Impact of Patient Attrition from Bariatric Surgery Practice on Clinical Outcomes.

BACKGROUND: Obesity has become a global epidemic. Bariatric surgery remains the most successful modality for producing sustained weight loss. Attrition rates after bariatric surgery are currently reported between 3 and 63% depending on the type of bariatric operation and the length of follow-up provided by the bariatric surgery team. It is currently unknown if patient attrition from bariatric surgery programs impact clinical outcomes. The availability of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) and the Mayo Clinic Midwest unified electronic medical record (EMR) provide a unique opportunity to explore this topic. METHODS: Raw data was downloaded from MBSAQIP database for all laparoscopic Roux-en-Y gastric bypass (LRYGB) cases between May 1, 2008 and January 8, 2015 (N = 1242). Baseline weight and preexisting comorbidities (type 2 diabetes, hypertension, and hyperlipidemia) were recorded using the MBSAQIP database and the EMR. Current weight and comorbidity data (type 2 diabetes, hypertension, and hyperlipidemia) were subsequently collected at the time closest to the patient's surgical anniversary dates during the following assessment periods: years 1, 2, and 3 after surgery. Mean percentage total weight loss (TWL) was calculated at each time frame for each patient. Data was summarized using descriptive statistics, including counts and percentages for categorical variables by either year or year and location. RESULTS: The number of patients seen by the bariatric surgery practice (BSP) compared to those seen by other providers within our practice (attrition to bariatric surgery practice (ABSP)) was highest in year 1 and reduced each subsequent year (year 1: BSP N = 740, ABSP N = 166, year 2: BSP N = 425, ABSP N = 309, and year 3: BSP N = 235, ABSP N = 325). The mean TWL in the BSP and ABSP groups at year 1 was 31.84% versus 30.19%, at year 2 was 31.34% versus 29.67%, and at year 3 was 29.01% versus 27.71% respectively. Differences were statistically significant between groups at years 1 and 2 (p < 0.05). A statistically significant difference was not found in year 3 despite a trend towards higher TWL in the BSP group. Among all patients, statistically significant differences (p < 0.0001) were observed between baseline and years 1, 2, and 3 for type 2 diabetes, hypertension, and hyperlipidemia. CONCLUSIONS: Our study confirms the problem of patient attrition to follow up at our BSP. It is also the first to suggest a difference in weight loss outcomes among patients seen in BSP compared to those seen by other providers (ABSP) at 1 and 2 years after Roux-en-Y gastric bypass (LRYGB). The potential implications of this observation on long-term weight maintenance after LRYGB and the impact on metabolic comorbidities remain unknown but warrant further investigation. It also warrants the development of strategies to improve patient retention in BSP and/or engagement of medical providers to achieve that end.

Adolescent bariatric surgery program characteristics: the Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study experience.

The number of adolescents undergoing weight loss surgery (WLS) has increased in response to the increasing prevalence of severe childhood obesity. Adolescents undergoing WLS require unique support, which may differ from adult programs. The aim of this study was to describe institutional and programmatic characteristics of centers participating in Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS), a prospective study investigating safety and efficacy of adolescent WLS. Data were obtained from the Teen-LABS database, and site survey completed by Teen-LABS investigators. The survey queried (1) institutional characteristics, (2) multidisciplinary team composition, (3) clinical program characteristics, and (4) clinical research infrastructure. All centers had extensive multidisciplinary involvement in the assessment, pre-operative education, and post-operative management of adolescents undergoing WLS. Eligibility criteria and pre-operative clinical and diagnostic evaluations were similar between programs. All programs have well-developed clinical research infrastructure, use adolescent-specific educational resources, and maintain specialty equipment, including high weight capacity diagnostic imaging equipment. The composition of clinical team and institutional resources is consistent with current clinical practice guidelines. These characteristics, coupled with dedicated research staff, have facilitated enrollment of 242 participants into Teen-LABS.

Bariatric-related medical malpractice experience: survey results among ASMBS members.

BACKGROUND: The medicolegal aspects of bariatric surgery are very difficult to analyze scientifically because there is no central, searchable database of closed case claims and little incentive for malpractice insurers to divulge data. Examining medicolegal data may provide insight into the financial and psychological burden on physicians. Detailed data also may be used to improve patient safety and determine common causes of negligence. METHODS: All U.S.-based members of the American Society of Metabolic and Bariatric Surgeons were asked to complete a survey regarding their bariatric-related medical malpractice experience. RESULTS: Of the 1672 eligible members that received the survey, 330 responded (19.7%). Mean years in practice was 15.3 ± 9. Mean annual cost of malpractice insurance was $59,200 ± $52,000 (N = 197). The respondent surgeons experienced 1.5 ± 3.2 lawsuits on average over the course of their practice. Of the 330 respondents, 144 (48%) did not report a bariatric-related lawsuit filed against them. Of the 464 lawsuits reported by 156 surgeons, 126 were settled out of court (27%), 249 were dropped (54%), and 54 (18%) went to trial. Seventy-two percent of cases that went to trial were found to be in favor of the defense. The mean lifetime amount paid for suits was $250,000±$660,000. The probability of a bariatric surgeon experiencing a lawsuit was independently associated with the years in practice (P = .03) and number of total cases the surgeon has performed (P = .01). The annual cost of malpractice insurance was independently predicted by the amount paid in previous claims (P = .01). CONCLUSIONS: The probability of a medical malpractice lawsuit correlates positively to the number of procedures performed and the number of years the surgeon has been in practice.

Importance of hospital versus surgeon volume in predicting outcomes for gastric bypass procedures.

BACKGROUND: A relationship between surgical volume and improved surgical outcomes has been described in gastric bypass patients but the relative importance of surgeon versus hospital volume is unknown. Our objective was to examine whether in-hospital and 30-day mortality are determined more by surgeon volume or hospital volume or whether each has an independent effect. A retrospective cohort study was performed of all hospitals in Pennsylvania providing gastric bypass surgery from 1999 to 2003. METHODS: Data from the Pennsylvania Health Care Cost Containment Council included 14,714 gastric bypass procedures in patients aged >18 years. In-hospital and 30-day mortality were stratified by hospital volume categories (high [≥300], medium [125-299], and low [<125]) and surgeon volume categories (high [≥50] and low [<50]). Multivariate analyses were performed using logistic regression analysis to control for patient demographics and severity. RESULTS: High-volume surgeons at high-volume hospitals had the lowest in-hospital mortality rates of all categories (.12%) and low-volume surgeons at low-volume hospitals had the poorest outcomes (.57%). The same trend was observed for 30-day mortality (.30% versus .98%). After controlling for other covariates, high-volume surgeons at high-volume hospitals also had significantly lower odds of both in-hospital (odds ratio 20, P = .002) and 30-day mortality (odds ratio .30, P = .001). This relationship held true even after excluding surgeons who only performed procedures within a single year. CONCLUSION: In Pennsylvania, both higher surgeon and hospital volume were associated with better outcomes for bariatric surgical procedures. Although a high-surgeon volume correlated with lowered mortality, we also found that high-volume hospitals demonstrated improved outcomes, highlighting the importance of factors other than surgical expertise in determining the outcomes.

Estudio descriptivo de la mejora de la calidad percibida en los pacientes sometidos a cirugía bariátrica tras la implantación de una vía clínica / Descriptive study on the improvement of quality perceived after the introduction of a clinical pathway by patients subjected to bariatric surgery

Objetivo. Evaluar el grado de satisfacción de los pacientes incluidos en una vía clínica de cirugía laparoscópica de la obesidad y analizar los factores relacionados con la satisfacción. Material y métodos. A una cohorte consecutiva de pacientes se les invitó a cumplimentar, de forma anónima y voluntaria, la encuesta SERVQHOS el penúltimo día de su alta hospitalaria. Resultados. De un total de 103 pacientes (53 mujeres), 71 (70%) respondieron la encuesta. Un 97,3% respondió «como se esperaba» o «por encima de las expectativas» a las cuestiones planteadas. El 98,6% se mostró «muy satisfecho» o «satisfecho» con la atención recibida y el 97,2% recomendaría el hospital a otras personas. Las cuestiones mejor relacionadas con la satisfacción global fueron la tecnología empleada (p=0,008), la apariencia del personal (p=0,019), el interés del personal sanitario por cumplir lo que promete (p=0,002) y para solucionar los problemas del enfermo (p=0,021), la información prestada por el equipo médico (p=0,039) y el tiempo de espera para ser atendido por el médico (p=0,002). En el estudio multivariante, la única variable con capacidad predictiva, en relación con la satisfacción global, fue el trato personalizado (r=0,52). La mediana de estancia hospitalaria fue de 3 días, y el 76% de los encuestados la consideró suficiente. El porcentaje de máxima satisfacción fue significativamente inferior en las mujeres, los solteros, aquellos sin ocupación profesional y con estudios universitarios. Conclusiones. Los pacientes obesos mórbidos incluidos en una vía clínica de cirugía bariátrica tienen una buena percepción de la asistencia sanitaria recibida(AU)

Objectives. To evaluate the level of perceived satisfaction in patients undergoing bariatric procedures after implementing a clinical pathway, and to analyse factors related to a high degree of satisfaction. Material and methods. A cohort of patients was invited to fulfil, anonymously and voluntarily, a SERVQHOS survey the day before hospital discharge. Results. Seventy-one (53 female) out of 103 patients (70%) responded to the questionnaire. A total of 97.3% of patients who completed the survey answered to the questions "as expected" or "above expectations". Most (98.6%) of the patients were "very satisfied" or "satisfied" with the care received, and 97.2% would recommend the hospital to others. Questions better related to overall satisfaction were technology used (P=.008), staff appearance (P=.019), the interest of staff to fulfil a promise (P=.002), and to solve the problems of the patient (P=.021), information provided by the medical staff (P=.039) and waiting time until being seen by the doctor (P=.002). In the multivariate study, only the "personalized care" achieved the category of a predictive variable (r=0.52). Median hospital stay was 3 days, and 76% of patients considered it adequate. The percentage of highest satisfaction was significantly lower in female, singles, unemployed, and those with academic studies. Conclusions. Morbid obese patients included in a clinical pathway of bariatric surgery had a good perception with the care received(AU)

[Evaluation of obesity treatment in children and adolescents (EvAKuJ Study). Role of therapeutic concept, certification, and quality indicators]. / Evaluation von Therapieangeboten für adipöse Kinder und Jugendliche (EvAKuJ-Projekt). Welche Rolle spielen Behandlungskonzept, AGA-Zertifizierung und initiale Qualitätsangaben?

AIM: Different providers of obesity treatment in children and adolescents in Germany were compared using the following criteria: outpatient/inpatient; with/without AGA certification; good/less good quality. METHODS: A total of 1,916 patients (8-16.9 years) from 48 study centers were examined before (t0), after (t1), and at least 1 year after therapy (t2/3). Body mass index (BMI), blood pressure, blood lipids, and psychosocial data were measured. RESULTS: Patients from inpatient rehabilitation centers were older and more obese. Patients from AGA-certified centers were more obese, and the completeness of comorbidity screening was higher. There were no differences in short- or long-term BMI reduction. "Good" treatment centers (classified after the UKE study 2004) did not differ from those centers not rated as "good" in weight reduction. Patients treated in "good" centers were more obese, and screening for comorbidity was better. No differences in drop out and loss to follow-up were found. CONCLUSION: There were only small differences between the different groups. Pronounced differences were found between the individual treatment centers. In order to improve therapy processes and outcomes, benchmarking and quality management have to be extended.

Clinical experience using appetite suppressants and SSRIs.

The use of sympathomimetic appetite suppressants and serotonin-selective reuptake inhibitors (SSRIs) has been questioned due to anecdotal reports of serotonin syndrome. This survey of bariatric physicians using these medications in clinical practice did not find any cases of serotonin syndrome among 1174 patients. The monitored use of the combination of these medicines by trained practitioners is justifiable.