Withdrawal from bariatric treatment - an analysis under various demographic conditions

Poland is high on a list of countries affected by epidemics of obesity, a problem that has especially suddenly increased in the post-transformation period.

MATERIALS AND METHOD

Documentation of 115 subsequent patients diagnosed with grade 3 obesity, considered eligible for surgical treatment, was analysed since 2015. A subgroup of 68 patients was selected from this group and the included patients who decided to cancel their treatment at various stages. Their history since presentation at the obesity treatment centre, BMI with its history, age, education and place of residence were analysed, followed by a telephone survey. 42 patients were finally contacted. Special attention was placed on the analysis of patients taking into account their place of residence. Patients were divided into inhabitants of rural and urban areas.

RESULTS

In the study group of 68 patients, 19 (27.9%) were inhabitants of rural areas and 49 (72.1%) of urban areas. Women accounted for 67.6%, and men for 32.4%. The mean age of patients when they presented for treatment was 43 years. On average, men presented 5 years later compared to women. The mean BMI on qualification for treatment of obesity was 47.6 kg/m². The mean BMI max - 49.6 kg/m². There were no differences regarding education in both populations. Despite the lack of differences regarding changes in the BMI since withdrawal from treatment, as many as 63% of patients from rural areas reached the BMI max in this time.

CONCLUSIONS

There were demographic differences between the degree of obesity observed among patients receiving bariatric treatment, and inhabitants of urban areas were favoured. Patients from rural areas who withdrew from bariatric treatment and were left without medical care significantly more often achieved their maximum body weight, when compared to those living in urban areas. The active participation of physicians, both specialists and general practitioners, in the life of obese patients is imperative.

Following up nonrespondents to an online weight management intervention: randomized trial comparing mail versus telephone

Background

Attrition, or dropout, is a problem faced by many online health interventions, potentially threatening the inferential value of online randomized controlled trials.

Objective

In the context of a randomized controlled trial of an online weight management intervention, where 85% of the baseline participants were lost to follow-up at the 12-month measurement, the objective was to examine the effect of nonresponse on key outcomes and explore ways to reduce attrition in follow-up surveys.

Methods

A sample of 700 nonrespondents to the 12-month online follow-up survey was randomly assigned to a mail or telephone nonresponse follow-up survey. We examined response rates in the two groups, costs of follow-up, reasons for nonresponse, and mode effects. We ran several logistic regression models, predicting response or nonresponse to the 12-month online survey as well as predicting response or nonresponse to the follow-up survey.

Results

We analyzed 210 follow-up respondents in the mail and 170 in the telephone group. Response rates of 59% and 55% were obtained for the telephone and mail nonresponse follow-up surveys, respectively. A total of 197 respondents (51.8%) gave reasons related to technical issues or email as a means of communication, with older people more likely to give technical reasons for noncompletion; 144 (37.9%) gave reasons related to the intervention or the survey itself. Mail follow-up was substantially cheaper: We estimate that the telephone survey cost about US $34 per sampled case, compared to US $15 for the mail survey. The telephone responses were subject to possible social desirability effects, with the telephone respondents reporting significantly greater weight loss than the mail respondents. The respondents to the nonresponse follow-up did not differ significantly from the 12-month online respondents on key outcome variables.

Conclusions

Mail is an effective way to reduce attrition to online surveys, while telephone follow-up might lead to overestimating the weight loss for both the treatment and control groups. Nonresponse bias does not appear to be a significant factor in the conclusions drawn from the randomized controlled trial.

Hospitalization before and after gastric bypass surgery

CONTEXT

The use of Roux-en-Y gastric bypass (RYGB) has been reported to be effective in the treatment of obesity and its related comorbidities. Utilization of inpatient services after RYGB is less well understood.

OBJECTIVE

To determine the rates and indications for inpatient hospital use before and after RYGB.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective study of Californians receiving RYGB in California hospitals from 1995 to 2004.

MAIN OUTCOME MEASURE

Hospitalization in the 1 to 3 years after RYGB.

RESULTS

In California from 1995 to 2004, 60,077 patients underwent RYGB-11,659 in 2004 alone. The rate of hospitalization in the year following RYGB was more than double the rate in the year preceding RYGB (19.3% vs 7.9%, P<.001). Furthermore, in the subset of patients (n = 24,678) with full 3-year follow-up, a mean of 8.4% were admitted a year before RYGB while 20.2% were readmitted in the year after RYGB, 18.4% in the second year after RYGB, and 14.9% in the third year after RYGB. The most common reasons for admission prior to RYGB were obesity-related problems (eg, osteoarthritis, lower extremity cellulitis), and elective operation (eg, hysterectomy), while the most common reasons for admission after RYGB were complications often thought to be procedure related, such as ventral hernia repair and gastric revision. In multivariate logistic regression models predicting 1-year readmission after RYGB, increasing Charlson Comorbidity Index score, and hospitalization in the 3-year period prior to RYGB were significantly associated with readmission within a year.

CONCLUSIONS

Increases in hospital use after surgery appear to be related to RYGB. Payers, clinicians, and patients must consider the not-inconsequential rate of rehospitalization after this type of surgery.

Trends in bariatric surgical procedures

CONTEXT

The increasing prevalence and associated sociodemographic disparities of morbid obesity are serious public health concerns. Bariatric surgical procedures provide greater and more durable weight reduction than behavioral and pharmacological interventions for morbid obesity.

OBJECTIVE

To examine trends for elective bariatric surgical procedures, patient characteristics, and in-hospital complications from 1998 to 2003 in the United States.

DESIGN, SETTING, AND PATIENTS

The Nationwide Inpatient Sample was used to identify bariatric surgery admissions from 1998-2002 (with preliminary data for 12 states from 2003) using International Classification of Diseases, Ninth Revision, codes for foregut surgery with a confirmatory diagnosis of obesity or by diagnosis related group code for obesity surgery. Annual estimates and trends were determined for procedures, patient characteristics, and adjusted complication rates.

MAIN OUTCOME MEASURES

Trends in bariatric surgical procedures, patient characteristics, and complications.

RESULTS

The estimated number of bariatric surgical procedures increased from 13,365 in 1998 to 72,177 in 2002 (P<.001). Based on preliminary state-level data (1998-2003), the number of bariatric surgical procedures is projected to be 102 794 in 2003. Gastric bypass procedures accounted for more than 80% of all bariatric surgical procedures. From 1998 to 2002, there were upward trends in the proportion of females (81% to 84%; P = .003), privately insured patients (75% to 83%; P = .001), patients from ZIP code areas with highest annual household income (32% to 60%, P<.001), and patients aged 50 to 64 years (15% to 24%; P<.001). Length of stay decreased from 4.5 days in 1998 to 3.3 days in 2002 (P<.001). The adjusted in-hospital mortality rate ranged from 0.1% to 0.2%. The rates of unexpected reoperations for surgical complications ranged from 6% to 9% and pulmonary complications ranged from 4% to 7%. Rates of other in-hospital complications were low.

CONCLUSIONS

These findings suggest that use of bariatric surgical procedures increased substantially from 1998 to 2003, while rates of in-hospital complications were stable and length of stay decreased. However, disparities in the use of these procedures, with disproportionate and increasing use among women, those with private insurance, and those in wealthier ZIP code areas should be explored further.

Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures

CONTEXT

Case series demonstrate that bariatric surgery can be performed with a low rate of perioperative mortality (0.5%), but the rate among high-risk patients and the community at large is unknown.

OBJECTIVES

To evaluate the risk of early mortality among Medicare beneficiaries and to determine the relative risk of death among older patients.

DESIGN

Retrospective cohort study.

SETTING AND PATIENTS

All fee-for-service Medicare beneficiaries, 1997-2002.

MAIN OUTCOME MEASURES

Thirty-day, 90-day, and 1-year postsurgical all-cause mortality among patients undergoing bariatric procedures.

RESULTS

A total of 16 155 patients underwent bariatric procedures (mean age, 47.7 years [SD, 11.3 years]; 75.8% women). The rates of 30-day, 90-day, and 1-year mortality were 2.0%, 2.8%, and 4.6%, respectively. Men had higher rates of early death than women (3.7% vs 1.5%, 4.8% vs 2.1%, and 7.5% vs 3.7% at 30 days, 90 days, and 1 year, respectively; P<.001). Mortality rates were greater for those aged 65 years or older compared with younger patients (4.8% vs 1.7% at 30 days, 6.9% vs 2.3% at 90 days, and 11.1% vs 3.9% at 1 year; P<.001). After adjustment for sex and comorbidity index, the odds of death within 90 days were 5-fold greater for older Medicare beneficiaries (aged > or =75 years; n = 136) than for those aged 65 to 74 years (n = 1381; odds ratio, 5.0; 95% confidence interval, 3.1-8.0). The odds of death at 90 days were 1.6 times higher (95% confidence interval, 1.3-2.0) for patients of surgeons with less than the median surgical volume of bariatric procedures (among Medicare beneficiaries during the study period) after adjusting for age, sex, and comorbidity index.

CONCLUSIONS

Among Medicare beneficiaries, the risk of early death after bariatric surgery is considerably higher than previously suggested and associated with advancing age, male sex, and lower surgeon volume of bariatric procedures. Patients aged 65 years or older had a substantially higher risk of death within the early postoperative period than younger patients.

Bariatric surgery: Asia-Pacific perspective

BACKGROUND

There is a world-wide epidemic of overweight, obesity and morbid obesity. Bariatric surgery today, as the only effective therapy for morbid obesity, is expanding exponentially to meet the global epidemic of morbid obesity. Bariatric surgeons in the Asia-Pacific region had founded the Asia-Pacific Bariatric Surgery Group (APBSG) at Seoul, Korea on October 6, 2004.

METHODS

E-mail requests for information were sent to the national bariatric surgery leaders. These requests were followed, if necessary, by second e-mail requests and communications seeking clarification. The summary data was also discussed at the 1st Asia-Pacific Bariatric Consensus Meeting held in Taipei, February 27, 2005.

RESULTS

11 countries or areas in Asia had started bariatric surgery and responded to the general questions. In 2004, 636 bariatric operations were performed by 61 bariatric surgeons. The earliest data for starting bariatric surgery was in 1974 in Taiwan. Following the development of gastric partition, Taiwan performed the first case in 1981, Japan in 1982 and Singapore in 1987. In 2004, 11 countries have started bariatric surgery. The APBSG was founded in 2004. In 2004, 12.1% of operations were open and 87.9% laparoscopic. The 6 most popular operations were: laparoscopic adjustable banding 42.3%; laparoscopic gastric bypass 34.2%; open vertical banded gastroplasty 7.5%; laparoscopic vertical banded gastroplasty 6.3%; laparoscopic sleeve gastrectomy 6.3%; open gastric bypass 4.2%. Pooling open and laparoscopic procedures, relative percentages were gastric banding 42.3%; gastric bypass 38.4%; vertical banded gastroplasty 13.8%. The APBSG consensus meeting recommended bariatric surgery in Asian patients with BMI >37 or >32 with diabetes or two other obesity-related co-morbidities.

CONCLUSIONS

Bariatric surgery is expanding rapidly in Asia to meet rapidly increasing obesity. The modification of the indications for bariatric surgery in the Asian is proposed.

Obesity, weight loss and bariatric surgery

Obesity is shaping up to be the major health care problem and one of the most frequent causes of preventable death in Western countries in the 21st century. Bariatric surgery is the only current treatment that has been shown to achieve major and durable weight loss. Major weight loss in the severely obese leads to total or partial control of a wide range of common and serious diseases, such as diabetes, heart disease and hypertension. Laparoscopic adjustable gastric banding is the most common type of obesity surgery performed in Australia. It is effective, relatively safe and minimally invasive. The blocks to broader application of bariatric surgery should be identified and resolved.

National Variations in Morbid Obesity and Bariatric Surgery Use

BACKGROUND

Exploring bariatric surgery use provides data on effective treatment allocation. This study analyzed national rates of bariatric surgery use and the burden of morbid obesity by gender, census region, and age.

STUDY DESIGN

Patients 18 years of age or older undergoing bariatric surgery were identified from the US 2002 Nationwide Inpatient Sample, and the national morbidly obese population 18 years of age or older was determined using the Centers for Disease Control and Prevention 2002 Behavioral Risk Factor Surveillance System databases. General population data were obtained from 2000 census data. Annual rates of bariatric surgery procedures were determined by gender, age group, and census region (Northeast, Midwest, South, and West). Rate ratios were calculated and significance tested through 95% confidence intervals (95% CI), accounting for the Nationwide Inpatient Sample and Behavioral Risk Factor Surveillance System sampling design.

RESULTS

In 2002, a national cohort of 69,490 bariatric surgery patients was identified. Of these patients 85% were women and 76% were ages 18 to 49 years. The prevalence of morbid obesity (body mass index > or = 40 kg/m(2)) in the US in 2002 was 1.8%; 60% of morbidly obese people were women, and 63% were ages 18 to 49 years. The rates of bariatric surgery procedures per 100,000 morbidly obese individuals ranged from a low of 139 in men aged 60 years and older in the Midwest to a high of 5,156 in women ages 40 to 49 years in the Northeast. For both men and women, bariatric surgery rates in the West and Northeast were 1.35 (95% CI 1.31 to 1.40, p < 0.05) to 4.51 (95% CI 4.15 to 4.89, p < 0.05) times higher than in the South, respectively; rates in the Midwest were similar to those in the South.

CONCLUSIONS

National estimates suggest that bariatric surgery rates do not parallel the burden of morbid obesity by region or age. Additional evaluation of these differences is necessary for optimal bariatric surgery use.

Binge eating among African American and Caucasian bariatric surgery candidates

Bariatric surgery is an increasingly utilized treatment for severe obesity, especially among women. Although African American women have high rates of severe obesity, most research investigating psychological correlates of obesity has been conducted with Caucasians. This study examined the characteristics of African American women seeking bariatric surgery, and ethnic differences in BED rates and correlates of binge eating. Finally, we examined whether the association between psychological factors associated with binge eating was moderated by ethnicity. Results indicated that African American women had higher BMIs, higher self esteem, and less depression than Caucasians. There were no differences in rates of binge eating or BED. Both depression and self esteem accounted for unique variance in binge eating; however, these relationships were not moderated by ethnicity. These results further highlight African Americans' vulnerability to EDs, and suggest that depression and low self esteem are equally relevant to binge eating in African American and Caucasian women.

National Analysis of Adverse Patient Safety Events in Bariatric Surgery

Identifying risk factors for adverse events after bariatric surgery (BaS) can help define high-risk groups to improve patient safety. We calculated cumulative incidence of adverse events and identified risk factors for these events using validated surgical patient safety indicators (PSIs) developed by the Agency for Healthcare Research and Quality. BaS patients ≥18 years old were identified using the 2002 Nationwide Inpatient Sample. Cumulative incidence at discharge was calculated for accidental puncture or laceration (APL), pulmonary embolus or deep venous thrombosis (PE/DVT), and postoperative respiratory failure (RF). Factors predictive of these PSIs were identified. From 7,853,982 discharges, a national cohort of 69,490 BaS patients was identified. During BaS hospitalization, the cumulative incidences per 1000 discharges of APL, PE/DVT, and RF were 12.6, 3.4, and 7.3, respectively. Risk factors for APL included male gender (odds ratio [OR] 1.6, 95% confidence interval 1.1–2.3, P < 0.05) and age of 40–49 years (OR 1.6 [1.1–2.3], P < 0.05) compared to ages 18–39 years. Patients aged 50–59 years (OR 3.5 [1.6–7.7], P < 0.05) had a higher chance of PE/DVT compared to those 18–39 years. Male gender (OR 1.8 [1.1–2.9], P < 0.05), ages 40–49 (OR 2.1 [1.1–4.2], P < 0.05) and 50–59 (OR 3.8 [2.1–6.9], P < 0.05), a history of chronic lung disease (OR 1.7 [1.1–2.7], P < 0.05), and Medicare coverage compared to private insurance (OR 2.2 [1.2–3.8], P < 0.05) were predictive of RF. This study established national measures for BaS adverse events. Further, risk factors associated with adverse events varied by gender, age, insurance status, and comorbidity. Evaluation of these higher risk BaS groups is needed to improve patient safety.

Bariatric and Associated Operations in Private and Academic Practices

BACKGROUND

The types of bariatric and the associated operations performed by academic and private surgeons were surveyed.

METHODS

A survey containing 8 questions regarding type of practice, type of surgery, associated procedures during bariatric surgery, years in practice and bariatric training was e-mailed to all members of the American Society for Bariatric Surgery.

RESULTS

46% of the members responded and were divided between those who performed their procedures laparoscopically and those who performed open procedures. Laparoscopic adjustable gastric banding was almost exclusively performed in academic centers and encompassed 20% of their bariatric operations, while the gastric bypass was the most common operation performed (65%), followed by vertical banded gastroplasty and duodenal switch. Operations performed simultaneously indicated that cholecystectomies were performed equally in private practice (92.5%) and the academic sector (95%), with higher incidence in open procedures (95%) compared to laparoscopic (40%). Of the surgeons performing appendectomies, 20% were in private practice and 10% in academic. Liver biopsy was performed with the same incidence in private and academic practices (60%). A minority of responders had formal fellowship training (17%), and many had learned from a partner (40%). The approach was dictated by the surgical training (85%) and background.

CONCLUSION

No significant difference was found between the private and academic surgeons in performing operations. Appendectomy is rarely performed academically, and cholecystectomy is mostly performed in the open procedure.

Bariatric surgery: review of common procedures and mortality analysis

Obesity is a growing epidemic, and its burden on the health care system and its impact on mortality are well known. Bariatric surgery is increasingly used worldwide to treat morbid obesity, generally defined as body mass index > or = 40 kg/m2. Common bariatric surgical procedures are described and mortality analyses of two recent clinical studies are presented.