Beyond race: social vulnerability and access to metabolic and bariatric surgery.

BACKGROUND: Metabolic and bariatric surgery (MBS) is under-accessed by non-White patients, who are disproportionately affected by obesity. We hypothesized that unique barriers experienced by socially vulnerable patients drive disparate MBS utilization. OBJECTIVES: To determine whether socially vulnerable patients experience greater attrition and face more insurance-mandated medical weight management (MWM) requirements. SETTING: Urban, academic center. METHODS: This retrospective cohort study included adults evaluated for MBS in 2018. Social vulnerability was determined using the 2018 Social Vulnerability Index. Outcomes included attrition, or failure to undergo surgery within 1year, and the number and duration of MWM requirements. Multivariable logistic regression and negative binomial regression tested these associations. RESULTS: In 2018, 339 patients were evaluated for MBS (83% female, 70% Black). The attrition rate was 57%. On adjusted analyses, patients in the highest social vulnerability quartile had double the odds of attrition compared to their least vulnerable counterparts (OR 2.33, 95% CI 1.11-4.92, P = .03). Highly vulnerable patients had double the number (IRR 2.29, 95% CI 1.42-3.72, P = .001) and nearly quadruple the duration (IRR 3.90, 95% CI 1.93-7.86, P < .001) of MWM requirements compared to those with low social vulnerability. Odds of attrition increased by 11% and 20% for each additional MWM visit (OR 1.11, 95% CI 1.02-1.20, P = .02) and month (OR 1.20, 95% CI 1.08-1.33, P = .001), respectively. CONCLUSIONS: Patients with high social vulnerability were less likely to undergo MBS and faced more insurance-mandated preoperative requirements, which independently predicted attrition. Insurance-mandated MWM is inequitable and may contribute to disparate care of patients with severe obesity.

Supervised weight loss requirements disproportionately affect Black patients seeking weight loss surgery.

BACKGROUND: We use our high-volume institutional experience with a majority Black population to examine the role of supervised weight loss (SWL) requirements perpetuating disparities in bariatric surgery. OBJECTIVE: To determine if there are racial disparities in the required amount of supervised weight loss prior to approval for bariatric surgery. SETTING: University hospital. METHODS: A retrospective review was conducted of all patients seen at our institution's bariatric surgery clinic in 2018. Odds of undergoing surgery within 1 year and mean number of SWL requirements were determined using descriptive statistics for Black patients as compared with non-Hispanic White patients. Finally, a logistic model was constructed to examine likelihood of undergoing an operation within 1 year for patients of varying SWL requirements. RESULTS: A total of 335 patients were included (75% Black, 25% White). Within 1 year, 37% of Black patients compared with 53% of White patients had undergone an operation (relative risk .7, P = .01). Mean insurance-mandated SWL sessions were significantly higher for Black patients (3.6 ± 2.8) versus non-Hispanic White patients (2.2 ± 2.7) (P < .01). Mean program-mandated SWL sessions were also significantly higher for Black patients (2.5 ± 2.6) versus non-Hispanic White patients (.8 ± 1.8) (P < .01). Increasing SWL requirements significantly reduced the odds of undergoing surgery at 1 year within the entire cohort (odds ratio .86, P < .01). CONCLUSIONS: Black patients are disproportionally affected by SWL requirements, which strongly correlate with decreased likelihood of undergoing a bariatric operation as compared with their White counterparts. Even after overcoming barriers to see a bariatric surgery provider, Black patients still face disproportionally more barriers to surgery. Bariatric centers must be sensitive to the effect of SWL requirements, as it is negatively associated with the likelihood of a patient receiving a bariatric operation.

Value of Ambulatory Modified Radical Mastectomy.

BACKGROUND: Modified radical mastectomy (MRM) still is largely performed in inpatient settings. This study sought to determine the value (expenditures and complications) of ambulatory MRM. METHODS: Health Care Utilization Project (HCUP) state databases from 2016 were queried for patients who underwent MRM. The study examined rates of 30-day readmission for surgical-site infection (SSI) or hematoma, charges by index care setting, and predictors of 30-day readmission. RESULTS: Overall, 8090 patients underwent MRM: 5113 (63 %) inpatient and 2977 (37 %) ambulatory patients. Compared with the patients who underwent inpatient MRM, those who underwent ambulatory MRM were older (61 vs. 59 years), more often white (66 % vs. 57 %), in the lowest income quartile (28 % vs. 21 %), insured by Medicare (43 % vs. 33 %) and residents in a small metro area (6 % vs. 4 %) (all p < 0.01). Of the 5113 patients treated as inpatients, 126 (2.5 %) were readmitted, whereas 50 (1.7 %) of the ambulatory patients were readmitted (p = 0.02). The adjusted charge for inpatient MRM without readmission was $113,878 (range, $107,355-120,402) compared with $94,463 (range, $86,021-102,907) for ambulatory MRM, and the charge for inpatient MRM requiring readmission was $159,355 (range, $147,142-171,568) compared with $139,940 (range, $125,808-154,073) for ambulatory MRM (all p < 0.01). This difference remained significant after adjustment for hospital length of stay. Adjusted logistic regression showed that the ambulatory setting was protective for readmission (odds ratio, 0.49; 95 % confidence interval, 0.35-0.70; p < 0.01). CONCLUSIONS: The analyses suggest that ambulatory MRM is both safe and less expensive. The findings advocate that MRM, a last holdout of inpatient care within breast surgical oncology, can be transitioned to the ambulatory setting for appropriate patients.

Longitudinal Trends in 30-Day Mortality Between Multi-Site and Single-Site Surgeons.

BACKGROUND: Quality leaders are concerned that creation of multi-hospital health systems may lead to surgeons traveling to and from distant hospitals and thus to more fragmented surgical care and worse outcomes for their patients. Despite this concern, little empirical data exist on outcomes of multi-site versus single-site surgeons. METHODS: Using national Medicare data, we assessed trends in the number of multi-site vs. single-site surgeons from 2011 to 2016. We performed a multivariable regression analysis to compare overall 30-day mortality differences, stratified by system and rural status, and examined trends over time. RESULTS: The number of multi-site surgeons and the percentage of multi-site surgeons per hospital decreased over time (24.2%-19.0%; 44.3%-41.8%). Overall, multi-site surgeons had lower 30-day mortality than single-site surgeons (2.24% vs 2.50%, P < 0.01). When stratified by system status, multi-site surgeons performed better in-system (2.47% vs 2.58%, P < 0.01); by rural status, multi-site surgeons had lower mortality in non-rural hospitals (2.42% vs 2.51%, P < 0.01). The statistically significant but small mortality advantage of multi-site versus single-site surgeons decreased over time, such that by 2016 there was no difference in outcomes between multi-site and single-site surgeons. CONCLUSION: For the majority of study years, multi-site surgeons had lower 30-day mortality than single-site surgeons, but this trend narrowed until outcomes were equivalent by 2016. Surgeons operating at multiple hospitals can provide surgical care to patients without any evidence of increased mortality.

Toward Autonomy and Conditional Independence: A Standardized Script Improves Patient Acceptance of Surgical Trainee Roles.

BACKGROUND: Progressive autonomy leading to conditional independence is necessary to achieve competence in surgical skills and decision making. Trust and transparency are ethical imperatives, but practices vary regarding the extent of disclosure of specific resident roles. We tested whether a standardized preoperative script would improve patient acceptance of resident involvement in perioperative care. METHODS: Patients admitted to a resident-run acute care general surgery service between October 2017 and October 2018 were enrolled in an IRB-approved study. During the first half of the rotation (control), operative consent was obtained according to individual practice without specified explanation of resident roles. During the second half (intervention), the senior resident read a short semistructured script specifically explaining team roles and responsibilities, including the degree of resident independence and supervision by attendings. On postoperative day 3, patients completed a survey assessing understanding of their surgical care. RESULTS: Sixty-two patients under the care of 10 rotating chief residents were enrolled; 46 patients completed the survey, 23 in each arm (74% response rate). Ten patients in the control arm (43%) compared to only 3 (13%) in the intervention arm indicated that residents should not be allowed to perform portions of operations (odds ratio 4.94, p = 0.047). Patients in the intervention arm felt that care team roles were more adequately explained to them before their operation (p = 0.002). There was no difference in the number of patients naming a resident as "their doctor." CONCLUSIONS: Use of a short script specifying resident roles improves patient acceptance of trainee participation in perioperative care.