Combined group and individual model for postbariatric surgery follow-up care.

BACKGROUND: The prevalence of bariatric surgery in the United States has increased significantly during the past decade, increasing the number of patients requiring postbariatric surgery follow-up care. Our objective was to develop and implement an efficient, financially viable, postbariatric surgery practice model that would be acceptable to patients. The setting was the Mayo Clinic (Rochester, MN). METHODS: By monitoring the attendance rates and using patient surveys, we tested patient acceptance of a new, shared medical appointment practice model in the care of postbariatric surgery patients. Efficiency was assessed by comparing differences in time per patient and total provider time required between the former and new care models. Individual-only patient/provider visits were replaced by combined group and individual visits (CGV). RESULTS: Our CGV model was well-attended and accepted. The patient attendance rate was >90% at all postoperative follow-up points. Furthermore, 83%, 85.2%, and 75.7% of the 3-, 6-, and 12-month postbariatric surgery patients, respectively, responded that they would not prefer to have only individual visits with their healthcare providers. The CGV model also resulted in greater time efficiency and cost reduction. On average, 5 patients were seen within 4.9 provider hours compared with 10.4 provider hours with the individual-only patient/provider visit model. Furthermore, the average billable charge for the CGV model's group medical nutrition therapy was 50-64% less than the equivalent individual medical nutrition therapy used in the individual-only patient/provider visit model. CONCLUSION: Shared medical appointments have a valuable role in the care of the postbariatric surgery population, offering a time- and cost-effective model for healthcare provision that is well-accepted by patients.

Outcomes, health status, and medical resource utilization after bariatric surgery.

Surgical results, economic consequences, and shortterm health of obese patients were evaluated before and after bariatric surgery. Of 35 patients in Mayo Health Plan Arizona eligible for bariatric surgery and scheduled for gastric restriction with Roux-en-Y gastrojejunostomy, 22 (7 men, 15 women) completed pre- and postoperative (6- and 12-mo) short form (SF)-12 Health Surveys. Nineteen patients had open bariatric procedures and 3 had laparoscopic procedures. Comorbid conditions, hospital course, weight loss, and complications were examined. Health care utilization (actual dollars paid by plan) for the preceding year and at 1- and 2-yr follow-up were compared. Major comorbid conditions included diabetes mellitus or impaired fasting glucose, hyperlipidemia, sleep apnea, and hypertension. Mean length of hospital stay was 4.8 d after open procedures and 2 d after laparoscopic procedures. No serious operative or postoperative complications occurred. From a baseline average body mass index (BMI) of 51.9, the 6- and 12-mo BMI averages were 39.6 (23.7% decrease) and 35.3 (32% decrease), respectively. Both physical and mental status improved. From baseline, physical health changed 18 and 21.2 points at 6 and 12 mo, respectively (p < 0.001), and mental health changed 9.3 points at each interval (p =0.003). Each postoperative year, resource utilization decreased (mean= $1300 per patient). Our findings of good surgical outcomes, significant weight loss, improved health status, and potential financial savings in this small sample may help patients, insurers, and self-funded employer groups evaluate the appropriateness of bariatric procedures.

Is Roux-en-Y gastric bypass safe after previous antireflux surgery? Technical feasibility and postoperative symptom assessment.

BACKGROUND: Clinically significant morbid obesity is associated with an increased risk of gastroesophageal reflux disease. Vertical Roux-en-Y gastric bypass (RYGBP) is known to eliminate acid (and bile) in the pouch of cardia, which would provide control of reflux symptoms. The aim of our study was to assess the technical considerations, morbidity, and safety of RYGBP after previous antireflux surgery and evaluate postoperative reflux symptoms. METHODS: Retrospective review of all patients undergoing RYGBP after previous antireflux surgery from three institutions. Follow-up (mean 18 months) data were obtained from medical records and by questionnaire. RESULTS: A total of 19 patients (18 women and 1 man) underwent standard (n = 18) or distal (n = 1) RYGBP 8 +/- 1 years after Nissen (n = 18) or Toupet (n = 1) fundoplication. Open RYGBP was undertaken in 17 of 19 patients. No postoperative deaths occurred. Substantive complications occurred in 4 patients (21%) and included hemorrhage requiring transfusion, concomitant splenectomy, and reoperation for suspected leak in 2. Of the 19 patients, 16 returned the questionnaire, 15 of whom reported subjective improvement in reflux symptoms after RYGBP compared with after antireflux surgery. No patient in this series required medical therapy for reflux symptoms at the last follow-up visit. The body mass index decreased from 42 +/- 2 kg/m(2) to 32 +/- 2 kg/m(2) (mean +/- SEM); all patients with >or=1 year of follow-up had a body mass index of