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Kamyszek RW, Newman N, Ragheb JW, Sjoding MW, Joo H, Maile MD, Cassidy RB, Golbus JR, Engoren MC, Mathis MR. Differences between patients in whom physicians agree versus disagree about the preoperative diagnosis of heart failure. J Clin Anesth 2023; 90:111226. [PMID: 37549434 DOI: 10.1016/j.jclinane.2023.111226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/29/2023] [Accepted: 07/30/2023] [Indexed: 08/09/2023]
Abstract
STUDY OBJECTIVE To quantify preoperative heart failure (HF) diagnostic agreement and identify characteristics of patients in whom physicians agreed versus disagreed about the diagnosis. DESIGN Observational cohort study. SETTING Patients undergoing major non-cardiac surgery at an academic center between 2015 and 2019. PATIENTS 40,659 patients undergoing major non-cardiac surgery, among which a stratified subsample of 1018 patients with and without documented HF was reviewed. INTERVENTIONS Via a panel of physicians frequently managing patients with HF (cardiologists, cardiac anesthesiologists, intensivists), detailed chart reviews were performed (two per patient; median review time 32 min per reviewer per patient) to render adjudicated HF diagnoses. MEASUREMENTS Adjudicated diagnostic agreement measures (percent agreement, Krippendorf's alpha) and univariate comparisons (standardized differences) between patients in whom physicians agreed versus disagreed about the preoperative HF diagnosis. MAIN RESULTS Among patients with documented HF, physicians agreed about the diagnosis in 80.0% of cases (consensus positive), disagreed in 13.8% (disagreement), and refuted the diagnosis in 6.3% (consensus negative). Conversely, among patients without documented HF, physicians agreed about the diagnosis in 88.0% (consensus negative), disagreed in 8.4% (disagreement), and refuted the diagnosis in 3.6% (consensus positive). The estimated agreement for the 40,659 cases was 91.1% (95% CI 88.3%-93.9%); Krippendorff's alpha was 0.77 (0.75-0.80). Compared to patients in whom physicians agreed about a HF diagnosis, patients in whom physicians disagreed exhibited fewer guideline-defined HF diagnostic criteria. CONCLUSIONS Physicians usually agree about HF diagnoses adjudicated via chart review, although disagreement is not uncommon and may be partly explained by heterogeneous clinical presentations. Our findings inform preoperative screening processes by identifying patients whose characteristics contribute to physician disagreement via chart review. Clinical Trial Number / Registry URL: Not applicable.
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Affiliation(s)
- Reed W Kamyszek
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Noah Newman
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jacqueline W Ragheb
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael W Sjoding
- Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Computational Bioinformatics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Hyeon Joo
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael D Maile
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ruth B Cassidy
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jessica R Golbus
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Milo C Engoren
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael R Mathis
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Computational Bioinformatics, University of Michigan Medical School, Ann Arbor, MI, USA.
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Brown SES, Hall M, Cassidy RB, Zhao X, Kheterpal S, Feudtner C. Tracheostomy, Feeding-Tube, and In-Hospital Postoperative Mortality in Children: A Retrospective Cohort Study. Anesth Analg 2023; 136:1133-1142. [PMID: 37014983 DOI: 10.1213/ane.0000000000006413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
BACKGROUND Neuromuscular/neurologic disease confers increased risk of perioperative mortality in children. Some patients require tracheostomy and/or feeding tubes to ameliorate upper airway obstruction or respiratory failure and reduce aspiration risk. Empiric differences between patients with and without these devices and their association with postoperative mortality have not been previously assessed. METHODS This retrospective cohort study using the Pediatric Health Information System measured 3- and 30-day in-hospital postsurgical mortality among children 1 month to 18 years of age with neuromuscular/neurologic disease at 44 US children's hospitals, from April 2016 to October 2018. We summarized differences between patients presenting for surgery with and without these devices using standardized differences. Then, we calculated 3- and 30-day mortality among patients with tracheostomy, feeding tube, both, and neither device, overall and stratified by important exposures, using Fisher exact test to test whether differences were significant. RESULTS There were 43,193 eligible patients. Unadjusted 3-day mortality was 1.3% (549/43,193); 30-day mortality was 2.7% (1168/43,193). Most (79.1%) used neither a feeding tube or tracheostomy, 1.2% had tracheostomy only, 15.5% had feeding tube only, and 4.2% used both devices. Compared to children with neither device, children using either or both devices were more likely to have multiple CCCs, dysphagia, chronic pulmonary disease, cerebral palsy, obstructive sleep apnea, or malnutrition, and a prolonged intensive care unit (ICU) stay within the previous year. They were less likely to present for high-risk surgeries (33% vs 57%). Having a feeding tube was associated with decreased 3-day mortality overall compared to having neither device (0.9% vs 1.3%, P = .003), and among children having low-risk surgery, and surgery during urgent or emergent hospitalizations. Having both devices was associated with decreased 3-day mortality among children having low-risk surgery (0.8% vs 1.9%; P = .013), and during urgent or emergent hospitalizations (1.6% vs 2.9%; P = .023). For 30-day mortality, having a feeding tube or both devices was associated with lower mortality when the data were stratified by the number of CCCs. CONCLUSIONS Patients requiring tracheostomy, feeding tube, or both are generally sicker than patients without these devices. Despite this, having a feeding tube was associated with lower 3-day mortality overall and lower 30-day mortality when the data were stratified by the number of CCCs. Having both devices was associated with lower 3-day mortality in patients presenting for low-risk surgery, and surgery during urgent or emergent hospitalizations.
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Affiliation(s)
- Sydney E S Brown
- From the Department of Anesthesiology, The University of Michigan, Ann Arbor, Michigan
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Ruth B Cassidy
- From the Department of Anesthesiology, The University of Michigan, Ann Arbor, Michigan
| | - Xinyi Zhao
- From the Department of Anesthesiology, The University of Michigan, Ann Arbor, Michigan
| | - Sachin Kheterpal
- From the Department of Anesthesiology, The University of Michigan, Ann Arbor, Michigan
| | - Chris Feudtner
- The Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Golbus JR, Joo H, Janda AM, Maile MD, Aaronson KD, Engoren MC, Cassidy RB, Kheterpal S, Mathis MR. Preoperative clinical diagnostic accuracy of heart failure among patients undergoing major noncardiac surgery: a single-centre prospective observational analysis. BJA Open 2022; 4:100113. [PMID: 36643721 PMCID: PMC9835767 DOI: 10.1016/j.bjao.2022.100113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/16/2022] [Accepted: 11/09/2022] [Indexed: 12/12/2022]
Abstract
Background Reliable diagnosis of heart failure during preoperative evaluation is important for perioperative management and long-term care. We aimed to quantify preoperative heart failure diagnostic accuracy and explore characteristics of patients with heart failure misdiagnoses. Methods We performed an observational cohort study of adults undergoing major noncardiac surgery at an academic hospital between 2015 and 2019. A preoperative clinical diagnosis of heart failure was defined using keywords from the history and clinical examination or administrative documentation. Across stratified subsamples of cases with and without clinically diagnosed heart failure, health records were intensively reviewed by an expert panel to develop an adjudicated heart failure reference standard using diagnostic criteria congruent with consensus guidelines. We calculated agreement among experts, and analysed performance of clinically diagnosed heart failure compared with the adjudicated reference standard. Results Across 40 555 major noncardiac procedures, a stratified subsample of 511 patients was reviewed by the expert panel. The prevalence of heart failure was 9.1% based on clinically diagnosed compared with 13.3% (95% confidence interval [CI], 10.3-16.2%) estimated by the expert panel. Overall agreement and inter-rater reliability (kappa) among heart failure experts were 95% and 0.79, respectively. Based upon expert adjudication, heart failure was clinically diagnosed with an accuracy of 92.8% (90.6-95.1%), sensitivity 57.4% (53.1-61.7%), specificity 98.3% (97.1-99.4%), positive predictive value 83.5% (80.3-86.8%), and negative predictive value 93.8% (91.7-95.9%). Conclusions Limitations exist to the preoperative clinical diagnosis of heart failure, with nearly half of cases undiagnosed preoperatively. Considering the risks of undiagnosed heart failure, efforts to improve preoperative heart failure diagnoses are warranted.
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Affiliation(s)
- Jessica R. Golbus
- Department of Internal Medicine, Division of Cardiovascular Medicine, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Hyeon Joo
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Allison M. Janda
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Michael D. Maile
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Keith D. Aaronson
- Department of Internal Medicine, Division of Cardiovascular Medicine, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Milo C. Engoren
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Ruth B. Cassidy
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
| | - Michael R. Mathis
- Department of Anesthesiology, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
- Department of Computational Bioinformatics, Michigan Medicine - University of Michigan, Ann Arbor, MI, USA
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Burns ML, Saager L, Cassidy RB, Mentz G, Mashour GA, Kheterpal S. Association of Anesthesiologist Staffing Ratio With Surgical Patient Morbidity and Mortality. JAMA Surg 2022; 157:807-815. [PMID: 35857304 DOI: 10.1001/jamasurg.2022.2804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Recent studies have investigated the effect of overlapping surgeon responsibilities or nurse to patient staffing ratios on patient outcomes, but the association of overlapping anesthesiologist responsibilities with patient outcomes remains unexplored to our knowledge. Objective To examine the association between different levels of anesthesiologist staffing ratios and surgical patient morbidity and mortality. Design, Setting, and Participants A retrospective, matched cohort study consisting of major noncardiac inpatient surgical procedures performed from January 1, 2010, to October 31, 2017, was conducted in 23 US academic and private hospitals. A total of 866 453 adult patients (aged ≥18 years) undergoing major inpatient surgery within the Multicenter Perioperative Outcomes Group electronic health record registry were included. Anesthesiologist sign-in and sign-out times were used to calculate a continuous time-weighted average staffing ratio variable for each operation. Propensity score-matching methods were applied to create balanced sample groups with respect to patient-, operative-, and hospital-level confounders and resulted in 4 groups based on anesthesiologist staffing ratio. Groups consisted of patients receiving care from an anesthesiologist covering 1 operation (group 1), more than 1 to no more than 2 overlapping operations (group 1-2), more than 2 to no more than 3 overlapping operations (group 2-3), and more than 3 to no more than 4 overlapping operations (group 3-4). Data analysis was performed from October 2019 to October 2021. Exposure Undergoing a major inpatient surgical operation that involved an anesthesiologist providing care for up to 4 overlapping operations. Main Outcomes and Measures The primary composite outcome was 30-day mortality and 6 major surgical morbidities (cardiac, respiratory, gastrointestinal, urinary, bleeding, and infectious complications) derived from International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision discharge diagnosis codes. Results In all, 578 815 adult patients (mean [SD] age, 55.7 [16.2] years; 55.1% female) were analyzed. After matching operations according to anesthesiologist staffing ratio, 48 555 patients were in group 1; 247 057, group 1-2; 216 193, group 2-3; and 67 010, group 3-4. Increasing anesthesiologist coverage responsibilities was associated with an increase in risk-adjusted surgical patient morbidity and mortality. Compared with patients in group 1-2, those in group 2-3 had a 4% relative increase in risk-adjusted mortality and morbidity (5.06% vs 5.25%; adjusted odds ratio [AOR], 1.04; 95% CI, 1.01-1.08; P = .02) and those in group 3-4 had a 14% increase in risk-adjusted mortality and morbidity (5.06% vs 5.75%; AOR, 1.15; 95% CI, 1.09-1.21; P < .001). Conclusions and Relevance This study's findings suggest that increasing overlapping coverage by anesthesiologists is associated with increased surgical patient morbidity and mortality. Therefore, the potential effects of staffing ratios in perioperative team models should be considered in clinical coverage efforts.
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Affiliation(s)
- Michael L Burns
- Department of Anesthesiology, University of Michigan, Ann Arbor
| | - Leif Saager
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Ruth B Cassidy
- Department of Anesthesiology, University of Michigan, Ann Arbor
| | - Graciela Mentz
- Department of Anesthesiology, University of Michigan, Ann Arbor
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Lager CJ, Esfandiari NH, Luo Y, Subauste AR, Kraftson AT, Brown MB, Varban OA, Meral R, Cassidy RB, Nay CK, Lockwood AL, Bellers D, Buda CM, Oral EA. Metabolic Parameters, Weight Loss, and Comorbidities 4 Years After Roux-en-Y Gastric Bypass and Sleeve Gastrectomy. Obes Surg 2019; 28:3415-3423. [PMID: 29909517 DOI: 10.1007/s11695-018-3346-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Sleeve gastrectomy (LSG) is now the predominant bariatric surgery performed, yet there is limited long-term data comparing important outcomes between LSG and Roux-en-Y gastric bypass (RYGB). This study compares weight loss and impact on comorbidities of the two procedures. METHODS We retrospectively evaluated weight, blood pressure, hemoglobin A1c, cholesterol, and medication use for hypertension, diabetes, and hyperlipidemia at 1-4 years post-operatively in 380 patients who underwent RYGB and 334 patients who underwent LSG at the University of Michigan from January 2008 to November 2013. Follow-up rates from 714 patients initially were 657 (92%), 556 (78%), 507 (71%), and 498 (70%) at 1-4 years post-operatively. RESULTS Baseline characteristics were similar except for higher weight and BMI in LSG. There was greater weight loss with RYGB vs. LSG at all points. Hemoglobin A1c and total cholesterol improved more in RYGB vs. LSG at 4 years. There was greater remission of hypertension and discontinuation of all medications for hypertension and diabetes with RYGB at 4 years. CONCLUSIONS Weight loss, reduction in medications for hypertension and diabetes, improvements in markers of diabetes and hyperlipidemia, and remission rates of hypertension were superior with RYGB vs. LSG 4 years post-operatively. Choice of bariatric procedures should be tailored to surgical risk, comorbidities, and weight loss goals.
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Affiliation(s)
- Corey J Lager
- Division of Metabolism, Endocrinology, and Diabetes, Brehm Center for Diabetes, Michigan Medicine, 24 Frank Lloyd Wright Drive, Domino's Farm, Lobby C, Ann Arbor, MI, 48106, USA
| | - Nazanene H Esfandiari
- Division of Metabolism, Endocrinology, and Diabetes, Brehm Center for Diabetes, Michigan Medicine, 24 Frank Lloyd Wright Drive, Domino's Farm, Lobby C, Ann Arbor, MI, 48106, USA
| | - Yingying Luo
- Department of Endocrinology, Peking University People's Hospital, No. 11, Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Angela R Subauste
- Division of Endocrinology, University of Mississippi, 2500 N State St, Jackson, MS, 39216, USA
| | - Andrew T Kraftson
- Division of Metabolism, Endocrinology, and Diabetes, Brehm Center for Diabetes, Michigan Medicine, 24 Frank Lloyd Wright Drive, Domino's Farm, Lobby C, Ann Arbor, MI, 48106, USA
| | - Morton B Brown
- School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Oliver A Varban
- Division of Minimally Invasive Surgery, Department of General Surgery, Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Rasimcan Meral
- Division of Metabolism, Endocrinology, and Diabetes, Brehm Center for Diabetes, Michigan Medicine, 24 Frank Lloyd Wright Drive, Domino's Farm, Lobby C, Ann Arbor, MI, 48106, USA
| | - Ruth B Cassidy
- Division of Minimally Invasive Surgery, Department of General Surgery, Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Catherine K Nay
- Division of Metabolism, Endocrinology, and Diabetes, Brehm Center for Diabetes, Michigan Medicine, 24 Frank Lloyd Wright Drive, Domino's Farm, Lobby C, Ann Arbor, MI, 48106, USA
| | - Amy L Lockwood
- Division of Metabolism, Endocrinology, and Diabetes, Brehm Center for Diabetes, Michigan Medicine, 24 Frank Lloyd Wright Drive, Domino's Farm, Lobby C, Ann Arbor, MI, 48106, USA
| | - Darlene Bellers
- Division of Metabolism, Endocrinology, and Diabetes, Brehm Center for Diabetes, Michigan Medicine, 24 Frank Lloyd Wright Drive, Domino's Farm, Lobby C, Ann Arbor, MI, 48106, USA
| | - Colleen M Buda
- Division of Minimally Invasive Surgery, Department of General Surgery, Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Elif A Oral
- Division of Metabolism, Endocrinology, and Diabetes, Brehm Center for Diabetes, Michigan Medicine, 24 Frank Lloyd Wright Drive, Domino's Farm, Lobby C, Ann Arbor, MI, 48106, USA.
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Frey DP, Bauer ME, Bell CL, Low LK, Hassett AL, Cassidy RB, Boyer KD, Sharar SR. Virtual Reality Analgesia in Labor: The VRAIL Pilot Study-A Preliminary Randomized Controlled Trial Suggesting Benefit of Immersive Virtual Reality Analgesia in Unmedicated Laboring Women. Anesth Analg 2019; 128:e93-e96. [PMID: 31094789 DOI: 10.1213/ane.0000000000003649] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
This pilot study investigated the use of virtual reality (VR) in laboring women. Twenty-seven women were observed for equivalent time during unmedicated contractions in the first stage of labor both with and without VR (order balanced and randomized). Numeric rating scale scores were collected after both study conditions. Significant decreases in sensory pain -1.5 (95% CI, -0.8 to -2.2), affective pain -2.5 (95% CI, -1.6 to -3.3), cognitive pain -3.1 (95% CI, -2.4 to -3.8), and anxiety -1.5 (95% CI, -0.8 to -2.3) were observed during VR. Results suggest that VR is a potentially effective technique for improving pain and anxiety during labor.
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Affiliation(s)
| | | | - Carrie L Bell
- Obstetrics and Gynecology, University of Michigan Health System, Ann Arbor, Michigan
| | - Lisa Kane Low
- School of Nursing, Women's Studies, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | | | | | | | - Sam R Sharar
- Department of Anesthesiology, University of Washington Harborview Medical Center, Seattle, Washington
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Lager CJ, Esfandiari NH, Subauste AR, Kraftson AT, Brown MB, Cassidy RB, Bellers D, Lockwood AL, Varban OA, Oral EA. Milestone Weight Loss Goals (Weight Normalization and Remission of Obesity) after Gastric Bypass Surgery: Long-Term Results from the University of Michigan. Obes Surg 2018; 27:1659-1666. [PMID: 28084587 DOI: 10.1007/s11695-016-2533-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Rates of weight normalization and obesity remission after Roux-en-Y gastric bypass (GB) are unknown. This study evaluated weight loss, rates of achieving body mass index (BMI) <25 or 30 kg/m2, recidivism, and predictors of success following GB. METHODS We retrospectively studied weight and BMI at baseline, 2 and 6 months, and annually at 1-7 years in 219 patients undergoing GB at the University of Michigan from January 2008 to November 2010. RESULTS Follow-up was excellent for a population traditionally associated with high attrition rates with data availability of 157/219, 145/219, 144/219, 134/219, 123/219, 82/161, and 29/64 patients at 1-7 years, respectively. Mean baseline BMI was 47.0 kg/m2. Weight normalization (BMI <25 kg/m2) occurred in 2.3-6.8% of patients. More importantly, 47% of patients achieved remission of obesity (BMI <30 kg/m2) at some time point and 24% (52/219) at the last observed time point. BMI <30 kg/m2 was associated with a lower initial BMI and follow-up for more than 2 years. CONCLUSIONS Rates of weight normalization are low after GB; however, a large number of patients achieved BMI <30 kg/m2. While the percent total weight loss and excess weight loss are both quite high in the entire cohort and this is likely associated with significant health benefits, our results still underscore the need to address obesity with intensive clinical attention earlier in its course.
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Affiliation(s)
- Corey J Lager
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan Health Systems, Brehm Center for Diabetes, 1000 Wall Street, Room 5313, Ann Arbor, MI, 48105, USA
| | - Nazanene H Esfandiari
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan Health Systems, Brehm Center for Diabetes, 1000 Wall Street, Room 5313, Ann Arbor, MI, 48105, USA
| | - Angela R Subauste
- Division of Endocrinology, University of Mississippi, 2500 N. State St., Jackson, MS, 39216, USA
| | - Andrew T Kraftson
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan Health Systems, Brehm Center for Diabetes, 1000 Wall Street, Room 5313, Ann Arbor, MI, 48105, USA
| | - Morton B Brown
- Department of Biostatistics, School of Public Health, University of Michigan, M4039 SPH II, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Ruth B Cassidy
- Division of Minimally Invasive Surgery, Department of General Surgery, University of Michigan, 1500 E Medical Center Dr SPC 5343, Ann Arbor, MI, 48109, USA
| | - Darlene Bellers
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan Health Systems, Brehm Center for Diabetes, 1000 Wall Street, Room 5313, Ann Arbor, MI, 48105, USA
| | - Amy L Lockwood
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan Health Systems, Brehm Center for Diabetes, 1000 Wall Street, Room 5313, Ann Arbor, MI, 48105, USA
| | - Oliver A Varban
- Division of Minimally Invasive Surgery, Department of General Surgery, University of Michigan, 1500 E Medical Center Dr SPC 5343, Ann Arbor, MI, 48109, USA
| | - Elif A Oral
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan Health Systems, Brehm Center for Diabetes, 1000 Wall Street, Room 5313, Ann Arbor, MI, 48105, USA.
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Varban OA, Cassidy RB, Bonham A, Carlin AM, Ghaferi A, Finks JF. Factors Associated With Achieving a Body Mass Index of Less Than 30 After Bariatric Surgery. JAMA Surg 2017; 152:1058-1064. [PMID: 28746723 DOI: 10.1001/jamasurg.2017.2348] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance Achieving a body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) of less than 30 is an important goal of bariatric surgery, given the increased risk for weight-related morbidity and mortality with a BMI above this threshold. Objective To identify predictors for achieving a BMI of less than 30 after bariatric surgery. Design, Setting, and Participants This retrospective study used data from the Michigan Bariatric Surgery Collaborative, a statewide quality improvement collaborative that uses a prospectively gathered clinical data registry. A total of 27 320 adults undergoing primary bariatric surgery between June 2006 and May 2015 at teaching and nonteaching hospitals in Michigan were included. Exposure Bariatric surgery. Main Outcomes and Measures Logistic regression was used to identify predictors for achieving a BMI of less than 30 at 1 year after surgery. Secondary outcome measures included 30-day postoperative complications and 1-year self-reported comorbidity remission. Results A total of 9713 patients (36%; mean [SD] age, 46.9 [11.3] years; 16.6% male) achieved a BMI of less than 30 at 1 year after bariatric surgery. A significant predictor for achieving this goal was a preoperative BMI of less than 40 (odds ratio [OR], 12.88; 95% CI, 11.71-14.16; P < .001). Patients who had a sleeve gastrectomy, gastric bypass, or duodenal switch were more likely to achieve a BMI of less than 30 compared with those who underwent adjustable gastric banding (OR, 8.37 [95% CI, 7.44-9.43]; OR, 21.43 [95% CI, 18.98-24.19]; and OR, 82.93 [95% CI, 59.78-115.03], respectively; P < .001). Only 8.5% of patients with a BMI greater than 50 achieved a BMI of less than 30 after bariatric surgery. Patients who achieved a BMI of less than 30 had significantly higher reported rates of medication discontinuation for hyperlipidemia (60.7% vs 43.2%, P < .001), diabetes (insulin: 67.7% vs 50.0%, P < .001; oral medications: 78.5% vs 64.3%, P < .001), and hypertension (54.7% vs 34.6%, P < .001), as well as a significantly higher rate of sleep apnea remission (72.5% vs 49.3%, P < .001) and higher satisfaction rate (92.8% vs 78.0%, P < .001) compared with patients who did not. Conclusions and Relevance Patients with a preoperative BMI of less than 40 are more likely to achieve a BMI of less than 30 after bariatric surgery and are more likely to experience comorbidity remission. Policies and practice patterns that delay bariatric surgery until the BMI is 50 or greater can result in significantly inferior outcomes.
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Affiliation(s)
- Oliver A Varban
- Department of Surgery, University of Michigan Health Systems, Ann Arbor
| | - Ruth B Cassidy
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Aaron Bonham
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Arthur M Carlin
- Wayne State University, Detroit, Michigan.,Department of Surgery, Henry Ford Health System, Detroit, Michigan
| | - Amir Ghaferi
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Jonathan F Finks
- Department of Surgery, University of Michigan Health Systems, Ann Arbor.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
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Alvarez R, Cassidy RB, Bonham AJ, Buda CM, Varban OA. Access to Bariatric Surgery: A Statewide Report on Wait Times for the Surgical Treatment of Morbid Obesity. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Varban OA, Sheetz KH, Cassidy RB, Stricklen A, Carlin AM, Dimick JB, Finks JF. Evaluating the effect of operative technique on leaks after laparoscopic sleeve gastrectomy: a case-control study. Surg Obes Relat Dis 2016; 13:560-567. [PMID: 28089439 DOI: 10.1016/j.soard.2016.11.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 09/10/2016] [Accepted: 11/29/2016] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To assess the effect of operative technique on staple line leaks after laparoscopic sleeve gastrectomy (LSG). BACKGROUND Staple-line leaks after LSG are a major source of morbidity and mortality. Variations in operative technique exist; however, their effect on leaks is poorly understood. METHODS We analyzed data from the Michigan Bariatric Surgery Collaborative (MBSC) to perform a case-control study comparing patients who had a clinically significant leak after undergoing a primary LSG to those who did not. A total of 45 patients with leaks were identified between January 2007 and December 2013. The leak group was matched 1:2 to a control group based on procedure type, age, body mass index, sex, and year the procedure was performed. Technique-specific factors were assessed by reviewing operative notes from all primary bariatric procedures in our study population. Conditional logistic regression was used to identify techniques associated with leaks. To increase the power of our analysis, we used a significance level of .10. RESULTS Leak rates with LSG have decreased over the past 5 years (1.18% to .36%) as annual case volume has increased (846 cases/yr to 4435 cases/yr). Surgeons who performed 43 or more cases per year had a leak rate<1%. Leaks were more common among cases requiring a blood transfusion (26.2% versus 1.08%, P = .0031) and when cases were converted to open surgery (7.14% versus 0%, P = .0741). However, there was no significant difference in operative time between cases involving a leak and their matched controls (95.4 min versus 87.1 min, P = .1197). Oversewing of the staple line was the only technique associated with less leaks after controlling for confounding factors (OR .397 CI .174, .909, P = .0665). Notably, surgeons who oversewed routinely were also found to have higher case volume (307 versus 140, P = .0216) and less overall complication rates (4.81% versus 7.95%, P = .0027). Furthermore, oversewing technique varied widely as only 22.6% of cases involved oversewing of the entire staple line. CONCLUSION Despite considerable variation in operative technique, leak rates with laparoscopic sleeve gastrectomy have decreased over time as operative volume has increased. Oversewing of the staple line was associated with fewer leaks, but specific suturing technique was not uniform and oversewing was performed routinely by more experienced surgeons with higher case volumes and less complication rates overall. Before standardizing surgical technique one must take into account variations in surgeon skill and experience.
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Affiliation(s)
- Oliver A Varban
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan.
| | - Kyle H Sheetz
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
| | - Ruth B Cassidy
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Amanda Stricklen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Arthur M Carlin
- Wayne State University, Detroit, Michigan; Department of Surgery, Henry Ford Health System, Dearborn, Michigan
| | - Justin B Dimick
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Jonathan F Finks
- Department of Surgery, University of Michigan Health Systems, Ann Arbor, Michigan
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Varban OA, Cassidy RB, Sheetz KH, Cain-Nielsen A, Carlin AM, Schram JL, Weiner MJ, Bacal D, Stricklen A, Finks JF. Technique or technology? Evaluating leaks after gastric bypass. Surg Obes Relat Dis 2016; 12:264-72. [DOI: 10.1016/j.soard.2015.07.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 07/16/2015] [Accepted: 07/18/2015] [Indexed: 01/19/2023]
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