was conducted among African migrants in China in 2019.

SETTING

Participants were recruited online and offline to participate in a self-report survey. Online participants were recruited through WeChat across China, and offline participants were recruited in Guangzhou.

PARTICIPANTS

We recruited participants who were from an African country; had spent at least 1 month cumulatively in China; were at least 18 years old; were willing to provide informed consent. A total of 1025 participants were recruited online and offline, 19 of them were excluded due to invalid response and 1006 people were finally included in the analysis.

OUTCOME MEASURES

The primary outcome was health service utilisation and associated factors among African migrants during their stay in China in the past 12 months. The potential factors include the predisposing factors (demographic characteristics and social structure variables), enabling factors (annual income, health insurance in China) and need factors (non-communicable chronic and infectious diseases, depression) which determined by Anderson framework were measured.

RESULTS

Eight hundred and seven online and 218 offline participants completed the survey, including 624 males and 382 females, with an average age of 26.4±8.9 years. Around 28.5% reported health utilization in the past 12 months. Results showed that longer duration in China, migration to China for business (aOR=2.23, 95% CI:1.13-4.40) and study (aOR=5.00, 95% CI:2.74-9.11), living in apartment (aOR=2.59, 95% CI:1.62-4.14) or dormitory (aOR=3.22, 95% CI:2.17-4.80) in China, suffering from chronic diseases, communicable diseases, and greater depressive symptoms (aOR=1.91, 95% CI:1.42-2.56) facilitated health service utilization.

CONCLUSIONS

The healthcare service that African migrants received in China is low. The existing public health policies and intervention measures need to be improved to make health utilisation more accessible and feasible for African migrants.

The Effects of the Affordable Care Act on Utilization of Bariatric Surgery

INTRODUCTION

The Affordable Care Act (ACA) expanded Medicaid (ME) and instituted Essential Health Benefits (EHB) that included bariatric surgery coverage on a state-by-state opt-in basis, increasing insurance coverage of bariatric surgery.

MATERIALS AND METHODS

Using a difference-in-differences framework, changes in bariatric surgery rates, defined as utilization in the population of people with obesity, before and after the ACA were evaluated in four states. Bariatric surgery procedure data were taken from the Healthcare Cost and Utilization Project's State In-patient Database 2012-2015. Adjusted multivariable regressions were run in the Medicaid and commercially insured populations.

RESULTS

We identified 36,456 bariatric surgeries across the 286 Health Service Areas and time periods, with 31,732 covered by commercial insurers and 4724 covered by Medicaid. An unadjusted increase in utilization rates was seen in the Medicaid and Commercial populations in both ME- and EHB-covered states as well as non-expansion and EHB opt-out states over time. In the Medicaid population, after adjusting for confounders, there was a significant increase of 24.77 cases per 100,000 people with obesity (95% confidence interval: 12.41, 37.13) in the expansion states relative to the control and pre-period. The commercial population experienced a nonsignificant change in the rates of bariatric surgery, decreasing by 2.89 cases per 100,000 people with obesity (95% confidence interval: - 21.59, 15.81).

CONCLUSIONS

There was a significant increase in bariatric surgery rates among Medicaid beneficiaries associated with Medicaid expansion, but there was no change among the commercially insured.

Patient-provider discussions of bariatric surgery and subsequent weight changes and receipt of bariatric surgery

OBJECTIVE

The purpose of this study was to determine whether patients who discuss bariatric surgery with their providers are more likely to undergo the procedure and to lose weight.

METHODS

A retrospective cohort study of adults with BMI ≥ 35 kg/m² treated between 2000 and 2015 was conducted to analyze the relationship between a discussion of bariatric surgery in the first year after study entry and weight changes (primary outcome) and receipt of bariatric surgery (secondary outcome) over 2 years after study entry. Natural language processing was used to identify the documentation of bariatric surgery discussion in electronic provider notes.

RESULTS

Out of 30,560 study patients, a total of 2,659 (8.7%) discussed bariatric surgery with their providers. The BMI of patients who discussed bariatric surgery decreased by 2.18 versus 0.21 for patients who did not (p < 0.001). In a multivariable analysis, patients who discussed bariatric surgery with their providers lost more weight (by 1.43 [change in BMI]; 95% CI: 1.29-1.57) and had greater odds (10.2; 95% CI: 9.0-11.6; p < 0.001) of undergoing bariatric surgery.

CONCLUSIONS

Clinicians rarely discussed bariatric surgery with their patients. Patients who did have this discussion were more likely to lose weight and to undergo bariatric surgery.

Patient initiation and maintenance of GLP-1 RAs for treatment of obesity

Introduction: Healthcare providers (HCPs) see many patients with obesity-related complications and are therefore well placed to help treat obesity itself. However, limited collated information exists to help HCPs with the practical use of anti-obesity medications (AOMs). We focus on the initiation and maintenance of a glucagon-like peptide-1 receptor agonist (GLP-1 RA) for weight management, liraglutide 3.0 mg. Literature search was conducted between 25-28 November 2019 on PubMed and ClinicalTrials.gov.Areas covered: Clinical trial and real-world data describing weight-loss efficacy, cardiometabolic risk factors, incidence of adverse events (AEs), and persistence are presented to assist HCPs with patient discussions. Practical considerations to overcome barriers to optimal use are provided, equipping HCPs with the information required to aid with adherence to and persistence with AOMs. The use of other GLP-1- RA therapies in obesity is discussed in light of the recent US Food and Drug Administration approval of semaglutide 2.4 mg for weight management.Expert opinion: Liraglutide 3.0 mg provides benefits regarding weight loss and improvements in cardiometabolic risk factors. Promising areas of future research in the field of obesity include dual receptor agonists and the combination of glucagon-like peptide-1 receptor agonists with other molecules.

Predictors of surgical intervention for those seeking bariatric surgery

BACKGROUND

Bariatric surgery has been found to be effective in the treatment of severe obesity. Studies have shown that the majority of eligible patients do not undergo surgery.

OBJECTIVES

It is important to identify variables that may impact patient decision making and potentially lead to the disproportionate underutilization of bariatric surgery.

SETTING

The study was conducted at one academic medical center in central Pennsylvania.

METHODS

Bariatric patients who participated in a preoperative psychological assessment from 2017 to early 2020 completed comprehensive self-report questionnaires addressing sociodemographic variables, health history, psychopathology, and eating behaviors. Body mass index was calculated based on clinical measurements of each patient at the start of the preoperative program. Sociodemographic variables and self-report instrument scores were compared between those who completed surgery and those who did not.

RESULTS

Of the 1234 participants, significant differences were found between the compared variables. All minority groups were less likely to undergo surgery than White patients. Participants reporting higher impairment were less likely to progress to surgery. Impairments across 3 behavioral eating assessments were associated with a lower likelihood of surgery.

CONCLUSION

There are multiple factors that contribute to patient progression to surgery, and ultimately whether the patient undergoes bariatric surgery. Results show a need for further investigation surrounding the sociodemographic and psychosocial variables that influence the patient's advancement to surgery. Both providers and patients could benefit from a deeper understanding of potential barriers to utilization of bariatric surgery.

6-Month Gastrointestinal Quality of Life (QoL) Results after Endoscopic Sleeve Gastroplasty and Laparoscopic Sleeve Gastrectomy: A Propensity Score Analysis

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is currently the most commonly performed bariatric procedure. Endoscopic sleeve gastroplasty (ESG) is a promising new bariatric technique which is less invasive in its approach. To date no study has compared quality of life (QoL) outcomes between LSG and ESG. The aim of this study is to compare QoL after ESG and LSG using a propensity score analysis.

METHODS

QoL was evaluated by means of Gastrointestinal Quality of Life Index (GIQLI) questionnaire before and 6 months after the procedure. Patients were matched for age, sex, preoperative weight, and comorbidities.

RESULTS

Propensity score matching resulted in 23 pairs of patients homogeneous for age (p = 0.3), preoperative BMI (p = 0.3), sex (p = 0.74), and comorbidities (p = 0.9). Post-ESG patients, despite a less important %EWL (39.9 (17.5-58.9)vs 54.9 (46.2-65); p = 0.01) and %TWL (13.4 (7.8-20.9) vs 18.8 (17.6-21.8); p = 0.03), presented better QoL (14 [3-24] vs 13 (- 1-23) ΔGIQLI score; p = 0.79) with clear advantage for the gastrointestinal symptoms subdomain (66.5 (61-70.5) vs 59 (55-63); p = 0.001), while post-LSG patients presented a worsening of GERD symptoms (30.7% vs 0%) and an increased use of PPI therapy (p = 0.004). Resolution or improvement of comorbidities was similar (ESG 53% vs LSG 45.8%; p = 0.79) in both groups.

CONCLUSION

LSG may significantly affect QoL and results in worsening of gastrointestinal symptoms including GERD. ESG is a promising less invasive bariatric endoscopic procedure that demonstrated a positive impact on both QoL and comorbidities, which could lead to greater patient acceptance earlier in their disease or at a younger age.

Primary Care Physicians' Perceptions of Bariatric Surgery and Major Barriers to Referral

BACKGROUND

Each year from 2011 to 2017, fewer than 1% of eligible Americans underwent bariatric surgery to treat obesity and obesity-related comorbidities. Recent studies have suggested that a lack of knowledge within the primary care specialty about the safety and efficacy of bariatric surgery greatly affects referral. This study aimed to analyze a large cohort of primary care physicians' (PCPs) clinical perceptions regarding bariatric surgery and to identify major barriers to referral that could inform the implementation of a future educational strategy to address underutilization of bariatric surgery.

STUDY DESIGN

A prospective anonymous electronic survey was sent to all primary care physicians at a multicenter community-based academic hospital system between March and June of 2018, with 150 respondents, a response rate of 28%. The survey was composed of eleven questions in total, the first eight utilizing a five-point Likert scale, with answers including strongly disagree, disagree, neutral, agree, and strongly agree. The final three questions utilized freeform answers of numbers or text where appropriate.

RESULTS

Between 83 and 88% of PCPs responded favorably, either agree or strongly agree, to questions regarding the utility of bariatric surgery as an efficacious and valuable tool for the treatment of obesity and related comorbidities. PCPs reported an average body mass index (BMI) of 40.4 ± 5.0 kg/m² at which bariatric surgery is a patient's best option for weight loss and an average BMI of 38.0 ± 5.6 kg/m² at which surgery is the best option for management of comorbidities. Eighty-six percent of PCPs agree that having a BMI over 40 kg/m² is a greater risk to a patient's long-term health than undergoing bariatric surgery. However, only 46.6% of PCPs claimed any familiarity with the NIH eligibility criteria for bariatric surgery and only 59.5% responded affirmatively that they were comfortable participating in the long-term care of a postoperative bariatric patient. The two highest reported barriers to referral for bariatric surgery together account for 40% of PCPs responses: 21.5% of PCPs report concern regarding surgical complications and/or long-term side effects as the primary barrier for referral, and 18.5% report concern for ineffective weight loss after bariatric surgery as a primary barrier to referral.

CONCLUSION

Results of this study indicate that despite largely positive attitudes toward the use of bariatric surgery in a patient population with obesity, primary care physicians report significant barriers to confidently referring their own patients. Further, bariatric surgery is overlooked in a large group of patients with BMIs between 35 and 40 kg/m². Educational strategies to address these barriers should target rates of specific surgical complications and weight loss outcomes.

Analysis of Early Job Market Experiences and Perceptions Among Bariatric Surgery Fellowship Graduates and Bariatric Surgery Program Directors

PURPOSE

Over the past decade, an increasing number of bariatric surgeons are trained in fellowships annually despite only a modest increase in nationwide bariatric surgery volume. The study surveys the bariatric surgery job market trend in order to inform better career-choice decisions for trainees interested in this field.

MATERIALS AND METHODS

A national retrospective cohort survey over an 11-year period was conducted. Bariatric surgery fellowship graduates from 2008 to 2019 and program directors (PDs) were surveyed electronically. Univariate analysis was performed comparing responses between earlier (2008-2016) and recent graduates (2017-2019).

RESULTS

We identified a total of 996 graduates and 143 PDs. Response rates were 9% and 20% respectively (n = 88, 29). Sixty-eight percent of graduates felt there are not enough bariatric jobs for new graduates. Seventy-nine percent of PDs felt that it is more difficult to find a bariatric job for their fellows now than 5-10 years ago. Forty-eight percent of PDs felt that we are training too many bariatric fellows. Seventy-seven percent of all graduates want the majority of their practice to be comprised bariatric cases; however, only 42% of them reported achieving this. In the univariate analysis, recent graduates were less likely to be currently employed as a bariatric surgeon (64% vs. 86%, p = 0.02) and were less satisfied with their current case volume (42% vs. 66%, p = 0.01).

CONCLUSIONS

The temporal increase in bariatric fellowship graduates over the past decade has resulted in a significant decline in the likelihood of employment in a full-time bariatric surgical practice and a decline in surgeons' bariatric case volumes.

Successful weight loss after bariatric surgery in Appalachian state regardless of food access ranking score

BACKGROUND

Following bariatric surgery, an explicit dietary regimen is required to facilitate and maintain successful weight loss. Without adequate access to healthy foods, weight maintenance can be hindered.

OBJECTIVE

Examine influence degree of food access has on Appalachian bariatric surgery patient weight loss outcomes.

SETTING

Appalachian University hospital, United States.

METHODS

A retrospective chart review was used to examine the influence of food accessibility on weight loss outcomes in an Appalachian bariatric surgery patient population at a large tertiary hospital in West Virginia between 2013 and 2017. Demographic characteristics, health and family history, and 1-year surgery outcomes were collected. A state-specific food accessibility score was calculated for each patient address using the geographic information system. Patients were assigned a food access ranking score (FARS) between 0 (low food access) and 4 (high food access) based on criteria of quantity, quality, income, and vehicle access.

RESULTS

Patients (n = 369) were predominately married (60.5%), white (92.4%), female (77.8%), and underwent laparoscopic Roux-en-Y gastric bypass surgery (75.9%), with a mean age of 45 years. Most patients had low FARS (M = 1.67 ± .73; 72.6%). Nonwhite patients (P = .03) with a preoperative diagnosis of depression (P = .02) or without a family history of obesity (P = .01) were found to be in the lower FARS categories. FARS was not indicative of weight loss post surgery (P > .05).

CONCLUSIONS

Food accessibility in West Virginia was not associated with bariatric surgery weight outcomes at 1-year post operation. Lower food access was associated with nonwhite race/ethnicity, diagnosed depression at baseline, and no family history of obesity. Future studies should include more extended follow-up data collection and mixed-method approaches to capture perceptions of food access and its impact on the patients' postoperative journey.