The impact of mental health disorders on 30-day readmission after bariatric surgery

Mental health status as a predictor of emergency department visits and hospital readmissions post bariatric surgery: a retrospective cohort study

BACKGROUND

This retrospective cohort study aims to investigate emergency department (ED) visits and readmission after bariatric surgery among patients with a history of anxiety and/or depression. We predict that patients with a reported history of anxiety and/or depression will have more ED visits in the year following surgery than patients without a history of mental illness.

METHODS

Data were collected from the charts of all consecutive patients who underwent sleeve gastrectomy or gastric bypass surgery between March 2012 and December 2019. Data on baseline body mass index, mental health diagnosis and treatment and emergency department visits and hospital readmissions were retrospectively reviewed over the first year following surgery.

RESULTS

One thousand two hundred ninety-seven patients were originally included in this study and 1113 patients were included in the final analysis. Patients with a history of depression (OR 1.23; 95% CI 0.87-1.73), anxiety (OR 1.14; 95% CI 0.81-1.60), or both (OR 1.17; 95% CI 0.83-1.65) did not have a statistically significant increase in ED visits compared to patients without these disorders. Patients with a history of depression (OR 1.49; 95% CI 0.86-2.61), anxiety (OR 1.45; 95% CI 0.80-2.65) or both (OR 1.47; 95% CI 0.94-2.29) did not have a statistically significant increase in hospital readmissions in the first year after surgery compared to patients without these disorders. Patients treated with a sleeve gastrectomy were readmitted due to postoperative complications less frequently than those treated with other surgeries (OR 0.20; 95% CI 0.05-0.83).

CONCLUSION

Patients with a history of anxiety, depression or both did not have an increased rate of emergency department visits and hospital readmissions within the first year following bariatric surgery. This contradicts current literature and may be due to the multidisciplinary program patients undergo at this study's home institution.

Bariatric surgery outcomes in patients with bipolar or schizoaffective disorders

BACKGROUND

Obesity is associated with many co-morbidities and can cause harm to physical and mental well-being. While much has been studied in the general population about the outcomes of bariatric surgery, its implications in patients with bipolar/schizoaffective disorder (BSD) are less well understood.

OBJECTIVE

We aimed to describe outcomes of bariatric surgery in patients with BSD.

SETTING

Referral center for bariatric surgery.

METHODS

We conducted a retrospective chart review analysis of bariatric surgical procedures in patients with BSD between 2008 and 2021 at Mayo Clinic. Patients with BSD (cases) were matched via propensity score matching (1:2) with non-BSD controls based on surgical procedure, age, sex, body mass index, and type 2 diabetes. Hierarchical logistic regression model was performed using SAS software.

RESULTS

We matched 71 patients with BSD with 142 controls in a 1:2 ratio. After adjusting for baseline preoperative weight, patients with BSD had a 3.4% greater total weight loss compared with controls over 24 months (P = .02 [95% CI, .65-6.08]). Remission in obesity-related diseases, such as diabetes, hypertension, dyslipidemia, and sleep apnea, was similar in both groups. Perioperative complication rates were similar other than deep venous thrombosis, which showed a higher rate in patients with BSD (P = .04). Patients with long-term BSD were at increased risk of alcohol use compared with controls.

CONCLUSIONS

When compared with the general bariatric population, weight loss was similar to slightly improved, with a comparable risk and complication profile. Patients with BSD have increased alcohol use after bariatric surgery, highlighting the need for psychological care before and after surgery in this population.

Feasibility of Laparoscopic Sleeve Gastrectomy for Patients with Obesity and Disorders of Intellectual Development: a Single Institutional Experience

BACKGROUND

Owing to their difficulty following clinical advice for procedural safety and ideal surgical outcomes, bariatric and metabolic surgery (BMS) for patients with disorders of intellectual development (DID) is concerning. Studies reporting the feasibility of BMS for this population remain scarce. This study aims to clarify the feasibility of laparoscopic sleeve gastrectomy (LSG) for patients with clinically severe obesity and DID.

METHODS

A retrospective analysis of a single institutional prospective database collected from 2010 to 2022 was performed. The Wechsler Adult Intelligence Scale (WAIS) was used to measure intellectual ability before LSG. A multidisciplinary team approach was implemented to give special support and care to patients with DID. Patients were categorized into groups according to their WAIS scores. LSG outcomes were statistically compared between the DID and average intellectual ability groups.

RESULTS

Using the WAIS to measure intellectual ability among patients who underwent LSG, we identified 14 patients with DID (IQ score: < 69, mean IQ: 63.4) and 71 with average intellectual ability (IQ score: 90-109, mean IQ: 98.9). Operative outcomes were comparable between the groups as follows: operation time (DID: 163 ± 41 min, average intelligence: 162 ± 30 min), hospital stay (DID: 4 [4-5] days, average intelligence: 5 [4-6] days), and total comorbidities (DID: 7.1%, average intelligence: 8.4%). No reoperations were performed, and no mortalities were observed.

CONCLUSIONS

With medical and social support and care, performing LSG on patients with clinically severe obesity and DID is safe, with good short-term results.

Chronic psychiatric diagnoses increase emergency department utilization following bariatric surgery

INTRODUCTION

This study aims to evaluate the impact mental health disorders have on emergency department (ED) utilization following bariatric surgery. We hypothesize that the presence of preexisting psychiatric diagnoses is predictive of increased post-bariatric surgical ED usage as compared to a matched cohort without psychiatric comorbidities.

METHODS AND PROCEDURES

We utilized the Colorado All Payers Claim Database to identify patients undergoing laparoscopic sleeve gastrectomy, gastric band, or gastric bypass, (N = 5393). Patients with preexisting diagnoses of schizophrenia or bipolar disorder (PSY), and no concomitant mental health diagnosis were included (N = 427). Patients without a psychiatric diagnosis (CON) were used for comparison. Propensity score matching in a 1:1 ratio was done matching for age, sex, BMI, procedure type, and comorbidities. Baseline ED utilization was calculated over the year preceding surgery.

RESULTS

A total of 240 patients with bipolar disorder or schizophrenia were identified. After matching, baseline ED utilization was 62% higher in the PSY group (ED visits per person per month (EDVPP) of 0.17 (95%CI 0.16-0.18) in the PSY group compared to 0.10 (95%CI 0.09-0.12) in the CON group). ED utilization increased dramatically in the month following surgery for both PSY and CON groups (EDVPP 0.58 (95%CI 0.52-0.65) vs 0.34 (95%CI 0.28-0.41)), but visits returned to baseline for the CON but not PSY patients by three months after surgery (11% vs 60% above baseline, respectively). In the PSY group, ED utilization remained elevated at 18% above baseline for two years post-surgery (EDVPP 0.20 (95%CI 0.19-0.22).

CONCLUSIONS

Bariatric patients with schizophrenia or bipolar disorder have higher baseline ED usage compared to a matched cohort. ED usage increases post-operatively in all patients but to a greater extent in patients with these diagnoses. Such patients would benefit from intensive outpatient follow-up to limit ED visits.

Impact of post-discharge phone calls on non-urgent hospital returns < 90 days following primary bariatric surgery

INTRODUCTION

Quality of care delivery may improve patient outcomes post-bariatric surgery. We examined the quality of post-discharge phone calls (Ph_DC) to determine the impact on early (< 90 day) non-urgent hospital returns (NUHR) following primary bariatric surgery.

METHODS

A retrospective review was performed on patients who underwent Roux-en-Y-gastric bypass (RYGB) or sleeve gastrectomy (SG) in 2019. Patients were compared between presence of care coaching (Jan-June 2019) versus no care coaching (July-Dec 2019). Baseline demographics, comorbidities, psychiatric history, and Ph_DC were collected. Index Ph_DCs were coded for completeness using a scoring system and rated by call quality. Patients were stratified into NUHR versus control group (Never returns [NR]). Primary analysis examined the impact of Ph_DC on NUHR. Sub-analysis examined the impact of call quality. Univariate analysis was performed using Chi-square or Fisher's exact tests. Multivariate analysis (MVA) was used to determine predictors of NUHR. A p-value of ≤ 0.05 was statistically significant.

RESULTS

A total of 359 patients were included. Compared to the NR group (n = 294), NUHRs (n = 65) were more likely to be younger (41.3 + 12.1 versus 45.0 + 10.8 years, p = 0.024), with baseline anxiety (41.5% versus 23.5%, p = 0.003), and undergo RYGB (73.3% versus 57.8%, p = 0.031). There was a significant difference in number of Ph_DC in the NUHR and NR groups (p = 0.0206). Care-coached patients had significantly higher rates of high-quality phone calls (p < 0.0001) compared to non-care-coached patients. MVA demonstrated younger age (OR = 0.97, CI: 0.95-1.00; p = 0.023), anxiety (OR = 2.09, CI: 1.17-3.73; p = 0.012), RYGB (OR = 1.88, CI: 1.02-3.45; p = 0.042), and > 50% call quality versus no Ph_DC (OR = 0.45, CI: 0.25-0.83; p = 0.010) were independently associated with NUHRs.

CONCLUSION

High-quality Ph_DCs may play a role in mitigating NUHRs. Care coaching represents a potential intervention to decrease high rates of NUHR in primary bariatric surgery patients.

Associations between psychological evaluation outcomes, psychiatric diagnoses, and outcomes through 12 months after bariatric surgery

BACKGROUND

There is limited evidence about how patients' initial preoperative psychological evaluation outcomes (require follow-up [RFU], no required follow-up [NFU], and place on hold [POH]) and current psychiatric diagnoses associate with postoperative outcomes.

OBJECTIVES

To test the hypotheses that patients who receive a clinical decision of RFU versus NFU from their initial psychological evaluation will be (1) more likely to experience postoperative complications, readmissions, and emergency room visits and (2) experience less weight loss over 12-months. Specific diagnoses (any psychiatric diagnosis, depression, and anxiety) are also examined for their association with weight loss over 12 months.

SETTING

Midwestern medical center, United States.

METHODS

The sample included 322 patients (81.1% female and 64.0% White) with completed psychological evaluations between August 2019 and December 2020. Patient demographics, psychological evaluation outcomes, current diagnoses, and postoperative outcomes were extracted from the health record. Bivariate analyses determined associations between NFU/RFU and postoperative complications (yes, no), readmissions (yes, no), and emergency room visits (yes, no). Mixed multilevel models were conducted with dichotomous variables NFU/RFU, any psychiatric diagnoses (yes, no), depression diagnoses (yes, no), or anxiety diagnoses (yes, no) as the main fixed within-group factors with weight loss (weight or percent total weight loss) used as the repeated measures. Insurance and surgical procedure were included as covariates.

RESULTS

There were no significant differences in postoperative complications, readmissions, and emergency room visits between NFU and RFU groups. Patients who received a RFU versus an NFU had higher weights over 12 months (P = .001).

CONCLUSION

Hypothesis 2 was only partially supported. Patients who received an RFU versus an NFU had higher weights over 12 months, but this association was not found for percent total weight loss or any of the psychiatric within-subjects variables (i.e., psychiatric diagnoses, depression, and anxiety).

Impact of Mental Health on General Surgery Patients and Strategies to Improve Outcomes

Mental Health Disorders (MHD) are a growing concern nationwide. The significant impact MHD have on surgical outcomes has only recently started to be understood. This literature review investigated how mental health impacts the outcomes of general surgery patients and what can be done to make improvements. Patients with schizophrenia had the poorest surgical outcomes. Mental health disorders increased post-surgical pain, hospital length of stay, complications, readmissions, and mortality. Mental health disorders decreased wound healing and quality of care. Optimizing outcomes will be best accomplished through integrating more effective perioperative screening tools and interventions. Screenings tools can incorporate artificial intelligence, MHD data, resilience and its biomarkers, and patient mental health questionnaires. Interventions include cognitive behavioral therapy, virtual reality, spirituality, pharmacology, and resilience training.

The Norse Feedback in a population of patients undergoing bariatric surgery-Psychometric properties of a digital computer-adaptive questionnaire assessing mental health

The Norse Feedback (NF) is a questionnaire developed for patient-reported outcome monitoring with a clinical feedback system (PRO/CFS). As mental health is a concern after bariatric surgery, the use of the NF as part of PRO/CFS may be beneficial. The aim of this study is to test the reliability and validity of the NF in patients who have been accepted for or have undergone bariatric surgery. We performed separate robust confirmatory factor analyses (CFAs) to test the unidimensionality on 19 of the NF scales. We also performed correlation analyses on 19 of the NF scales with the Obesity-related Problems scale (OP). We included 213 patients. In the CFA analyses, three out of 12 scales with four or more items showed satisfactory psychometric properties in all goodness of fit indices (Suicidality, Need for Control and Self-Criticism). Four scales showed satisfactory psychometric properties in all indices but RMSEA (Somatic Anxiety, Substance Use, Social Safety and Cognitive Problems). Several of the scales demonstrated floor effects. In the correlation analyses, 18 of the 19 scales showed small-to-moderate correlation coefficients with the OP. Our demonstration of satisfactory psychometric properties on several important scales of the NF suggests that this tool may prove valuable in the routine follow-up of mental health in this population. However, further work is needed to innovate the NF for patients undergoing bariatric surgery.

What happens to patients undergoing cancer surgery with psychiatric comorbidities?: A nationwide retrospective cohort study

OBJECTIVE

We aimed to describe the surgical outcomes and readmissions rates in patients with psychological comorbidities who underwent surgical intervention for cancer.

BACKGROUND

The Hospital Readmission Reduction Program, a campaign by the Affordable Care Act, penalizes hospitals for greater readmission rates. One prevalent patient risk factor associated with hospital readmission is a comorbid psychiatric condition. Currently, no studies exist identifying psychiatric comorbidities and their effects on patients with cancer undergoing surgical intervention.

METHODS

A cross-sectional analysis was performed using the Nationwide Readmissions Database for 2010-2014 and included adult patients undergoing cancer resection operations. Multivariable logistic regression analyses were utilized to assess determinants of surgical outcomes and readmissions.

RESULTS

Of 1 016 636 eligible patients, 11.6% had psychiatric comorbidities. Patients with psychiatric disorders had greater risks of mortality (odds ratio [OR] = 1.21, 95% confidence interval [CI] = 1.18-1.25), complications (OR = 1.51, 95%CI = 1.50-1.52), extended length of stay (OR = 1.21, 95%CI = 1.20-1.22), and incurred healthcare expenditure at primary admission (OR = 1.16, 95% CI = 1.15-1.18). Psychiatric comorbidities were associated with an increased likelihood of readmission (OR = 1.13, 95%CI = 1.11-1.15).

CONCLUSIONS

Concomitant psychiatric conditions were attributed to poor surgical outcomes and a higher risk of readmissions. Multidisciplinary care within the perioperative setting should be encouraged for patients with psychiatric disorders.

Incidence and risk factors for 30-day readmission in ulcerative colitis: nationwide analysis in biologic era

BACKGROUND AND STUDY AIM

Ulcerative colitis (UC) is a chronic relapsing and remitting disease requiring frequent hospitalization. Biologics have become the recommended initial therapy for Biologics in patients with moderate to severe UC. Our aim was to estimate the changes in Nationwide Healthcare utilization and assess predictive factors of 30-day readmission, morbidity and mortality of UC.

METHODS

This is a retrospective observational study analyzing the Nationwide Readmission database from 2016 to 2017 using ICD-10 codes. The primary outcomes of the study were to assess the predictors of 30-day readmission in patients with UC.

RESULTS

Of the 54 138 adult patients with a primary diagnosis of UC, 13.2% were readmitted within 30 days of index hospitalization. The mortality rate (1.4 vs. 0.3%, P < 0.01), length of stay (7 vs. 4.9 days, P < 0.01) and hospital cost ($62 552 vs. $46 971, P < 0.01) were higher on readmission as compared to index hospitalization. We identified multiple patient-related factors (age <65years, men, VTE, protein calorie malnutrition, electrolyte imbalance, anemia, anxiety and alcohol abuse), hospital-related factors (teaching hospitals, high quintile hospitals), as independent predictors of 30-day UC readmission. Colonoscopy, Cannabis use, and colectomy were associated with decreased odds of 30-day readmission. The most common cause of UC was septicemia.

CONCLUSIONS

This is the largest nationwide study demonstrating predictors of 30-day readmission, mortality and morbidity associated with UC. Identification and amelioration of these risk factors will decrease readmission rate and mortality amongst UC patients.

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.

Emergency department encounters, hospital admissions, course of treatment, and follow-up care for behavioral health concerns in patients after Roux-en-Y gastric bypass surgery

BACKGROUND

The benefits of bariatric surgery are well-established, however, concerns surrounding postoperative psychiatric destabilization and alcohol misuse remain. Research has initiated the process of identifying risks associated with bariatric surgery, although less is known regarding when or why psychiatric hospitalizations occur postoperatively.

OBJECTIVES

The goal of the current study was to examine the incidence of, and contributing factors to, behavioral health-related emergency room (ER) encounters and hospitalization after bariatric surgery.

SETTING

Integrated multispecialty health system with an accredited bariatric surgery program.

METHODS

Retrospective review of patients who underwent Roux-en-Y gastric bypass (RYGB) surgery and had been readmitted to the hospital or presented to the ER after bariatric surgery at least once for a behavioral-health related reason.

RESULTS

Of 1449 patients, 93 had at least 1 psychiatric or substance use-related ER visit/hospitalization post-surgery and were included in the study; 53% had 1 ER/hospital encounter after bariatric surgery; 24% had 2 encounters, 11% had 3-4 encounters, and 10% of patients had ≥5 encounters. Across 267 postbariatric surgery encounters, 42.4% were due to alcohol-related problems. The index presentation for alcohol-related reasons occurred at a mean of 1942 days (approximately 5.3 yr; SD = 1217 d). Patients' index presentation for a psychiatric concern (41.3%) occurred at a mean of 1278 days (3.5 yr; SD = 1056 d) post-surgery.

CONCLUSION

A significant percentage of patients who present to the ER or hospital for behavioral health reasons after RYGB surgery had alcohol-related problems, long after their surgery. Psychologists working with bariatric surgery teams should prioritize ongoing assessment of and education on alcohol misuse in those seeking RYGB and in the long-term postoperative period.

Risk of Delayed Discharge and Reoperation of Gastric Bypass Patients with Psychiatric Comorbidity-a Nationwide Cohort Study

BACKGROUND

Gastric bypass (GBP) surgery is considered a safe and effective treatment for obesity. However, there is uncertainty regarding the impact of preexisting psychiatric comorbidity on GBP complications. We have investigated whether a psychiatric diagnosis before GBP surgery is associated with delayed discharge (the odds of being in the 90th percentile of length of stay) and rate of reoperation in a nationwide Swedish cohort.

METHODS

Patients undergoing GBP surgery during 2008-2012 were identified and followed up through the National Patient Register and the Prescribed Drug Register. Logistic regression models were fitted to the studied outcomes.

RESULTS

Among the 22,539 patients identified, a prior diagnosis of bipolar disorder, schizophrenia, depression, neurotic disorders, ADHD (attention deficit hyperactivity disorder), substance use disorder, eating disorder, personality disorder, or self-harm since 1997 (n = 9480) was found to be associated with delayed discharge after GBP surgery (odds ratio [OR] = 1.47, confidence interval [CI] 1.34-1.62), especially in patients with psychiatric hospitalization exceeding 1 week in the 2 years preceding GBP surgery (OR = 2.06, CI 1.30-3.28), compared with those not hospitalized within psychiatry. Likewise, patients with a prior psychiatric diagnosis were more likely to be reoperated within 30 days (OR = 1.25, CI 1.11-1.41), with twice the likelihood OR 2.23 (CI 1.26-3.92) for patients with psychiatric hospitalization of up to a week in the 2 years preceding GBP surgery, compared with patients who had not been hospitalized within psychiatry.

CONCLUSIONS

A psychiatric diagnosis before GBP surgery was associated with delayed discharge and increased likelihood of reoperation within 30 days. Patients with a prior psychiatric diagnosis may, therefore, need additional attention and support.

Surgical outcomes for people with serious mental illness are poorer than for other patients: a systematic review and meta-analysis

OBJECTIVE

To assess the association between having a serious mental illness and surgical outcomes for adults, including in-hospital and 30-day mortality, post-operative complications, and hospital length of stay.

STUDY DESIGN

Systematic review and meta-analysis of publications in English to 30 July 2018 of studies that examined associations between having a serious mental illness and surgical outcomes for adults who underwent elective surgery. Primary outcomes were in-hospital and 30-day mortality, post-operative complications, and length of hospital stay. Risk of bias was assessed with the Quality in Prognosis Studies (QUIPS) tool. Studies were grouped by serious mental illness diagnosis and outcome measures. Odds ratios (ORs) or mean differences (MDs), with 95% confidence intervals (CIs), were calculated in random effects models to provide pooled effect estimates.

DATA SOURCES

MEDLINE, EMBASE, PsychINFO, and the Cochrane Library.

DATA SYNTHESIS

Of the 3824 publications identified by our search, 26 (including 6 129 806 unique patients) were included in our analysis. The associations between having any serious mental illness diagnosis and having any post-operative complication (ten studies, 125 624 patients; pooled effect: OR, 1.44; 95% CI, 1.15-1.79) and a longer stay in hospital (ten studies, 5 385 970 patients; MD, 2.6 days; 95% CI, 0.8-4.4 days) were statistically significant, but not those for in-hospital mortality (three studies, 42 926 patients; OR, 1.21; 95% CI, 0.69-2.12) or 30-day mortality (six studies, 83 013 patients; OR, 1.85; 95% CI, 0.86-3.99).

CONCLUSIONS

Having a serious mental illness is associated with higher rates of post-operative complications and longer stays in hospital, but not with higher in-hospital or 30-day mortality. Targeted pre-operative interventions may improve surgical outcomes for these vulnerable patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42018080114 (prospective).

Characterization of urgent versus nonurgent early readmissions (<30 days) following primary bariatric surgery: a single-institution experience

BACKGROUND

Studies on early postoperative readmissions after bariatric surgery (BS) have examined readmissions as a single entity, regardless of urgency. Strategies to lower nonurgent readmissions would reduce unnecessary hospital utilization.

OBJECTIVES

To identify predictors of urgent readmissions (UR) versus nonurgent readmissions (NUR) at 30 days post-BS.

SETTING

Single academic institution.

METHODS

Patients undergoing primary BS over 2 years (n = 589) were retrospectively reviewed. Baseline demographic, medical, and hospitalization data were compared between readmitted patients, stratified by urgency, and nonreadmitted patients. Multivariate regression models of UR and NUR were created using variables with a P value ≤ .2 on univariate analyses. A P value ≤ .05 was considered statistically significant.

RESULTS

There were 39 documented instances of 30-day readmissions, of which 44% (n = 17) were NUR; NUR patients were more likely to be female (100% versus 78.2% male; P = .03) and trended toward being younger, experiencing ≥2 perioperative complications, and having a longer index hospital length of stay (LOS). Patients with URs had a higher baseline BMI (52.5 ± 11.4 kg/m² versus 48.7 ± 8.3 kg/m², respectively; P = .04), were more likely to have sleep apnea (77.3% versus 56.1%, respectively; P = .05), had a longer LOS (3 versus 2 d, respectively; P = .007), and were more likely to have ≥2 postoperative complications (46% versus 17.0%, respectively; P = .003) compared with those with an NUR. Independent predictors of NUR included public insurance (odds ratio [OR] = 3.7; 95% confidence interval [CI], 1.17-11.67; P = .03), younger age (OR = 1.05; 95% CI, 1-1.01; P = .04), and female sex, while URs were independently predicted by LOS (OR = 1.3; 95% CI, 1.04-1.5; P = .02).

CONCLUSIONS

Public insurance appears to be associated with NURs, while LOS predicts URs after BS. This suggests an important dichotomy within readmissions based on urgency, which has important implications for targeted quality initiatives.

Can a brief assessment of social support predict outcomes after bariatric surgery?

Social support is important to optimize bariatric surgery outcomes, but limited tools exist for brief and effective assessment preoperatively. The aims of the study were to determine the extent to which two ratings of social support can predict bariatric surgery outcomes, and to examine any associations between these two methods.In this retrospective study, patients were included for whom the Cleveland clinic behavioral rating system (CCBRS) and Flanagan quality of life scale (FQoLS) scores were obtained as part of their preoperative psychosocial evaluation. They were followed up for 6 to 24 months after bariatric surgery. Linear and logistic regressions were performed with patients' CCBRS and FQoLS scores as independent variables, and percent excess weight loss (%EWL), length of stay (LOS), complications, readmissions and loss to follow-up as dependent variables. The prediction of CCBRS ratings from FQoLS social support items was also evaluated. A total of 415 patients were included in the analysis. There were significant associations between the CCBRS and three of the four relevant FQoLS self-ratings. As CCBRS and FQoLS scores increased, complications decreased significantly. The CCBRS alone additionally predicted decreased length of hospital stay and approached significance for predicting decreased readmission rates. There were no associations between %EWL and behavior ratings. The degree of patients' social support is associated with important bariatric surgery outcomes. It is possible to obtain this valuable information via the administration of brief assessments prior to bariatric surgery.

Impact of a Mobile App to Support Home Recovery of Patients Undergoing Bariatric Surgery

BACKGROUND

Perioperative patient education and engagement are critical components of care in patients undergoing bariatric surgery, given the short length of stay and the requirements to adhere to various instructions. The use of patient engagement mobile technology may promote adherence to perioperative protocols and improve care by potentially identifying complications earlier and reducing associated health care costs.

MATERIALS AND METHODS

We introduced a mobile app that provides bariatric patients with access to educational materials and the ability to report on their symptoms. Using the data from the app and linking the data to patient outcomes collected in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, we examined the effects of the app on readmission, length of stay, visits to the emergency department (ED), and patient satisfaction.

RESULTS

A total of 505 patients were enrolled in the app between July 2017 and March 2019. Among them, 396 patients who met the inclusion criteria for the study were compared with 458 patients in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database who were not enrolled in the app for the same study period. While the use of the app was not associated with the rates of prolonged length of stay, ED visits, and readmission, patients who completed a survey at 30 d after discharge reported that the app helped them avoid phone calls to the hospital (48.5%) and ED visits (13.0%). Furthermore, 94.8% of these patients reported that they would recommend the app to other patients undergoing the same surgery.

CONCLUSIONS

Additional features, such as the ability for patients to directly communicate with the health care providers within the app, may be effective in decreasing unnecessary health care utilization.

Impact of psychiatric comorbidities on outcomes related to thyroid and parathyroid operations

BACKGROUND

We examined the effect of psychiatric comorbidities on perioperative surgical outcomes and the leading causes of readmissions in patients who underwent thyroid and parathyroid operations.

METHOD

Patient information was retrieved from the Nationwide Readmission Database (2010-2017). Multivariate analysis was used to identify predictors for hospital readmissions.

RESULTS

A total of 181,007 and 53,808 patients underwent thyroid and parathyroid operations, respectively. Of those, 8,468 (4.7%) and 6,112 (11.4%) patients were readmitted within 30 days. Psychiatric comorbidities were more frequent in readmitted cohorts after thyroidectomies (14.9% vs 10.4%; P < .001) and parathyroidectomies (16.8% vs 11.5%; P < .001), with anxiety being the most frequent cause (thyroid: 7.87%, parathyroid: 6.8%). Psychiatric comorbidities were associated with greater risk of in-hospital mortality (thyroid: odds ratio = 2.07, 95% confidence interval = 1.13-3.53; P = .015 and parathyroid: odds ratio = 1.67, 95% confidence interval = 1.04-2.70; P = .005), postoperative complications (thyroid: odds ratio = 1.528, 95% confidence interval = 1.473-1.585; P < .001 and parathyroid: odds ratio = 3.26, 95% confidence interval = 2.84-3.73; P < .001), prolonged duration of stay (thyroid: beta coefficient = 1.142, 95% confidence interval = 1.076-1.207; P < .001 and parathyroid: beta coefficient = 2.15, 95% confidence interval = 1.976-2.32; P < .001), and 30-day readmissions (thyroid: hazard ratio = 1.18, 95% confidence interval = 1.03-1.18; P = .047 and parathyroid: hazard ratio = 1.23, 95% confidence interval = 1.11-1.36; P < .001). Psychosis had the greatest risk of readmission (thyroid: hazard ratio = 1.51 and parathyroid: hazard ratio = 1.42), and dementia (odds ratio = 2.58) had the greatest risk of postoperative complications.

CONCLUSION

Concomitant psychiatric conditions after thyroid and parathyroid operations were associated with increased risk of postoperative complications, prolonged hospital stays, and greater rates of readmissions.

Benefits and risks of bariatric surgery in patients with bipolar disorders

The prevalence of bipolar disorders in patients requesting bariatric surgery is estimated to be 1.5% to 3.4%. There are currently no specific recommendations regarding the way bariatric surgery should be managed in the context of bipolar disorder. The aim was to document the benefit-risk of bariatric surgery in patients with bipolar disorders. A systematic literature review was carried out. In addition, results were reported from a survey of current clinical practice in French referent centers for obesity care. Finally, 3 clinical cases from the "Severe Obesity Outcome Network" cohort are described. This systematic review shows there are few studies in the literature regarding the outcomes of bariatric surgery in patients with bipolar disorders and no randomized, controlled trials. Weight loss appeared similar in all patients, but psychiatric complications were sometimes reported in those with bipolar disorders. Almost all 11 referent centers for obesity care that responded had carried out bariatric surgery in patients with stable bipolar disorders. Postsurgical psychiatric destabilization occurred and included, at least, a need to reinforce treatment and follow-up. In the 3 case studies, postsurgical manic or hypomanic decompensation occurred. Thus, although effective in terms of weight loss, bariatric surgery could be a destabilizing factor for those with bipolar disorders. Current practice is to contraindicate surgery in patients with unstable disorders. There are insufficient data to conclude on the benefits and safety of bariatric surgery in patients with stable bipolar disease. Further studies are required to fully determine the benefits and risks.

Healthcare cost and utilization of bariatric surgical patients with and without preoperative mental health diagnoses

BACKGROUND

Postoperative healthcare cost and use among patients with and without preoperative mental health illness are not well known.

OBJECTIVE

This study compared total healthcare spending and use (emergency department [ED] visits and inpatient admissions) after 1 year post operation of those with and without preoperative mental health disorders.

SETTING

United States.

METHODS

Mental illness disorders were identified using International Classification of Disease-9/10 diagnosis codes in a statewide bariatric surgery registry and in claims databases that were linked to identify the study cohort. Generalized linear regression and zero-inflated negative binomial regression were used for the healthcare cost and use outcomes.

RESULTS

Among 3580 registry patients with private insurance, 1610 patients with continuous enrollment and without missing body mass index data were included. Among patients, 56.8% (n = 915) had diagnosed mental health disorders before surgery. Those with mental illness spent more in total cost than those without mental illness (unstandardized coefficient = $18,513, P value < .01) in the first year after surgery. Those with mental illness had a 73% higher rate in ED visits (P value < .01), 83% higher rate in preventable ED use (P value < .01), and a 101% higher rate in hospital admissions (P value < .01) than those without mental illness.

CONCLUSIONS

Patients with mental health diagnoses before having bariatric surgery appear to have significant positive association with surgical outcomes relating to postsurgical healthcare cost and utilization. Greater postsurgical surveillance may be warranted for bariatric surgery patients with preoperative mental illness to reduce postoperative ED visits and inpatient admissions.

The relationship between food insecurity and binge and night eating symptoms in prebariatric surgery patients is mediated by depressive symptoms

BACKGROUND

Eleven percent of households in the United States experience food insecurity, which is a lack of access to adequate, desirable food for a healthy lifestyle. Although food insecurity is associated with increased risk of obesity and nonadherence to dietary management of chronic diseases such as diabetes, the correlates of food insecurity have not yet been studied in a bariatric surgery population.

OBJECTIVES

To replicate, in a bariatric sample, previous findings that food insecurity is related to eating pathology and to test the hypothesis that this relationship is mediated by depressive symptoms.

SETTING

University hospital, United States.

METHODS

Two hundred forty bariatric surgery candidates responded to self-report measures of food insecurity and mood, night-eating, and binge-eating symptoms. The sample was 74% female and 71% white, with a mean age of 41.09 (11.84) years. Based on responses to the United States Department of Agriculture Adult Food Security Survey Model, 15.8% were categorized as food insecure and 25.8% as marginally food secure. Multiple regression models with bootstrapping for confidence interval estimates were used to explore mediation hypotheses.

RESULTS

Food insecurity was positively associated with symptoms of night eating and binge eating, and these relationships were cross-sectionally mediated by depressive symptoms.

CONCLUSIONS

Food insecure bariatric candidates may be at increased risk of poorer postoperative outcomes because of lack of access to needed food and the detrimental mental health impact of this lack of access.

The impact of self-efficacy and health literacy on outcome after bariatric surgery in Sweden: a protocol for a prospective, longitudinal mixed-methods study

INTRODUCTION

A person-centred approach, to know about a person's individual weaknesses and strengths, is warranted in today's healthcare in Sweden. When a person suffers from obesity, there are not only risks for comorbidities but also increased risk for decreased health-related quality of life (HRQoL). After bariatric surgery, there are also risks for complications; however, healthcare service expects the person to have sufficient ability to handle recovery after surgery. The need is to investigate how a person's self-efficacy and health literacy(HL) skills are important to determine their effect on recovery as well as HRQoL after bariatric surgery. It can, involve the person in the care, improve shared decision-making, and perhaps decrease complications and readmissions.

METHOD AND ANALYSIS

This is a prospective, longitudinal mixed-methods study with the intent of including 700 patients from three bariatric centres in Sweden (phase 1); 20 patients will be included in a qualitative study (phase 2). Inclusion criteria will be age >17 years, scheduled primary bariatric surgery and ability to read and understand the Swedish language in speech and in writing. Inclusion criteria for the qualitative study will be patients who reported a low self-efficacy, with a selection to ensure maximum variation regarding age and gender. Before bariatric surgery patients will answer a questionnaire including 20 items. Valid and reliable instruments will be used to investigate general self-efficacy (10 items) and functional and communicative and critical HL (10 items). This data collection will then be merged with data from the Scandinavian Obesity Surgery Registry. Analysis will be performed 30 days, 1 year and 2 years after bariatric surgery. One year after bariatric surgery the qualitative study will be performed. The main outcomes are the impact of a person's self-efficacy and HL on recovery after bariatric surgery.

ETHICS AND DISSEMINATION

The study has received approval from the ethical review board in Uppsala, Sweden (number 2018/256). The study results will be disseminated through peer-reviewed publications and conference presentations to the scientific community and social media.

Baseline psychiatric diagnoses are associated with early readmissions and long hospital length of stay after bariatric surgery

BACKGROUND

The impact of well-controlled or historical psychiatric diagnoses in patients seeking bariatric surgery (BS) on perioperative outcomes is unclear. The primary objective of this study was to determine the impact of psychiatric diagnoses on hospital length of stay (LOS), 30-day readmission rates after BS, and post-operative weight loss outcomes.

METHODS

Patients who underwent laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (LRNYGB) from 2014 to 2016 at a single academic institution were retrospectively reviewed. Baseline demographic data and psychiatric history including depression, anxiety, and/or bipolar disorder (DAB) were obtained from the electronic medical record. Hospital LOS, 30-day readmissions, and % excess body weight loss (%EBWL) were obtained on all patients and compared between DAB patients and those without any psychiatric history.

RESULTS

During the study period, 354 patients were reviewed, of which 78% were female; 60% underwent LSG. The mean preoperative BMI was 48.9 ± 8.4 m/kg². Major depression was the leading diagnosis (42%), and 13% had both depression and anxiety. The 30-day readmission rate was significantly higher than the control (10.5% vs. 3.7%, p = 0.02). Mean hospital LOS and the incidence of long hospital LOS (≥ 4 days) was not different between the groups, although within LSG patients, the incidence of long hospital LOS trended towards being higher for DAB patients (9.2% vs. 4%, p = 0.10). Patients with depression and anxiety had a higher incidence of long LOS (23.4% vs. 9.2%, p < 0.005). While 6-month %EBWL was significantly lower for DAB patients (41% vs. 46%, p = 0.004), 1-year weight loss outcomes were not different, even when adjusting for surgical procedure.

CONCLUSION

Patients with baseline or historical DAB had significantly higher early readmission rates, and those with multiple diagnoses were associated with a hospital LOS ≥ 4 days. Future studies should focus on elucidating the impact of psychiatric diagnoses on these quality metrics.