The relationship of distance from the surgical centre on attendance and weight loss after laparoscopic gastric bypass surgery in the United Kingdom

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

INTRODUCTION

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

METHODS

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

DISCUSSION

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

Characteristics of Patients Lost to Follow-up after Bariatric Surgery

After bariatric surgery lifelong follow-up is recommended. Evidence of the consequences and reasons for being lost to follow-up (LTFU) is sparse. In this prospective study follow-up data of all patients who underwent bariatric surgery between 2008 and 2017 at a certified obesity centre were investigated. LTFU patients were evaluated through a structured telephone interview. Overall, 573 patients (female/male 70.9%/29.1%), aged 44.1 ± 11.2 years, preoperative BMI 52.1 ± 8.4 kg/m2 underwent bariatric surgery. Out of these, 33.2% had type 2 diabetes mellitus and 74.4% had arterial hypertension. A total of 290 patients were LTFU, of those 82.1% could be reached. Baseline characteristics of patients in follow-up (IFU) and LTFU were comparable, but men were more often LTFU (p = 0.01). Reported postoperative total weight loss (%TWL) and improvements of comorbidities were comparable, but %TWL was higher in patients remaining in follow-up for at least 2 years (p = 0.013). Travel issues were mentioned as the main reason for being LTFU. A percentage of 77.6% of patients reported to regularly supplement micronutrients, while 71.0% stated regular monitoring of their micronutrient status, mostly by primary care physicians. Despite comparable reported outcomes of LTFU to IFU patients, the duration of the in-centre follow-up period affected %TWL. There is a lack of sufficient supplementation and monitoring of micronutrients in a considerable number of LTFU patients.

Patient proximity to follow-up care after bariatric surgery: Does it matter?

One factor that may play a significant role in the follow-up care compliance and long-term weight loss of post-bariatric surgery patients is the geographical distance from the surgery center to the patient's home address. This is a retrospective review which aims to evaluate whether the distance from a patient's home address to two Gundersen Health System (GHS) facilities (La Crosse and Onalaska, Wisconsin) is predictive of follow-up appointment compliance and subsequent long-term weight loss. 1336 patients undergoing bariatric surgery at GHS between October 15, 2013 and Dec 31, 2022 were included. Patients were grouped according to the distance between their home addresses and GHS with 60 ​% of patients living less than 30 miles from GHS, 33 ​% living 30 to 60 miles from GHS, and the remaining 7.3 ​% living >60 miles away. No significant difference was observed in the distribution of patients falling short, meeting, or exceeding the recommended number of post-operative appointments with a surgery provider based on proximity (p ​= ​0.10). As distance increased, the number of nutrition and behavioral health appointments completed per year decreased [nutrition/dietary appointments (p ​= ​0.046); behavioral health appointments (p ​= ​0.040)]. The pattern of percent excess weight loss (%EWL) over time was significantly different based on distance from home (p ​< ​0.001). Specifically, we found a similar %EWL among all groups in the first year post-operatively but an 18.8 ​% higher %EWL in the >60-mile group compared to the <60-mile group at 5 years (SE ​= ​5.4, P ​= ​0.0014). The lower number of post-op nutrition and behavioral health visits among patients living farther from the surgery center was an expected result, given potentially greater inconvenience of follow-up appointments for these patients. However, there was a paradoxical finding of significantly increased %EWL among patients living >60 miles from the surgery center. Greater distance from the bariatric surgical center was therefore not found to represent a barrier to favorable weight loss outcomes.

Exploring Social Support Dynamics After Bariatric Surgery: Insights From Patients and Providers

INTRODUCTION

Weight loss after bariatric surgery is impacted by several factors, and social support is one of them. Our objective was to characterize patient and provider perceptions about social support after bariatric surgery.

METHODS

We reported a secondary analysis of qualitative data acquired from semi-structured interviews conducted from January-November 2020 with bariatric surgery patients and providers. Participants included primary care providers, health psychologists, registered dietitians, bariatric surgeons, and patients with at least 1 y of follow-up after their bariatric procedure. Interview guides were designed using a hybrid of Andersen's Behavioral Model of Health Services and Torain's Framework for Surgical Disparities. Using directed content analysis, study team members generated codes, which were categorized into themes about social support pertaining to dietary habits, physical activity, and follow-up care.

RESULTS

Forty-five participants were interviewed, including 24 patients (83% female; 79% White; mean age 50.6 ± 10.7 y) and 21 providers (six primary care providers, four health psychologists, five registered dieticians, and six bariatric surgeons). We identified four themes relating to social support affecting weight loss after surgery: (1) family involvement in helping patients adjust to the bariatric diet, (2) engagement in activities with partners/friends, (3) help with transportation to appointments, and (4) life stressors experienced by patients within their social relationships.

CONCLUSIONS

Continued assessment of interpersonal factors after bariatric surgery is essential for weight loss maintenance. Providers can contribute by reinforcing the facilitators of social support and making referrals that may help patients overcome barriers to social support for sustained weight loss after surgery.

Influence of mental and behavioral factors on weight loss after bariatric surgery: A systematic review and meta-analysis

INTRODUCTION

Multiple factors are related to lower weight loss after bariatric surgery. This review and meta-analysis evaluates the influence of several mental and behavioral factors on weight loss.

METHOD

Six electronic databases were searched. Percentage excess weight loss (%EWL) was calculated for all moderator and non-moderator groups of the variables: symptoms of depression, anxiety and binge eating, compliance, physical activity, quality of life, and body image. All moderators, surgery types, and follow-up moments were analyzed separately.

RESULTS

In total, 75 articles were included in the review; 12 meta-analyses were conducted. Higher postoperative compliance to follow-up was associated with 6.86%-13.68% higher EWL. Preoperative binge eating was related to more weight loss at 24- and 36-month follow-up (7.97% and 11.79%EWL, respectively). Patients with postoperative binge eating symptoms had an 11.92% lower EWL. Patients with preoperative depressive symptoms lost equal weight compared to patients without symptoms.

CONCLUSION

Despite the high heterogeneity between studies, a trend emerges suggesting that the presence of postoperative binge eating symptoms and lower postoperative compliance may be associated with less weight loss after bariatric-metabolic surgery. Additionally, preoperative depressive symptoms and binge eating do not seem to significantly impact weight loss.

Transportation and Access to Healthcare in Morocco: An Exploratory Study of Guelmim-Oued Noun Region

Objective

The aim of this study was to examine the correlation between accessibility to healthcare facilities and transportation in the Guelmim Oued Noun region of Morocco, where transportation barriers continue to pose a major challenge to accessing healthcare, despite efforts aimed at reducing access barriers.

Methods

Data collection for this study involved the administration of a survey among 328 outpatients residing in the Guelmim Oued Noun region, Morocco. The utilization of canonical correlation served as the analytical method, employed to quantify and assess the relationship between transportation related barriers and the access of healthcare services in the specified region.

Results

Our research reveals that transportation factors account for approximately 25% of the variation in access to healthcare services. The number of transportation modes utilized by outpatients and the affordability of transportation were found to be significant contributors to the transportation dimension. These findings confirm the significant relationship between transportation and access to healthcare facilities in the region under investigation.

Conclusion

Further research is recommended to specifically address transportation barriers to healthcare access services among socially excluded populations, with a focus on promoting mobility inclusivity.

Patients living farther from a tertiary care center are more likely to undergo peripheral arterial bypass for acute and chronic limb-threatening ischemia

OBJECTIVE

The aim of this study was to assess the association between the proximity to the tertiary care hospital and the severity of peripheral arterial disease (PAD) at the time of lower extremity bypass (LEB) in a rural-urban mix region.

METHODS

Patients undergoing LEB from 2010 to 2020 at Penn State Milton S. Hershey Medical Center were reviewed and stratified into two study groups based on a median distance from hospital (ie, Group I: ≥34 miles and Group II: <34 miles). Patients' demographic features, preoperative data including comorbidities, and medications were analyzed. A univariate analysis for the patient characteristics between the two study groups, along with evaluation of postoperative outcomes, and a multivariate predictive modeling to study the PAD stage as the indication of LEB was performed. A P-value of < .05 was set as a significant difference between the groups for all the analyses.

RESULTS

There were 175 patients (49.9%) in Group I and 176 patients (50.1%) in Group II with a mean age of 65 ± 11.92 years (median, 64.61 years). No significant difference was observed in gender (P = .530), age (P = .906), and functional status (P = .830) between study groups. It was observed that patients in Group I were more likely to be overweight or obese (71.3% vs 57%; P = .007) and had a prior history of myocardial infarction (24.3% vs 15.3%; P = .036) in comparison to Group II. No postoperative outcomes were found to be statistically different between the study groups. The multivariate analyses based on various confounders displayed that patients in Group I had 56% higher likelihood of LEB for chronic limb-threatening ischemia (adjusted odds ratio, 1.56; 95% confidence interval, 0.92-2.62; P = .042). Group I patients also had five times higher odds of LEB for acute limb ischemia (adjusted odds ratio, 5.07; 95% confidence interval, 1.42-18.13; P = .012) as compared with those in the Group II.

CONCLUSIONS

Patients' proximity to a major tertiary hospital may have implications on the disease progression for patients with PAD and could also be related to inadequate vascular services in primary and secondary hospitals. Lack of preventive care and disease management in regions afar from a tertiary hospital could be other implicating factors and highlights the need for outreach programs, along with distribution of vascular specialists, to reduce geographical disparities and ensure equity in access to care.

Transportation Factors and Postoperative Attendance and Weight Loss Through 24 Months

PURPOSE

Transportation, access to follow-up care, and association with weight loss are understudied in the bariatric population. The objective of this study was to determine how transportation variables associate with postoperative attendance and weight loss through 24 months.

MATERIALS AND METHODS

Seven hundred eighty-seven patients (81.3% female; 59.1% White) who had primary surgery (48.6% gastric bypass) from 2015 to 2019 were included. Sidewalk coverage and number of bus stops from patients' homes, driving distance in miles and minutes from patients' homes to the nearest bus stop and the clinic were measured. Bivariate analyses were conducted with the transportation variables and attendance and %TWL at 2 or 3, 6, 12, and 24 months. One mixed multilevel model was conducted with dependent variable %TWL over 24 months with visits as the between-subjects factor and covariates: race, insurance, surgical procedure, and driving distance to the clinic in minutes, attendance, and %TWL over 24 months; an interaction between distance, attendance, and visits.

RESULTS

There were no significant differences between the majority of the transportation variables and postoperative attendance or %TWL. Patients who had perfect attendance had improved %TWL at 12 months [t(534)=-1.92, p=0.056] and 24 months [t(393)=-2.69, p=0.008] compared to those who missed at least one appointment. Patients with perfect attendance and who had shorter driving times (under 20 min) to the clinic had greater weight loss through 24 months [F(10, 1607.50)=2.19, p=0.016)].

CONCLUSIONS

Overall, transportation factors were not associated with attendance and weight loss, with the exception of the interaction between shorter driving minutes to follow-up and perfect attendance.

Hand Therapy after Flexor and Extensor Tendon Repair: Assessing Predictors of Loss to Follow-up

Postoperative hand therapy (HT) is important for regaining function and preventing complications in patients undergoing tendon repair of the hand and wrist. Loss to follow-up (LTFU) can hinder this process; so we sought to determine factors that predict attrition of these patients.

Methods

Charts were retrospectively reviewed for patients who underwent extensor or flexor tendon repair of the hand, wrist, or forearm between 2014 and 2019. Demographic data, including age, sex, zip code, employment status, education level, and insurance type, were collected, and the rate of LTFU was calculated. Logistic regression was used to analyze factors.

Results

A total of 149 patients were identified and analyzed. The rate of LTFU was 42%. Factors that predicted loss were younger age, male gender, lower educational degree, and a documented psychiatric history. Employment status, insurance type, and distance from the HT center did not predict attrition. The number of HT weeks recommended by the occupational therapist did not differ between those who were lost and those who were not. Lost patients completed, on average, 57% of their suggested HT course.

Conclusions

The current study identified demographic factors associated with attrition in patients undergoing tendon repair of the distal upper extremity. Factors included patients who were younger, male gender, less educated, and had a documented psychiatric history. By identifying factors that predict LTFU, specific strategies can be developed to reduce attrition rates, particularly for at-risk populations, to improve patient care after tendon repair.

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

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

A Positive Emotion-Focused Intervention to Increase Physical Activity After Bariatric Surgery: Protocol for a Pilot Randomized Controlled Trial

Background

Physical activity levels after bariatric surgery are usually low, despite the significant protective health benefits of physical activity in this population. Positive psychological well-being is associated with improved adherence to health behaviors, but bariatric surgery patients often have negative associations with physical activity that prevent sustained engagement.

Objective

The Gaining Optimism After weight Loss Surgery (GOALS) pilot randomized controlled trial is aimed at testing a novel intervention to increase physical activity after bariatric surgery, which incorporates positive psychological skill-building with motivational interviewing and goal-setting.

Methods

The GOALS trial is a 2-arm, 24-week pilot randomized controlled trial that aims to enroll 58 adults who report less than 200 minutes per week of moderate to vigorous physical activity and a desire to become more active 6-12 months after bariatric surgery. GOALS is testing the feasibility, acceptability, and preliminary efficacy of a positive psychology–motivational interviewing telephone intervention targeting to increase physical activity and associated positive affect. Intervention components include positive psychology, goal-setting, self-monitoring via provided Fitbits, and motivational interviewing to overcome barriers and increase motivation. The intervention is compared to a physical activity education control that includes mailings with psychoeducation around physical activity and provision of a Fitbit. The primary outcomes of the pilot trial are feasibility and acceptability, measured as session completion rates and participant ratings of ease and helpfulness of each session. The main secondary outcome is change in accelerometer-measured moderate to vigorous physical activity post intervention and at 24-week follow-up. Additional outcomes include changes in attitudes related to physical activity, psychological well-being, and physical health measures.

Results

This multiphase project was funded in 2020 and institutional review board approval was obtained for the proposed trial in 2021. Recruitment for the randomized controlled trial began in July 2022. Upon completion of the pilot trial, we will examine the feasibility, acceptability, and preliminary efficacy of the intervention.

Conclusions

Although bariatric surgery is the most effective treatment available for severe obesity, weight regain occurs, often in the context of low psychological well-being. Many individuals would benefit from learning strategies to increase positive psychological well-being after bariatric surgery, which could help them maintain lifestyle changes. Positive psychology is a novel approach to improve adherence by increasing positive associations with health behaviors including physical activity. The GOALS pilot trial will determine whether this type of intervention is feasible and acceptable to this population and will provide a foundation for a future full-scale randomized controlled efficacy trial.

Trial Registration

ClinicalTrials.gov NCT04868032; https://clinicaltrials.gov/ct2/show/NCT04868032

International Registered Report Identifier (IRRID)

PRR1-10.2196/39856

Adherence of Obese Patients from Poland and Germany and Its Impact on the Effectiveness of Morbid Obesity Treatment

This study aimed to investigate and compare the adherence of patients treated for morbid obesity living in Poland and Germany. Methods: A cross-sectional international multicenter survey design was adopted. The study involved 564 adult subjects treated for morbid obesity at selected healthcare facilities in Germany (210 participants) and Poland (354 participants). A validated, custom-made questionnaire based on the literature related to this issue was used. Results: The degree of adherence was higher, but not statistically significant, among Polish patients (83.82% vs. 78.33%, p = 0.26140). Patient adherence was associated with gender, age, level of education, duration of obesity, number of health professionals involved in obesity treatment, and type of obesity treatment (p < 0.05). A positive correlation was observed in the case of age, level of education, and a growing number of health professionals involved in obesity treatment, whereas a negative correlation was observed in the case of the duration of obesity. Patients who underwent bariatric surgery significantly more often followed medical recommendations regarding lifestyle changes, compared to obese participants treated only conservatively. Adherence in the field of obesity treatment significantly increases the percentage of total weight loss and excess weight loss due to applied obesity treatment among both Polish and German groups (p < 0.001). Both the percentage of total weight loss and that of excess weight loss were significantly higher in the group of adherent patients compared to the nonadherent patients (p < 0.00001). The levels of perceived anxiety, stress, and depression were significantly higher in nonadherent patients in both countries. Conclusions: These findings confirm the role of adherence in the effective and satisfactory treatment of morbid obesity. There is a great need to improve patient adherence to overcome the consequences of the obesity pandemic.

Is Adherence to Follow-Up After Bariatric Surgery Necessary? A Systematic Review and Meta-Analysis

The association of adherence to follow-up (FU) after laparoscopic gastric bypass - and gastric sleeve with weight loss (WL) is unclear. The aim of this study was to evaluate this association. Fourteen full text articles were included in the systematic review. Eight studies were included in the meta-analysis concerning FU up to 3 years postoperatively and 3 for the FU between 3 and 10 years postoperatively. Results showed a significant association between adherence to FU 0.5 to 3 years postoperatively and percentage excess WL (%EWL) but did not demonstrate a significant association between FU > 3 years postoperatively and total WL (%TWL). In conclusion, adherence to FU may not be associated with WL and therefore stringent lifelong FU in its current form should be evaluated.

The Effect of High-Density Built Environments on Elderly Individuals' Physical Health: A Cross-Sectional Study in Guangzhou, China

The built environment refers to the objective material environment built by humans in cities for living and production activities. Existing studies have proven that the built environment plays a significant role in human health, but little attention is paid to the elderly in this regard. At the same time, existing studies are mainly concentrated in Western developed countries, and there are few empirical studies in developing countries such as China. Based on POI (point of interest) data and 882 questionnaires collected from 20 neighborhoods in Guangzhou, we employ multilevel linear regression modeling, mediating effect modeling, to explore the path and mechanism of the impact of the built environment on elderly individuals' physical health, especially the mediating effects of physical and social interaction activity. The results show that the number of POIs, the distance to the nearest park and square, and the number of parks and squares are significantly positively correlated with the physical health of the elderly, while the number of bus and subway stations and the distance to the nearest station are significantly negatively correlated. Secondly, physical activity and social networks play a separate role in mediating the effect of the built environment on elderly individuals' physical health. The results enrich the research on the built environment and elderly individuals' health in the context of high-density cities in China and provide some reference basis for actively promoting spatial intervention and cultivating a healthy aging society.

Weight loss and adherence to postoperative follow-up after vertical gastrectomy for obesity treatment

Purpose

To analyze the effectiveness of vertical gastrectomy in the treatment of obese patients, adherence to clinical follow-up and the influence of factors such as gender and age.

Methods

This is a retrospective, observational and descriptive study, conducted with patients undergoing vertical gastrectomy, operated at Hospital São Domingos, between January 2016 and July 2018.

Results

Most patients undergoing vertical gastrectomy were female (n = 193, 72.28%) and had a mean age of37.11 ± 8.96 years old. The loss of follow-up was 56.18%. Among adherent patients (n = 117; 43.82%), most patients were female (n = 89; 76.07%) and had a mean age of 37.92 ± 9.85 years old. The mean body mass index (BMI) of the adherents in the preoperative was 37.85 ± 3.72 kg/m². Both BMI and excess weight (EW) showed a statistically significant difference between pre- and postoperative period. Percentage of excess weight loss (% EWL) was satisfactory for 96.6% of adherent patients. Older patients had a statistically significant lower % EWL compared to the other groups.

Conclusions

Vertical gastrectomy was effective in the treatment of obese patients, with significant weight loss.

Impact of Routine and Long-Term Follow-Up on Weight Loss after Bariatric Surgery

BACKGROUND

Weight loss after bariatric surgery varies among patients. Patients who do not complete long-term follow-up are considered to loose less weight than those with regular follow-up visits.

OBJECTIVE

To evaluate the influence of patients' follow-up compliance on long-term excess weight loss (%EWL) and total weight loss (%TWL) after bariatric surgery, comparing results between gastric bypass (GB) and sleeve gastrectomy (SG).

METHODS

Patients with up to 5 years of follow-up data after bariatric surgery were included in this retrospective analysis. Patients were divided in 2 groups: those in group 1 who had attended every scheduled postoperative appointment and those in group 2 who had been lost to follow-up before 1 year and were later contacted by telephone. %EWL and %TWL were compared to determine the possible relationship between type of surgery and regularity of the follow-up.

RESULTS

A total of 385 patients were included. A significant difference in EWL was observed at 5 years in the SG group (78% for group 1 versus 39% for group 2; p = 0.02) and GB group (75% for group 1 versus 62% for group 2; p = 0.01). No significant differences between surgeries were found when comparing long-term EWL in group 1 patients 77% for SG versus 75% for GB. For group 2 patients, GB achieved greater EWL than SG; p = 0.005. %TWL patients in group 2 showed significant differences in all periods of study (p < 0.05).

CONCLUSION

Bariatric surgery patients who attended all scheduled follow-up appointments experienced significantly greater long-term EWL and TWL than those who did not. GB has apparent increased benefits for weight loss in long-term follow-up when compared with SG for patients who did not attend long-term follow-up. Therefore, continued long-term follow-up of bariatric patients should be encouraged to increase postoperative weight loss results.

Travel distance reduces follow-up compliance but has no effect on long-term weight loss success in bariatric patients

BACKGROUND

Patients seeking bariatric surgery are traveling longer distances to reach Bariatric Centers. The purpose of this study was to evaluate the impact of travel distance on adherence to follow-up and outcomes after bariatric surgery.

METHODS

A retrospective review of all consecutive patients who had undergone bariatric surgery from June 2013 to May 2014 was performed, and the patients were divided into two groups: those who traveled 50 miles or less and those who traveled more than 50 miles. Primary outcome assessed was the influence of distance on post-operative follow-up attrition over 4-year period. Secondary outcomes assessed were excess weight loss, length of stay (LOS), complications and readmission rates.

RESULTS

A total of 228 patients underwent bariatric surgery with 4 years of follow-up available. Of these, 145 patients traveled 50 miles or less and 83 patients traveled greater than 50 miles. Patient demographics were similar between the two groups. Those who traveled more had statistically higher probability of attrition up to 3-year follow-up mark. There was no difference in percent excess weight loss at each follow-up visit between the two cohorts. Furthermore, there was no difference in readmission rates (2% vs 5%), minor complications (14% vs 10%), major complications (3% vs 2%) and LOS (2.6 days vs 2.6).

CONCLUSION

The distance patients traveled for bariatric surgery did not affect their weight loss success, length of stay, postsurgical complications or readmission rate. Despite the lack of influence on postoperative outcomes, follow-up compliance was statistically affected by distance.

Tracking physical activity using smart phone apps: assessing the ability of a current app and systematically collecting patient recommendations for future development

Background

Within the United Kingdom’s National Health System (NHS), patients suffering from obesity may be provided with bariatric surgery. After receiving surgery many of these patients require further support to continue to lose more weight or to maintain a healthy weight. Remotely monitoring such patients’ physical activity and other health-related variables could provide healthworkers with a more ‘ecologically valid’ picture of these patients’ behaviours to then provide more personalised support. The current study assesses the feasibility of two smartphone apps to do so. In addition, the study looks at the barriers and facilitators patients experience to using these apps effectively.

Methods

Participants with a BMI > 35 kg/m² being considered for and who had previously undergone bariatric surgery were recruited. Participants were asked to install two mobile phone apps. The ‘Moves’ app automatically tracked participants’ physical activity and the ‘WLCompanion’ app prompted participants to set goals and input other health-related information. Then, to learn about participants’ facilitators and barriers to using the apps, some participants were asked to complete a survey informed by the Theoretical Domains Framework. The data were analysed using regressions and descriptive statistics.

Results

Of the 494 participants originally enrolled, 274 participants data were included in the analyses about their activity pre- and/or post-bariatric surgery (ages 18–65, M = 44.02, SD ± 11.29). Further analyses were performed on those 36 participants whose activity was tracked both pre- and post-surgery. Participants’ activity levels pre- and post-surgery did not differ. In addition, 54 participants’ survey responses suggested that the main facilitator to their continued use of the Moves app was its automatic nature, and the main barrier was its battery drain.

Conclusions

The current study tracked physical activity in patients considered for and who had previously undergone bariatric surgery. The results should be interpreted with caution because of the small number of participants whose data meet the inclusion criteria and the barriers participants encountered to using the apps. Future studies should take note of the barriers to develop more user-friendly apps.

Trial registration

ClinicalTrials.gov- NCT01365416 on the 3rd of June 2011.

Pre-operative Bariatric Clinic Attendance Is a Predictor of Post-operative Clinic Attendance and Weight Loss Outcomes

AIM

Our primary aim was to determine whether non-attendance at pre-operative clinics were associated with non-attendance at post-operative clinics and its influence on weight loss. We also sought to examine the relationship between gender, ethnicity and post-operative clinic attendance with respect to weight loss post-bariatric surgery.

METHODS

A retrospective audit was performed for patients undertaking the bariatric surgery program at the Auckland City Hospital between 2013 and 2016.

RESULTS

One hundred and eighty-four patients completed our program, with a mean age of 46.1 years. Mean weight at commencement was 133.3 kg, with a BMI of 47.4. At 2 years follow-up (n = 143), excess weight loss was 70.8% following RYGB and 68.0% following LSG (p = 0.5743). More patients attended all pre-operative than post-operative clinics (67.4% vs 37.5% p = < 0.001). One pre-operative clinic non-attendance was associated with less weight loss at 2 years and it increases the risk of missing at least 50% of post-operative clinics with a risk ratio of 2.73, p = 0.005. Non-attendance of at least 50% of post-operative clinics was also associated with less weight loss at 2 years (33.4 kg vs 44.3 kg, p = 0.040). Although Maori and Pacific Islanders more frequently missed > 50% of post-operative clinics, weight loss was similar between European, Maori and Pacific Islander populations (2-year weight loss 44.2 kg vs 40.74 kg vs 44.1 kg, respectively, p = 0.8192).

CONCLUSION

Pre-operative clinic non-attendance helps predict post-operative clinic non-attendance. Missing any pre-operative clinics and at least 50% of scheduled post-operative clinics is associated with poorer weight loss outcomes.

'No one is as invested in your continued good health as you should be:' an exploration of the post-surgical relationships between weight-loss surgery patients and their home bariatric clinics

This article traces the post-surgical relationship between weight-loss surgery (WLS) patients and their home bariatric clinics. Following surgery, there is substantive drop off in patient attendance at both follow-up appointments and support groups. While barriers to follow-up are often discussed with the bariatric literature, patients themselves are typically defined as the problem. Based upon a thematic analysis of 217 blog posts and comments in two top patient-led online forums, I demonstrate that bariatric patients tell a more complex story about their post-surgical lives. I argue that WLS patients constitute a population with highly specialised medical needs that is caught between the requirements for living with surgically altered digestive systems and a lack of sufficient post-operative follow-up care from their home bariatric clinics. Although online forums provide spaces for patients to examine these post-operative social and clinical experiences in critical terms, seek information and get support, ultimately the conversations serve to underline the value of personal responsibility for post-operative outcomes-a framing that echoes that of the bariatric profession. This framing should be understood within a larger climate of weight-based stigma and discrimination as well as neoliberal healthism.

The effect of distance on short-term outcomes in a regionalized, publicly funded bariatric surgery model

BACKGROUND

While high-volume Centers of Excellence (COE) for bariatric surgery may have improved clinical outcomes, their disparate distribution results in longer travel distances for patients. The purpose of this study was to investigate effect of distance from COE on outcomes and readmission.

METHODS

This was a retrospective study of all adults, aged 18 years or older, receiving bariatric surgery from April 2009 to March 2012 in the province of Ontario. Main outcomes included 30-day complication rates and readmission. Multivariable logistic regression was used to examine the impact of distance from patients' primary residence to their bariatric COE on patient outcomes and readmissions.

RESULTS

Five thousand and seven patients were identified, two-thirds residing within 100 km of a COE with a mean distance of 117.2 km. The majority of patients did not reside within a Local Integrated Health Network (LHIN) that contained a COE, while 18.3% of patients lived in rural areas. Using multivariable adjustment, for every 10 km increase from the COE where surgery was performed, the Odds Ratio (OR) for complications was 1.00 [95% Confidence Interval (CI) 0.99-1.01; P = 0.747]. Additionally, both residing in a LHIN without a COE, OR 1.10 (95% CI 0.87-1.40; P = 0.434), and rural status, OR 0.97 (95% CI 0.77-1.23; P = 0.821) showed no increase in risk of complication. Similarly, further distances did not influence rate of readmission, OR 0.99 (95% CI 0.98-1.00; P = 0.077) nor did rural status OR 1.31 (95% CI 0.97-1.76; P = 0.076).

CONCLUSION

The COE model, where a few centers in high population areas service a large geographic region, is adequate in ensuring patients that live further away receive appropriate short-term care.

Predictors of poor follow-up after bariatric surgery

OBJECTIVE

to identify predictive factors of loss of follow-up of patients submitted to Roux-en-Y gastric bypass and sleeve gastrectomy in a 48-month period.

METHODS

we conducted a retrospective, cohort study from January 2010 to December 2012. We analyzed thirteen variables and compared them to loss of follow-up.

RESULTS

among the 559 patients studied, there was a great reduction in the frequency (43.8%) of the consultations from the second postoperative year on, with a significant loss in the 4th year (70.8%). In the univariate analysis, only the variable "excess weight" was associated with loss of follow-up. The proportion of overweight (>49.95kg) was higher in the follow-up group with greater loss (>3 absences) (p=0.025). In the logistic regression, patients exposed to a greater excess weight (>49.95kg) presented a two-fold higher risk for loss of follow-up (>3 absences) (OR=2.04, 95% CI 1.15-3.62; p=0.015). In the univariate analysis, at the 48th postoperative month, only the variable "mesoregion of origin" was associated with loss of follow-up (p=0.012).

CONCLUSION

there was a progressive loss of follow-up from the second postoperative year on. Among the factors analyzed, only the variable "excess weight" greater than 49.95kg in the preoperative period was associated with loss of medical-surgical follow-up. In the 48th month of the postoperative period, there was a higher prevalence of loss of medical-surgical follow-up for patients outside the perimeter of the city of Recife (51%, p=0.052).

Measurement of adherence in bariatric surgery: a systematic review

After bariatric surgery, rates of adherence to behavioral recommendations, including attending regular appointments and following specific dietary, physical activity, and vitamin use recommendations, tend to be highly variable across studies. Lack of consistency in measurement of adherence is a likely contributor to this variability, making it challenging to determine the prevalence and impact of nonadherence in this population. PubMed was searched for articles measuring behavioral adherence or compliance in patients after bariatric surgery, resulting in 85 articles. Articles were reviewed for the definition and measurement of adherence in each area (appointment attendance, as well as dietary, physical activity, and vitamin use adherence), and on the use and reporting of recommended adherence measurement strategies. Over half of the articles measured adherence to appointment attendance. Significant variability was found across adherence definitions and measurement methods, and use of recommended adherence measurement strategies was poor. Adherence was mostly commonly measured via self-report (either verbal or written) using cutoffs for adherent versus nonadherent behavior. Over half of studies assessed adherence up to ≥2 years postsurgery. Recommendations for ways to improve adherence measurement in patients who have had bariatric surgery are outlined.

Bariatric Surgery Among Obese Veterans: a Retrospective Review of Complications and Intermediate Term Results from a Single Institution

BACKGROUND

The purpose of this study was to compare the results and complications among obese veterans undergoing sleeve gastrectomy and gastric bypass at a low-volume center.

MATERIALS AND METHODS

This is a retrospective review of bariatric procedures performed by a single surgeon from 2009-2013. Outcomes of interest were mortality, complications, and length of stay. Weight loss and comorbidity resolution were compared between sleeve gastrectomy (SG) and Roux-y gastric bypass (RYGB). Length of stay and distance traveled to receive services were analyzed. Distributed groups were compared with Student's t test. Welch's correction was used where variances were unequal via ANOVA. Complications were compared using Fisher's exact test.

RESULTS

Eighty-five patients (SG = 51, RYGB = 34) were analyzed. Postoperatively, patients were seen in clinic, contacted by phone or email, and their electronic health care records were reviewed. Average length of follow-up was 114.3 weeks. Mortality was 0 %. Complication rates were comparable between groups. The percent total weight loss was 22.6 % for the SG and 27.5 % for the RYGB (p = 0.02). The percent excess weight loss was 49 % for SG and 55 % for RYGB (p = 0.149). Percent excess body mass index (BMI) loss was 54 and 61 % (p = 0.197) for SG and RYGB, respectively. Comorbidity resolution was similar between groups except for diabetes which was superior for RYGB (p = 0.03). Veterans lived an average of 141.3 miles from our VA, and all 85 patients were able to be contacted for follow-up.

CONCLUSIONS

Despite long travel distances for high-risk veterans, bariatric surgery can be performed safely even at a low-volume VA hospital with acceptable morbidity and mortality and excellent follow-up. There was no difference in morbidity or mortality between patients undergoing SG vs RYGB.

Project HELP: a Remotely Delivered Behavioral Intervention for Weight Regain after Bariatric Surgery

BACKGROUND

Weight regain following bariatric surgery is common and potentially compromises the health benefits initially attained after surgery. Poor compliance to dietary and physical activity prescriptions is believed to be largely responsible for weight regain. Patients may benefit from developing specialized psychological skills necessary to engage in positive health behaviors over the long term. Unfortunately, patients often face challenges to physically returning to the bariatric surgery program for support in developing and maintaining these behaviors. Remotely delivered interventions, in contrast, can be conveniently delivered to the patient and have been found efficacious for a number of health problems, including obesity. To date, they have received little attention with bariatric surgery patients. The study aimed to evaluate a newly developed, remote acceptance-based behavioral intervention for postoperative weight regain.

METHODS

Patients at least 1.5 years out from surgery who experienced postoperative weight regain were recruited to receive the 10-week intervention. Participants were assessed at baseline, mid-treatment, post-treatment, and at 3-month follow-up.

RESULTS

Support for the intervention's feasibility and acceptability was achieved, with 70 % retention among those who started the program and a high mean rating (4.7 out of 5.0) of program satisfaction among study completers. On average, weight regain was reversed with a mean weight loss of 5.1 ± 5.5 % throughout the intervention. This weight loss was maintained at 3-month follow-up. Significant improvements in eating-related and acceptance-based variables also were observed.

CONCLUSIONS

This pilot study provides initial support for the feasibility, acceptability, and preliminary efficacy of a remotely delivered acceptance-based behavioral intervention for postoperative weight regain.

Are differences in travel time or distance to healthcare for adults in global north countries associated with an impact on health outcomes? A systematic review

OBJECTIVES

To investigate whether there is an association between differences in travel time/travel distance to healthcare services and patients' health outcomes and assimilate the methodologies used to measure this.

DESIGN

Systematic Review. We searched MEDLINE, Embase, Web of Science, Transport database, HMIC and EBM Reviews for studies up to 7 September 2016. Studies were excluded that included children (including maternity), emergency medical travel or countries classed as being in the global south.

SETTINGS

A wide range of settings within primary and secondary care (these were not restricted in the search).

RESULTS

108 studies met the inclusion criteria. The results were mixed. 77% of the included studies identified evidence of a distance decay association, whereby patients living further away from healthcare facilities they needed to attend had worse health outcomes (eg, survival rates, length of stay in hospital and non-attendance at follow-up) than those who lived closer. 6 of the studies identified the reverse (a distance bias effect) whereby patients living at a greater distance had better health outcomes. The remaining 19 studies found no relationship. There was a large variation in the data available to the studies on the patients' geographical locations and the healthcare facilities attended, and the methods used to calculate travel times and distances were not consistent across studies.

CONCLUSIONS

The review observed that a relationship between travelling further and having worse health outcomes cannot be ruled out and should be considered within the healthcare services location debate.

Managing severe obesity: understanding and improving treatment adherence in bariatric surgery

Severe obesity (body mass index ≥40 kg/m²) is a chronic disease that is associated with significantly increased risk of serious and chronic health problems as well as impaired quality of life. For those with severe obesity, bariatric surgery is the most effective treatment for significant and long-term weight loss and resolution of comorbid medical conditions, particularly diabetes. Long-term success is thought to depend to some degree on the patient's ability to adhere to a complex set of behaviors, including regular attendance at follow up appointments and following stringent dietary, exercise, and vitamin recommendations. Here, we summarize the current research on behavioral adherence in patients with severe obesity presenting for bariatric surgery and we highlight challenges and make recommendations for improved self-management before and after surgery.