Financial Incentives to Improve Patient Follow-up and Weight Loss After Bariatric Surgery.

OBJECTIVE: To examine effects of a financial incentives program on follow-up and weight loss after bariatric surgery. SUMMARY BACKGROUND DATA: Consistent follow-up may improve weight loss and other health outcomes after bariatric surgery. Yet, rates of follow-up after surgery are often low. METHODS: Patients from 3 practices within a statewide collaborative were invited to participate in a 6-month financial incentives program. Participants received incentives for attending postoperative appointments at 1, 3, and 6 months which doubled when participants weighed less than their prior visit. Participants were matched with contemporary patients from control practices by demographics, starting body mass index and weight, surgery date, and procedure. Preintervention estimates used matched historic patients from the same program and control practices with the criteria listed above. Patients between the 2 historic groups were additionally matched on surgery date to ensure balance on matched variables. We conducted differ-ence-in-differences analyses to examine incentives program effects. Follow-up attendance and percent excess weight loss were measured postoperative months 1, 3, 6, and 12. RESULTS: One hundred ten program participants from January 1, 2018 to July 31, 2019 were matched to 203 historic program practice patients (November 20 to December 27, 2017). The control group had 273 preinter-vention patients and 327 postintervention patients. In difference-in-differ-ences analyses, the intervention increased follow-up rates at 1 month (+14.8%, P <0.0001), 3months (+29.4%, P <0.0001), and 6 months (+16.4%, P <0.0001), but not at 12 months. There were no statistically significant differences in excess weight loss. CONCLUSIONS: A financial incentives program significantly increased follow-up after bariatric surgery for up to 6 months, but did not increase weight loss. Our study supports use of incentivized approaches as one way to improve postoperative follow-up, but may not translate into greater weight loss without additional supports.

Out-of-pocket Costs for Commercially-insured Patients in the Years Following Bariatric Surgery: Sleeve Gastrectomy Versus Roux-en-Y Gastric Bypass.

OBJECTIVE: To compare out-of-pocket (OOP) costs for patients up to 3 years after bariatric surgery in a large, commercially-insured population. SUMMARY OF BACKGROUND DATA: More information on OOP costs following bariatric surgery may affect patients' procedure choice. METHODS: Retrospective study using the IBM MarketScan commercial claims database, representing patients nationally who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) January 1, 2011 to December 31, 2017. We compared total OOP costs after the surgical episode between the 2 procedures using difference-in-differences analysis adjusting for demographics, comorbidities, operative year, and insurance type. RESULTS: Of 63,674 patients, 64% underwent SG and 36% underwent RYGB. Adjusted OOP costs after SG were $1083, $1236, and $1266 postoperative years 1, 2, and 3. For RYGB, adjusted OOP costs were $1228, $1377, and $1369. In our primary analysis, SG OOP costs were $122 (95% confidence interval [CI]: -$155 to -$90) less than RYGB year 1. This difference remained consistent at -$119 (95%CI: -$158 to -$79) year 2 and -$80 (95%CI: -$127 to -$35) year 3. These amounts were equivalent to relative differences of -7%, -7%, and -5% years 1, 2, and 3. Plan features contributing the most to differences were co-insurance years 1, 2, and 3.The largest clinical contributors to differences were endoscopy and outpatient care year 1, outpatient care year 2, and emergency department use year 3. CONCLUSIONS: Our study is the first to examine the association between bariatric surgery procedure and OOP costs. Differences between procedures were approximately $100 per year which may be an important factor for some patients deciding whether to pursue SG or gastric bypass.

Births After Bariatric Surgery in the United States: Incidence, Obstetric Outcomes, and Reinterventions.

OBJECTIVE: To characterize incidence and outcomes for bariatric surgery patients who give birth. BACKGROUND: Patients of childbearing age comprise 65% of bariatric surgery patients in the United States, yet data on how often patients conceive and obstetric outcomes are limited. METHODS: Using the IBM MarketScan database, we performed a retrospective cohort study of female patients ages 18 to 52 undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass from 2011 to 2017. We determined the incidence of births in the first 2 years after bariatric surgery using Kaplan-Meier estimates. We then restricted the cohort to those with a full 2-year follow-up to examine obstetric outcomes and bariatric-related reinterventions. We reported event rates of adverse obstetric outcomes and delivery type. Adverse obstetric outcomes include pregnancy complications, severe maternal morbidity, and delivery complications. We performed multivariable logistic regression to examine associations between birth and risk of reinterventions. RESULTS: Of 69,503 patients who underwent bariatric surgery, 1464 gave birth. The incidence rate was 2.5 births per 100 patients in the 2 years after surgery. Overall, 85% of births occurred within 21 months after surgery. For 38,922 patients with full 2-year follow-up, adverse obstetric event rates were 4.5% for gestational diabetes and 14.2% for hypertensive disorders. In all, 48.5% were first-time cesarean deliveries. Almost all reinterventions during pregnancy were biliary. Multivariable logistic regression analysis showed no association between postbariatric birth and reintervention rate (odds ratio: 0.93, 95% confidence interval: 0.78-1.12). CONCLUSIONS: In this first national US cohort, we find giving birth was common in the first 2 years after bariatric surgery and was not associated with an increased risk of reinterventions. Clinicians should consider shifting the dialogue surrounding pregnancy after surgery to shared decision-making with maternal safety as one component.

A qualitative analysis describing attrition from bariatric surgery to identify strategies for improving retention in patients who desire treatment.

BACKGROUND: Among patients who express interest in bariatric surgery, dropout rates from bariatric surgery programs are reported as high as 60%. There is a lack of understanding how we can better support patients to obtain treatment of this serious chronic disease. METHODS: Semi-structured interviews with individuals who dropped out of bariatric surgery programs from three clinical sites were conducted. Transcripts were iteratively analyzed to understand patterns clustering around codes. We mapped these codes to domains of the Theoretical Domains Framework (TDF) which will serve as the basis of future theory-based interventions. RESULTS: Twenty patients who self-identified as 60% female and 85% as non-Hispanic White were included. The results clustered around codes of "perceptions of bariatric surgery," "reasons for not undergoing surgery," and "factors for re-considering surgery." Major drivers of attrition were burden of pre-operative workup requirements, stigma against bariatric surgery, fear of surgery, and anticipated regret. The number and time for requirements led patients to lose their initial optimism about improving health. Perceptions regarding being seen as weak for choosing bariatric surgery, fear of surgery itself, and possible regret over surgery grew as time passed. These drivers mapped to four TDF domains: environmental context and resources, social role and identity, emotion, and beliefs about consequences, respectively. CONCLUSIONS: This study uses the TDF to identify areas of greatest concern for patients to be used for intervention design. This is the first step in understanding how we best support patients who express interest in bariatric surgery achieve their goals and live healthier lives.

Patient-reported Comorbidity Assessment After Bariatric Surgery: A Potential Tool to Improve Longitudinal Follow-up.

OBJECTIVE: To determine the accuracy of postoperative patient-reported comorbidity assessment, as it may be an important mechanism for long-term follow-up in surgical patients. SUMMARY OF BACKGROUND DATA: Less than 1% of patients who qualify actually undergo bariatric surgery which may be due to concerns surrounding long-term efficacy. Longitudinal follow-up of patients' comorbidities remains a challenge. METHODS: Retrospective, cross-sectional study of bariatric surgery patients from 38 sites within a state-wide collaborative from 2017 to 2018. A minimum of 10 and maximum of 20 responses to a 1-year postoperative questionnaire from each site were randomly sampled. We examined percent agreement between patient-reported and medical chart audit comorbidity assessment and further evaluated agreement by intraclass correlation or κ statistic. Postoperative comorbidities assessed include weight, hyperlipidemia, hypertension, diabetes, depression, obstructive sleep apnea, gastroesophageal reflux disease (GERD), anxiety, and pain. RESULTS: Five hundred eighty-five patients completed postoperative questionnaires after laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass. The response rate was 64% during the study period. Patients reported weight with a mean difference of 2.7 lbs from chart weight (intraclass correlation = 0.964). Agreement between patient report and audit for all comorbidities was above 80% except for GERD (71%). κ statistics were greater than 0.6 (good agreement) for hyperlipidemia, hypertension, diabetes, and depression. Anxiety ( κ = 0.45) and obstructive sleep apnea ( κ = 0.53) had moderate agreement. Concordance for GERD and pain were fair (both κ = 0.38). CONCLUSIONS: Patient-reported comorbidity assessment has high levels of agreement with medical chart audit for many comorbidities and can improve understanding of long-term outcomes. This will better inform patients and providers with hopes of 1 day moving beyond the 1%.

Bariatric Surgery in Medicare Patients: Examining Safety and Healthcare Utilization in the Disabled and Elderly.

OBJECTIVE: To compare safety and healthcare utilization after sleeve gastrectomy versus Roux-en-Y gastric bypass in a national Medicare cohort. SUMMARY BACKGROUND DATA: Though bariatric surgery is increasing among Medicare beneficiaries, no long-term, national studies examining comparative effectiveness between procedures exist. Bariatric outcomes are needed for shared decision-making and coverage policy concerns identified by the cMS Medicare Evidence Development and Coverage Advisory Committee. METHODS: Retrospective instrumental variable analysis of Medicare claims (2012-2017) for 30,105 bariatric surgery patients entitled due to disability or age. We examined clinical safety outcomes (mortality, complications, and reinterventions), healthcare utilization [Emergency Department (ED) visits, rehospitalizations, and expenditures], and heterogeneity of treatment effect. We compared all outcomes between sleeve and bypass for each entitlement group at 30 days, 1 year, and 3 years. RESULTS: Among the disabled (n = 21,595), sleeve was associated with lower 3-year mortality [2.1% vs 3.2%, absolute risk reduction (ARR) 95% confidence interval (CI): -2.2% to -0.03%], complications (22.2% vs 27.7%, ARR 95%CI: -8.5% to -2.6%), reinterventions (20.1% vs 27.7%, ARR 95%CI: -10.7% to -4.6%), ED utilization (71.6% vs 77.1%, ARR 95%CI: -8.5% to -2.4%), and rehospitalizations (47.4% vs 52.3%, ARR 95%Ci: -8.0% to -1.7%). Cumulative expenditures were $46,277 after sleeve and $48,211 after bypass (P = 0.22). Among the elderly (n = 8510), sleeve was associated with lower 3-year complications (20.1% vs 24.7%, ARR 95%CI: -7.6% to -1.7%), reinterventions (14.0% vs 21.9%, ARR 95%CI: -10.7% to -5.2%), ED utilization (51.7% vs 57.2%, ARR 95%CI: -9.1% to -1.9%), and rehospitalizations (41.8% vs 45.8%, ARR 95%Ci: -7.5% to -0.5%). Expenditures were $38,632 after sleeve and $39,270 after bypass (P = 0.60). Procedure treatment effect significantly differed by entitlement for mortality, revision, and paraesophageal hernia repair. CONCLUSIONS: Bariatric surgery is safe, and healthcare utilization benefits of sleeve over bypass are preserved across both Medicare elderly and disabled subpopulations.

Comparative Safety of Sleeve Gastrectomy and Gastric Bypass: An Instrumental Variables Approach.

OBJECTIVE: To compare the safety of sleeve gastrectomy and gastric bypass in a large cohort of commercially insured bariatric surgery patients from the IBM MarketScan claims database, while accounting for measurable and unmeasurable sources of selection bias in who is chosen for each operation. SUMMARY OF BACKGROUND DATA: Sleeve gastrectomy has rapidly become the most common bariatric operation performed in the United States, but its longer-term safety is poorly described, and the risk of worsening gastroesophageal reflux requiring revision may be higher than previously thought. Prior studies comparing sleeve gastrectomy to gastric bypass are limited by low sample size (in randomized trials) and selection bias (in observational studies). METHODS: Instrumental variables analysis of commercially insured patients in the IBM MarketScan claims database from 2011 to 2018. We studied patients undergoing bariatric surgery from 2012 to 2016. We identified re-interventions and complications at 30 days and 2 years from surgery using Comprehensive Procedural Terminology and International Classification of Disease (ICD)-9/10 codes. To overcome unmeasured confounding, we use the prior year's sleeve gastrectomy utilization within each state as an instrumental variable-exploiting variation in the timing of payers' decisions to cover sleeve gastrectomy as a natural experiment. RESULTS: Among 38,153 patients who underwent bariatric surgery between 2012 and 2016, the share of sleeve gastrectomy rose from 52.6% (2012) to 75% (2016). At 2 years from surgery, patients undergoing sleeve gastrectomy had fewer re-interventions (sleeve 9.9%, bypass 15.6%, P < 0.001) and complications (sleeve 6.6%, bypass 9.6%, P = 0.001), and lower overall healthcare spending ($47,891 vs $55,213, P = 0.003), than patients undergoing gastric bypass. However, at the 2-year mark, revisions were slightly more common in sleeve gastrectomy than in gastric bypass (sleeve 0.6%, bypass 0.4%, P = 0.009). CONCLUSIONS AND RELEVANCE: In a large cohort of commercially insured patients, sleeve gastrectomy had a superior safety profile to gastric bypass up to 2 years from surgery, even when accounting for selection bias. However, the higher risk of revisions in sleeve gastrectomy merits further exploration.

Female Patient Perceptions on Financial Incentives to Promote Follow-Up After Bariatric Surgery.

INTRODUCTION: Financial incentives to promote recommended behaviors have been applied in many healthcare settings, but to our knowledge, have never been tested as a strategy to improve patient follow-up after bariatric surgery. Given that females make up majority of bariatric surgery patients, our goal was to explore female patient perceptions on the effects of a financial incentive program designed to increase follow-up after bariatric surgery. METHODS: This was an exploratory qualitative study of patient participants in a pilot program investigating financial incentives. We performed qualitative interviews with female patients to include personal experiences with bariatric surgery, progress toward goals, and concerns related to post-surgical behaviors. The data was analyzed iteratively through inductive thematic analysis. RESULTS: Twenty-one female patients who had undergone bariatric surgery and enrolled in the financial incentive program participated in this study. Participants had generally positive impressions of the financial incentive program. Participants described the utility of the program in helping to pay for expenses associated with bariatric surgery; feeling that participation was their way of demonstrating that they were compliant with post-surgical recommendations; and that it provided additional motivation. All patients stated that even without the financial incentive they would have continued to follow-up. CONCLUSIONS: While financial incentives can provide additional motivation for patients following bariatric surgery, they are not the primary reason that patients choose to follow-up. Understanding the motivation of patients who choose to follow-up (or not) may better inform investigations intended to improve follow-up rates after bariatric surgery.

Variation in pre-operative insurance requirements for bariatric surgery.

BACKGROUND: For patients who wish to undergo bariatric surgery, variation in pre-operative insurance requirements may represent inequity across insurance plan types. We conducted a cross-sectional assessment of the variation in pre-operative insurance requirements. METHODS: Original insurance policy documents for pre-operative requirements were obtained from bariatric surgery programs across the entire USA and online insurance portals. Insurance programs analyzed include commercial, Medicaid, and Medicare/TriCare plans. Poisson regression adjusting for U.S. Census region was used to evaluate variation in pre-operative requirements. Analyses were done at the insurance plan level. Our primary outcome was number of requirements required by each plan by insurance type. Our secondary outcome was number of months required to participate in medically supervised weight loss (MSWL). RESULTS: Among 43 insurance plans reviewed, representing commercial (60.5%), Medicaid (25.6%), and Medicare/TriCare (14.0%) plans, the number of pre-operative requirements ranged from 1 to 8. Adjusted Poisson regression showed significant variation in pre-operative requirements across plan types with Medicaid-insured patients required to fulfill the greatest number (4.1, 95%CI 2.7 to 5.4) compared to 2.7 (95%CI 2.2 to 3.2, P = 0.028) for commercially insured patients and 2.1 (95%CI 1.1 to 3.1, P = 0.047) for Medicare/TriCare-insured patients. Medicaid-insured patients were also required to complete a greater number of months in MSWL (6.6, 95%CI 5.5 to 7.6) compared to commercially (3.8, 95%CI 2.9 to 4.8, P < .001) and Medicare/TriCare-insured patients (1.7, 95%CI 0.3 to 3.0, P = .001). CONCLUSION: The greater frequency of pre-operative requirements in Medicaid plans compared to Medicare/TriCare and commercial plans demonstrates inequity across insurance types which may negatively impact access to bariatric surgery. Pre-operative insurance requirements must be reevaluated and standardized using established evidence to ensure all individuals have access to this life-saving intervention.

Questioning the legitimacy of bariatric surgery: a qualitative analysis of individuals from the community who qualify for bariatric surgery.

BACKGROUND: Little is known about how individuals in the community who qualify for bariatric surgery perceive it and how this affects their likelihood to consider it for themselves. This study is the first qualitative study of a racially and ethnically diverse cohort to understand perceptions of bariatric surgery. METHODS: We designed a descriptive study to understand attitudes about bariatric surgery. We interviewed 32 individuals who met NIH criteria for bariatric surgery but have never considered bariatric surgery. We purposively sampled to ensure the majority of participants were non-white. Using an Interpretive Description framework, an exploratory, iterative method was used to code interviews and arrive at final themes. RESULTS: Participants self-identified as 88% female, 75% Black, 3% Hispanic, 3% Pacific Islander, and 19% white. Three major themes emerged from our data regarding legitimacy of bariatric surgery. First, participants perceived bariatric surgery to be something commercialized rather than needed treatment. They equated bariatric surgery with "botulism of the lips" or "cool sculpting." Second, an important contributor to the lack of legitimacy as a medical treatment was that many had not heard about bariatric surgery before from their doctors. Doctors were trusted sources for legitimate information about health. Lastly, conflicting information over bariatric surgery-related diet and weight loss further diminished the legitimacy of bariatric surgery. As one participant reflected about pre-operative weight loss requirements, "[If] I'm going to do that, I might as well just keep losing the weight. Why even go do the surgery?". CONCLUSION: Though bariatric surgery is a safe, effective, and durable therapy for patients with obesity, the majority of individuals we interviewed had concerns over the legitimacy of bariatric surgery as a medical treatment. Moving forward in reaching out to communities about bariatric surgery, healthcare providers and systems should consider the presentation of information to attenuate these concerns.

Comparative effectiveness of sleeve gastrectomy vs Roux-en-Y gastric bypass in patients giving birth after bariatric surgery: reinterventions and obstetric outcomes.

BACKGROUND: Women of childbearing age comprise approximately 65% of all patients who undergo bariatric surgery in the USA. Despite this, data on maternal reintervention and obstetric outcomes after surgery are limited especially with regard to comparative effectiveness between sleeve gastrectomy and Roux-en-Y gastric bypass, the most common procedures today. METHODS: Using IBM MarketScan claims data, we performed a retrospective cohort study of women ages 18-52 who gave birth after undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass with 2-year continuous follow-up. We balanced the cohort on observable characteristics using inverse probability weighting. We utilized multivariable logistic regression to examine the association between procedure selection and outcomes, including risk of reinterventions (revisions, enteral access, vascular access, reoperations, other) or adverse obstetric outcomes (pregnancy complications, severe maternal morbidity, and delivery complications). In all analyses, we controlled for age, U.S. state, and Elixhauser or Bateman comorbidities. RESULTS: From 2011 to 2016, 1,079 women gave birth within the first two years after undergoing bariatric surgery. Among these women, we found no significant difference in reintervention rates among those who had gastric bypass compared to sleeve gastrectomy (OR 1.41, 95% CI 0.91-2.21, P = 0.13). We then examined obstetric outcomes in the patients who gave birth after bariatric surgery. Compared to patients who underwent sleeve gastrectomy, those who had Roux-en-Y gastric bypass were not significantly more likely to experience any adverse obstetric outcomes. CONCLUSION: In this first national cohort of females giving birth following bariatric surgery, no significant difference was observed in persons who underwent Roux-en-Y gastric bypass versus sleeve gastrectomy with respect to either reinterventions or obstetric outcomes. This suggests possible equipoise between these two procedures with regards to safety within the first two years following a bariatric procedure among women who may become pregnant, but more research is needed to confirm these findings in larger samples.

Volume-outcome relationships for Roux-en-Y gastric bypass patients in the sleeve gastrectomy era.

BACKGROUND: Sleeve gastrectomy is now the most common bariatric operation performed. With lower volumes of Roux-en-Y gastric bypass (RYGB), it is unclear whether decreasing surgeon experience has led to worsening outcomes for this procedure. METHODS: We used State Inpatient Databases from Florida, Iowa, New York, and Washington. Bariatric surgeons were designated as those who performed ten or more bariatric procedures yearly. Patients who had RYGB were included in our analysis. Using multi-level logistic regression, we examined whether surgeon average yearly RYGB volume was associated with RYGB patient 30-day complications, reoperations, and readmissions and 1-year revisions and readmissions. RESULTS: From 2013 to 2017 there were 27,714 patients who underwent laparoscopic RYGB by 311 surgeons. Median surgeon volume was 77 RYGBs per year. The distribution was 10 bypasses yearly at the 5th percentile, 16 bypasses at the 10th percentile, 38 bypasses at the 25th percentile, and 133 bypasses at the 75th percentile. Multi-level regression revealed that patients of surgeons with lower RYGB volumes had small but statistically significant increased risks of 30-day complications and 1-year readmissions. At 30 days, risk for any complication was 6.71%, 6.43%, and 5.55% at 10, 38, and 133 bypasses per year, respectively (p = 0.01). Risk for readmission at 1 year was 13.90%, 13.67%, and 12.90% at 10, 38, and 133 bypasses per year, respectively (p = 0.099). Of note, volume associations with complications and reoperations due to hemorrhage and leak were not statistically significant. There was also no significant association with revisions. CONCLUSION: This is the first study to examine the association of surgeon RYGB volume with patient outcomes as the national experience with RYGB diminishes. Overall, surgeon RYGB volume does not appear to have a large effect on patient outcomes. Thus, patients can safely pursue RYGB in this early phase of the sleeve gastrectomy era.

The Role of Commercial Health Insurance Characteristics in Bariatric Surgery Utilization.

OBJECTIVE: The aim of this study was to understand relationships among insurance plan type, out-of-pocket cost sharing, and the utilization of bariatric surgery among commercially insured patients. BACKGROUND: Only 1% of eligible persons undergo bariatric operations, and this underutilization is often attributed to lack of insurance coverage. But even among the insured, underinsurance is now recognized as a major barrier to accessing medical care. The relationships among commercial insurance design, out-of-pocket cost sharing, and elective surgery utilization, particularly in bariatrics, are not well understood. METHODS: Retrospective review of 73,002 commercially insured members of the IBM MarketScan commercial claims database who underwent bariatric surgery from 2014 to 2017. The exposure variables were insurance plan type and out-of-pocket cost sharing. The outcome was utilization of bariatric surgery. We also examined seasonal trends in bariatric surgery utilization stratified by average levels of cost sharing. RESULTS: Utilization of bariatric surgery was higher in plans with lower cost sharing, such as PPOs (20 operations/100,000 enrollees) than in HDHPs (high-deductible health plans, 12.1 operations/100,000 enrollees). Overall, every $1000 increase in cost sharing was associated with 5 fewer bariatric operations per 100,000 insured lives; this association was strongest in plans with high cost sharing (high-deductible and consumer-directed health plans). Members of all plan types had higher surgical utilization in quarter 4 relative to quarter 1 of each year; these seasonal variations were also most pronounced in plans with high cost sharing. CONCLUSIONS: Insurance plan types with higher cost sharing have lower utilization of bariatric surgery. Underinsurance may represent a newly identified barrier to surgical care that should be addressed by advocates and policymakers.

Perioperative risks of bariatric surgery among patients with and without history of solid organ transplant.

Bariatric surgery is effective among patients with previous transplant in limited case series. However, the perioperative safety of bariatric surgery in this patient population is poorly understood. Therefore, we assessed the safety of bariatric surgery among previous-transplant patients using a database that captures >92% of all US bariatric procedures. All primary, laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass procedures between 2017 and 2018 were identified from the MBSAQIP dataset. Patients with previous transplant (n = 610) were compared with patients without previous transplant (n = 321 447). Primary outcomes were 30 day readmissions, surgical complications, medical complications, and death. Multivariable logistic regression with predictive margins was used to compare outcomes. Previous transplant patients experienced higher incidence of readmissions (8.0% vs 3.5%), surgical complications (5.0% vs 2.7%), and medical complications (4.3% vs 1.5%). There was no difference in incidence of death (0.2% vs 0.1%). Among individual complications, there no statistical differences in intraabdominal leak, unplanned reoperation, myocardial infarction, or infectious complications. Baseline estimated glomerular filtration rate was found to be a strong moderator of primary outcomes, with the highest risk of complications occurring at the lowest baseline estimated glomerular filtration rate. Given the many long-term benefits of bariatric surgery among patients with previous transplant, our findings should not preclude this patient population from operative consideration.

The Silent Epidemic: Causes and Consequences of Medical Learner Burnout.

PURPOSE OF REVIEW: Clinician burnout has significant socioeconomic, health, and quality of life implications. However, there has been little attention directed at medical students and house officers (i.e., medical learners). This review provides pertinent evidence regarding burnout as it relates to medical learners including risk factors and potential interventions. We conclude with recommendations on future research directions and potential approaches to address this epidemic of medical learner burnout. RECENT FINDINGS: Burnout is a significant issue among medical learners that is impacted both by interpersonal and environmental factors. There are points of heightened vulnerability for medical learners throughout their training. However, studies are unable to reach consensus regarding effective interventions to mitigate the impact of burnout. Furthermore, some elements of burnout are not readily reversible even after removing risk factors. Burnout is a significant concern for medical learners with wide-ranging physical, emotional, and psychosocial consequences. However, the current body of literature is sparse and does not provide consistent guidance on how to address burnout in medical learners. It is clear additional attention is needed in understanding burnout among learners and establishing proactive approaches to minimize its negative impact.

Alagille syndrome mutation update: Comprehensive overview of JAG1 and NOTCH2 mutation frequencies and insight into missense variant classification.

Alagille syndrome is an autosomal dominant disease with a known molecular etiology of dysfunctional Notch signaling caused primarily by pathogenic variants in JAGGED1 (JAG1), but also by variants in NOTCH2. The majority of JAG1 variants result in loss of function, however disease has also been attributed to lesser understood missense variants. Conversely, the majority of NOTCH2 variants are missense, though fewer of these variants have been described. In addition, there is a small group of patients with a clear clinical phenotype in the absence of a pathogenic variant. Here, we catalog our single-center study, which includes 401 probands and 111 affected family members amassed over a 27-year period, to provide updated mutation frequencies in JAG1 and NOTCH2 as well as functional validation of nine missense variants. Combining our cohort of 86 novel JAG1 and three novel NOTCH2 variants with previously published data (totaling 713 variants), we present the most comprehensive pathogenic variant overview for Alagille syndrome. Using this data set, we developed new guidance to help with the classification of JAG1 missense variants. Finally, we report clinically consistent cases for which a molecular etiology has not been identified and discuss the potential for next generation sequencing methodologies in novel variant discovery.

Differences in rural and urban outcomes: a national inspection of emergency general surgery patients.

BACKGROUND: About 19% of the United States population lives in rural areas and is served by only 10% of the physician workforce. If this misdistribution represents a shortage of available surgeons, it is possible that outcomes for rural patients may suffer. The objective of this study was to explore differences in outcomes for emergency general surgery (EGS) conditions between rural and urban hospitals using a nationally representative sample. METHODS: Data from the 2007-2011 National Inpatient Sample were queried for adult patients (≥18 years) with a primary diagnosis consistent with an EGS condition, as defined by the American Association for the Surgery of Trauma. Urban and rural patients were matched on patient-level factors using coarsened exact matching. Differences in outcomes including mortality, morbidity, length of stay (LOS), and total cost of hospital care were assessed using multivariable regression models. Analogous counterfactual models were used to further examine hypothetical outcomes, assuming that all patients had been treated at urban centers. RESULTS: A total of 3,749,265 patients were admitted with an EGS condition during the study period. Of 3259 hospitals analyzed, 40.2% (n = 1310) were rural; they treated 14.6% of patients. Relative to urban centers, EGS patients treated at rural centers had higher odds of in-hospital mortality (odds ratio [OR]: 1.24; 95% confidence interval [CI]: 1.21-1.28) and lower odds of major complications (OR: 0.98; 95% CI: 0.96-0.99). Rural patients had 0.51 d (95% CI: 0.50-0.53) shorter LOS and $744 (95% CI: 712-774) higher cost of hospitalization compared to urban patients. In counterfactual models overall odds of death decreased by 0.05%, whereas the overall odds of complications increased by 0.02%. Overall difference in LOS and total costs were comparable with absolute differences of 0.08 d and $98, respectively. CONCLUSIONS: Despite the statistically significant difference in mortality and cost of care at rural versus urban hospitals, the magnitude of absolute differences is sufficiently small to indicate limited clinical importance. Large urban centers are designed to manage complex cases, but our results suggest that for cases appropriate to treat in rural hospitals, equivalent outcomes are found. These findings will inform future work on rural outcomes and provide impetus for regionalization of care for complex EGS presentations.

Collateral Benefit of Systematic Improvement in Bariatric Surgery Outcomes Following a Single Quality Improvement Project for Bleeding.

The study's aim was not only to use quality improvement system techniques to improve patient care specifically for bleeding but also to track other adverse outcomes. Key drivers were identified and mapped to interventions, namely venous thromboembolism prophylaxis, root cause analysis, indications conference, and operative technique standardization. Bleeding was reduced by 88%, and overall postoperative complications also fell by 63%. A targeted quality improvement project not only was effective in improving outcomes for the specific aim of bleeding but also resulted in improvement for other patient outcomes.