Shared Decision Making and Choice for Bariatric Surgery

Associations between Type of Bariatric Surgery and Obstructive Sleep Apnoea, Employment Outcomes, and Body Image Satisfaction: A Systematic Review and Meta-Analysis

INTRODUCTION

Bariatric surgery has been shown to provide significant patient benefits in terms of weight loss and mitigation of obesity-linked comorbidities, as well as providing improvements in occupational productivity and patient quality of life. However, the choice of which bariatric surgery procedure provides the most patient benefit in each of these cases is still in question. In this review, we provide a systematic review, with the objective of evaluating associations between different bariatric surgery procedures and mitigation of obesity-linked comorbidities, improvement in occupational productivity, and patient quality of life, concentrating on three areas: obstructive sleep apnoea (OSA), employment prospects, and body image.

METHODS

The CINAHL, PubMed, Web of Science, and CENTRAL databases were searched for eligible studies. Summary risk ratio (RR) and 95% confidence intervals were estimated using random-effects models. Thirty-three studies were included in this review, including 29 cohort studies and 4 randomised clinical trials (RCTs).

RESULTS

Pooled analysis of the observational studies showed significantly lower OSA remission in sleeve gastrectomy (SG) compared to Roux-en-Y gastric bypass (RYGB) across both short-term (1-2 years) and longer term (3+ years) follow-up periods (RR = 0.91, 95% CI = 0.84-0.99, p = 0.02; and RR = 0.88, 95% CI = 0.65-0.99, p = 0.03, respectively). In contrast, a meta-analysis of the RCT studies found no difference in OSA remission between SG and RYGB (RR = 1.01, 95% CI = 0.81-1.25, p = 0.93). An analysis of four studies showed significantly higher OSA remission for SG versus adjustable gastric banding (RR = 1.83, 95% CI = 1.57-2.14, p < 0.001). No significant difference was observed regarding improvement in employment status between SG and RYGB (RR = 0.77, 95% CI = 0.32-1.87, p = 0.57). A narrative synthesis of studies on body image reported no significant differences between body image scores and surgery types.

CONCLUSION

This review found significantly lower OSA remission in SG as compared to RYGB across different follow-up periods, while no significant statistical difference was observed in RCT studies. Further studies are recommended to assess the effectiveness of the various bariatric surgeries in relation to improving employment status and body image, where primary studies are lacking.

Online Search Trends Related to Bariatric Surgery and Their Relationship with Utilization in Australia

PURPOSE

There is an abundance of online information related to bariatric surgery. Patients may prefer a specific type of bariatric surgery based on what they read online. The primary aim of this study was to determine online search trends in bariatric surgery over time in Australia and worldwide. The secondary aim was to establish a relationship between public online search activity and the types of bariatric surgery performed in Australia.

MATERIALS AND METHOD

The terms "adjustable gastric band," "sleeve gastrectomy," and "gastric bypass surgery" were submitted for search volume analysis in Australia and worldwide using the Google Trends "Topic" search function. This was compared alongside the numbers of gastric bandings, sleeve gastrectomies, and gastric bypass surgeries performed in Australia over time to determine if there was a relationship between the two.

RESULTS

Search trends for "adjustable gastric band" and "sleeve gastrectomy" in Australia were similar to trends seen worldwide. However, search trends for "gastric bypass surgery" differ between Australia and the rest of the world. It took at least a year for online searches to reflect the higher number of sleeve gastrectomies performed relative to gastric bandings. There was a lag time of over four years before online searches reflected the higher number of gastric bypass surgery performed compared to gastric banding.

CONCLUSION

Search interests in Australia and worldwide were similar for gastric banding and sleeve gastrectomy but different for gastric bypass surgery. Online search activity did not have a significant association with the types of bariatric surgery being performed in Australia.

Factors Associated with the Decision to Complete Bariatric Metabolic Surgery among a Racially and Ethnically Diverse Sample of Adults: A Classification and Regression Tree Analysis

BACKGROUND

Less than 50% of eligible candidates who are referred complete Bariatric Metabolic Surgery (BMS). The factors influencing the decision to complete BMS, particularly how these factors vary across different racial and ethnic groups, remain largely unexplored.

METHODS

This prospective cohort study included adult patients referred to a bariatric surgeon or obesity medicine program between July 2019-September 2022. Sociodemographic characteristics, body mass index (BMI), anxiety, depression, body appreciation, and patient-physician relationship information were collected via survey and electronic health records. The association between BMS completion and potential decision-driving factors was examined using Classification and Regression Tree (CART) analysis.

RESULTS

A total of 406 BMS -eligible patients participated in the study (mean [SD] age: 47.5 [11.6] years; 87.2% women; 18.0% Hispanic, 39% non-Hispanic Black [NHB], and 39% non-Hispanic White [NHW]; mean [SD] BMI: 45.9 [10.1] kg/m2). A total of 147 participants (36.2%) completed BMS. Overall, the most influential factor driving the decision to complete BMS was younger age (< 68.4 years), higher patient satisfaction, and BMI (≥ 38.0 kg/m2). Hispanic participants prioritized age (< 55.4 years), female sex, and body appreciation. For NHB participants, the highest ranked factors were age < 56.3 years, BMI ≥ 35.8 kg/m2, and higher patient satisfaction. For NHW patients, the most influential factors were age (39.1 to 68.6 years) and higher body appreciation.

CONCLUSION

These findings highlight racial and ethnic group differences in the factors motivating individuals to complete BMS. By acknowledging these differences, healthcare providers can support patients from different backgrounds more effectively in their decision-making process regarding BMS.

Long term outcomes of metabolic/bariatric surgery in adults

The prevalence of obesity continues to rise around the world, driving up the need for effective and durable treatments. The field of metabolic/bariatric surgery has grown rapidly in the past 25 years, with observational studies and randomized controlled trials investigating a broad range of long term outcomes. Metabolic/bariatric surgery results in durable and significant weight loss and improvements in comorbid conditions, including type 2 diabetes. Observational studies show that metabolic/bariatric surgery is associated with a lower incidence of cardiovascular events, cancer, and death. Weight regain is a risk in a fraction of patients, and an association exists between metabolic/bariatric surgery and an increased risk of developing substance and alcohol use disorders, suicidal ideation/attempts, and accidental death. Patients need lifelong follow-up to help to reduce the risk of these complications and other nutritional deficiencies. Different surgical procedures have important differences in risks and benefits, and a clear need exists for more long term research about less invasive and emerging procedures. Recent guidelines for the treatment of obesity and metabolic conditions have been updated to reflect this growth in knowledge, with an expansion of eligibility criteria, particularly people with type 2 diabetes and a body mass index between 30.0 and 34.9.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association Between Patient Satisfaction With Their Patient-Physician Relationship and Completion of Bariatric Surgery by Race and Ethnicity Among US Adults

IMPORTANCE

Metabolic and bariatric surgery (MBS) is an effective and safe treatment for obesity and its comorbidities, but less than 50% of those who are eligible and referred for MBS complete the procedure. The patient-physician relationship could be a decisive factor in the decision to complete MBS; however, this relationship has not been explored, particularly among racially and ethnically diverse populations.

OBJECTIVE

To examine the association between patient-reported satisfaction with their patient-physician relationship and MBS completion by self-reported racial and ethnic group.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study included 408 patients who were referred to a bariatric surgeon or obesity medicine program between July 24, 2019, and May 19, 2022.

EXPOSURE

Patient satisfaction with their physician was measured by 7 dimensions (general satisfaction, technical quality, interpersonal manner, communication, financial aspects, time spent with physician, and accessibility and convenience) using the Patient Satisfaction Questionnaire Short Form.

MAIN OUTCOMES AND MEASURES

Completion status for MBS (yes or no).

RESULTS

A total of 408 patients (mean [SD] age, 47.3 [11.6] years; among 366 with data available, 317 [86.6%] women and 49 [13.4%] men) were included in the study. Of 363 patients with data available on race and ethnicity, 66 were Hispanic/Latinx (18.2%), 136 (37.5%) were non-Hispanic Black, 146 (40.2%) were non-Hispanic White, and 15 (4.1%) were other race or ethnicity. A total of 124 patients (30.4%) completed MBS. Overall, the mean (SD) patient satisfaction score was significantly greater in MBS completers vs noncompleters (3.86 [0.56] vs 3.61 [0.64]; P < .001). Multivariable logistic regression analysis showed technical quality was the most significant factor for MBS completion (adjusted odds ratio [aOR], 1.99 [95% CI, 1.24-3.19]), followed by communication (aOR, 1.78 [95% CI, 1.16-2.72]) and accessibility and convenience (aOR, 1.61 [95% CI, 1.03-2.53]). The interaction between racial and ethnic groups and patient satisfaction was not significant (eg, mean [SD] score for Hispanic/Latinx completers, 3.95 [0.55] vs 3.77 [0.60] for non-Hispanic White completers; P = .46 for interaction).

CONCLUSIONS AND RELEVANCE

These findings suggest that there is an association between patient satisfaction with the patient-physician relationship and the decision to complete MBS regardless of race and ethnicity. These findings have important implications for strategies to improve the proportion of qualified patients who complete MBS to achieve improved health outcomes.

Determining the Development Strategy and Suited Adoption Paths for the Core Competence of Shared Decision-Making Tasks through the SAA-NRM Approach

Shared decision making (SDM) is an interactive process that involves patients and their healthcare professionals reaching joint decisions about medical care through negotiation. As the initiators of medical decision-making in daily routine, physicians should be aware of and concerned about the SDM process. Thus, professional competency development for SDM has become increasingly critical for physicians' training. Therefore, this study investigates the professional competency and the important competency development aspects/criteria of SDM tasks through expert interviews and literature research. The study adopts the SAA (satisfaction-attention analysis) method to assess the status of competency development aspects/criteria and determine the NRM (network relation map) based on the DEMATEL (decision-making trial and evaluation laboratory) technique. The results demonstrate that the CE (concept and evaluation) aspect is the dominant aspect, and the CR (communication and relationship) aspect is the aspect being dominated. The CE aspect influences the aspects of SP (skill and practice), JM (joint information and decision making) and CR, and the SP aspect affects the aspects of JM and CR. Then, the JM aspect affects the CR aspect. The study also suggests suitable adoption paths of competency development for SDM tasks using the NRM approach. It provides recommendations and strategic directions for SDM competency development and sustainable training programs.

Establishing the Competency Development and Talent Cultivation Strategies for Physician-Patient Shared Decision-Making Competency Based on the IAA-NRM Approach

Shared decision making (SDM) is a collaborative process involving patients and their healthcare workers negotiating to reach a shared decision about medical care. However, various physician stakeholders (attending physicians, medical residents, and doctors in post-graduate years) may have different viewpoints on SDM processes. The purpose of this study is to explore the core competence of physicians in performing SDM tasks and to investigate the significant competency development aspects/criteria by applying the literature research and expert interviews. We adopt the IAA (importance awareness analysis) technique for different stakeholders to evaluate the status of competency development aspects/criteria and to determine the NRM (network relation map) based on the DEMATEL (decision-making trial and evaluation laboratory) technique. The study combines the IAA and NRM methods and suggests using the IAA-NRM approach to evaluate the adoption strategies and common suitable paths for different levels of physicians. Our findings reveal that SDM perception and practice is the primary influencer of SDM competence development for all stakeholders. The current model can help hospital administrators and directors of medical education understand the diverse stakeholders’ perspectives on the core competence of SDM tasks and determine common development plans. It provides strategic directions for SDM competency development and talent cultivation programs.

The Most Undertreated Chronic Disease: Addressing Obesity in Primary Care Settings

PURPOSE OF REVIEW

While obesity-related comorbidities are frequently addressed and treated in primary care (PC), obesity itself is undertreated. We review the current treatments for obesity and provide potential provider and system-level strategies for integrating weight management and improving longer term obesity care within PC settings.

RECENT FINDINGS

We now understand that the body develops multiple mechanisms to resist weight loss and promote weight regain, making both weight loss and weight loss maintenance challenging. Therefore, weight management often requires medically supervised interventions and should be treated on a long-term basis. However, there are multiple barriers to improving obesity care within PC settings. Clinically, utilizing strategies such as a shared decision-making approach and the 5As to discuss treatment options can facilitate formulating an obesity treatment plan. Utilizing telehealth, a team-based approach, and community partnering can increase patient access to intensive behavioral interventions. Future studies should evaluate other cost-effective methods to implement obesity care into the PC setting.