Impact of COVID-19 on the Postoperative Bariatric Surgery Patient Experience.

OBJECTIVE: To characterize patient and provider perceptions of the impact of coronavirus disease 2019 (COVID-19) on weight loss following bariatric surgery. BACKGROUND: COVID-19 has disrupted routines and healthcare throughout the United States, but its impact on bariatric surgery patients' postoperative experience is unknown. METHODS: Semistructured interviews with bariatric surgery patients, primary care providers, and health psychologists were conducted from April to November 2020. As part of a secondary analysis, patients and providers described how the COVID-19 pandemic affected the postoperative experience within 3 domains: dietary habits, physical activity, and follow-up care. Interview guides were created from 2 conceptual models: Torain's Surgical Disparities Model and Andersen's Behavioral Model of Health Services Use. Study team members derived codes, which were grouped into themes using conventional content analysis. RESULTS: Thirty-four participants were interviewed: 24 patients (12 Roux-en-Y gastric bypass and 12 sleeve gastrectomy), 6 primary care providers, and 4 health psychologists. Patients were predominately female (83%) and White (79%). Providers were predominately female (90%) and White (100%). COVID-19 affected the postoperative bariatric surgery patient experience via 3 mechanisms: (1) it disrupted dietary and physical activity routines due to facility closures and fear of COVID-19 exposure; (2) it required patients to transition their follow-up care to telemedicine delivery; and (3) it increased stress due to financial and psychosocial challenges. CONCLUSIONS: COVID-19 has exacerbated patient vulnerability. The pandemic is not over, thus bariatric surgery patients need ongoing support to access mental health professionals, develop new physical activity routines, and counteract increased food insecurity.

Patient and Provider Perceptions About Communication After Bariatric Surgery: A Qualitative Analysis.

INTRODUCTION: Communication between patients and providers can strongly influence patient behavior after surgery. The objective of this study was to assess patient and provider perceptions of how communication affected weight-related behaviors after bariatric surgery. MATERIALS AND METHODS: Semistructured interviews with bariatric surgery patients and providers were conducted from April-November 2020. Patients who had Medicaid within 3 y of surgery were defined as socioeconomically disadvantaged. Interview guides were derived from Andersen's Behavioral Model of Health Services and Torain's Framework for Surgical Disparities. Participants described postoperative experiences regarding diet, physical activity, and follow-up care. A codebook was developed deductively based on the two theories. Directed content analysis identified themes pertaining to patient-provider communication. RESULTS: Forty-five participants were interviewed, including 24 patients (83% female; 79% White), six primary care providers, four health psychologists, five registered dietitians, and six bariatric surgeons. Four themes regarding communication emerged: (1) Patients experiencing weight regain did not want to follow-up with providers to discuss their weight; (2) Patients from socioeconomically disadvantaged backgrounds had less trust and required more rapport-building from providers to enhance trust; (3) Patients felt that providers did not get to know them personally, which was perceived as a lack of personalized communication; and (4) Providers often changed their language to be simpler, so patients could understand them. CONCLUSIONS: Patient-provider communication after bariatric surgery is essential, but perceptions about the elements of communication differ between patients and providers. Reassuring patients who have attained less weight loss than expected and establishing trust with socioeconomically vulnerable patients could strengthen care after bariatric surgery.

The TOTAL trial for weight management participation: A randomized controlled trial protocol.

BACKGROUND: The three types of evidence-based treatment options for adults with overweight and obesity - behavioral weight management, anti-obesity medications (AOM), and bariatric surgery - are underutilized in the Veterans Health Administration (VHA) system. Our objective in this manuscript is to describe the study protocol for an adequately powered randomized controlled trial (RCT) of a behavioral intervention: TOTAL (Teaching Obesity Treatment Options to Adult Learners) to increase patient uptake of obesity treatment. METHODS: In this multi-site, parallel, RCT, eligible Veterans with a body mass index [BMI] ≥ 27 who had not received obesity treatment within the past 12 months were randomly assigned to TOTAL or usual care. TOTAL involves watching an 18-min video that highlights obesity health risks, pros/cons of all three evidence-based obesity treatments, and expected treatment outcomes. It also includes motivational sessions delivered via televideo at 2 weeks, 6 months, and 12 months after the video (target n = 494 participants). The primary outcome is initiation of behavioral weight management treatment within 18 months of randomization. Secondary outcomes include sustained behavioral weight management treatment, initiation of AOM, bariatric surgery referral, and weight change across 18 months. CONCLUSION: TOTAL, which seeks to increase delivery of weight management treatment within the largest integrated health system in the U.S., combines patient education with motivational interviewing components. If efficacious in this trial, further evaluation of intervention effectiveness and implementation throughout the VHA and other healthcare systems would be warranted.

Socioeconomic disparities and bariatric surgery outcomes: A qualitative analysis.

BACKGROUND: Disparities in socioeconomic status (SES) have been associated with less weight loss after bariatric surgery. The objective of this study was to identify socioeconomic barriers to weight loss after bariatric surgery. METHODS: We performed semi-structured interviews with bariatric surgery patients and providers from April-November 2020. Participants were asked to describe their post-operative experiences regarding dietary habits, physical activity, and follow-up care. Interview data were coded using Directed Content Analysis based on domains in Andersen's Behavioral Model of Health Services Use and Torain's Surgical Disparities Model. RESULTS: 24 patients (median of 4.1 years post-operatively; mean age 50.6 ± 10.7 years; 12 bypass and 12 sleeve; 83% female) and 21 providers (6 bariatric surgeons, 5 registered dietitians, 4 health psychologists, and 6 primary care providers) were interviewed. Barriers to weight loss included: 1) challenging employment situations; 2) limited income; 3) unreliable transportation; 4) unsafe/inconvenient neighborhoods; and 5) limited health literacy. CONCLUSIONS: Interventions targeting socioeconomic barriers to weight loss are needed to support patients, particularly those who are socioeconomically disadvantaged.

Individual-level barriers to bariatric surgery from patient and provider perspectives: A qualitative study.

BACKGROUND: Less than 1% adults in the United States who meet body mass index criteria undergo bariatric surgery. Our objective was to identify patient and provider perceptions of individual-level barriers to undergoing bariatric surgery. METHODS: Adults with severe obesity and obesity care providers described their experiences with the bariatric surgery care process in semi-structured interviews. Using conventional content analysis, individual-level barriers were identified within Andersen's Behavioral Model of Health Services Use. RESULTS: Of the 73 individuals interviewed, 36 (49%) were female, and 15 (21%) were non-white. Six individual-level barriers were identified: fear of surgery, fear of lifestyle change, perception that weight had not reached its "tipping point," concerns about dietary changes, lack of social support, and patient characteristics influencing referral. CONCLUSIONS: Patient and provider education should address patient fears of surgery and the belief that surgery is a "last resort." Bariatric surgery programs should strengthen social support networks for patients.

Protocol and short-term results for a feasibility randomized controlled trial of a video intervention for Veterans with obesity: The TOTAL (Teaching Obesity Treatment Options to Adult Learners) pilot study.

INTRODUCTION: All three evidence-based treatment options for adults with severe obesity - behavioral weight management, weight management medications (WMM), and bariatric surgery - are underutilized in the Veterans Health Administration (VHA) system. Our objective in this study was to develop and pilot-test the TOTAL (Teaching Obesity Treatment Options to Adult Learners) intervention, which seeks to increase Veteran participation in obesity treatment. METHODS: In this single-site, parallel, pilot RCT, Veterans with severe obesity with an upcoming behavioral weight management visit were sent a recruitment letter after meeting inclusion/exclusion criteria via electronic health record screening. Eligible Veterans were randomized to TOTAL or usual care. TOTAL consisted of an 18-min video highlighting obesity health risks and treatment outcomes, eligibility criteria, and pros/cons of all three evidence-based obesity treatments. The primary outcomes were trial design feasibility (recruitment and retention rates) and acceptability to Veterans, which was assessed via semi-structured interviews with participants one week after randomization to TOTAL. Secondary outcomes included attitudes and self-efficacy to initiate treatment one week post-randomization and BMI change six months post-randomization (assessed via Cohen's d). RESULTS: Forty-two Veterans were randomized (recruitment rate = 47.2%), and 40/42 completed one-week assessments (retention rate = 95.2%). The mean participant age was 59.2 ± 11.9 years. Female and non-White participants comprised 14.3% and 11.9% of the cohort, respectively. Semi-structured interviews with all 20 participants who received TOTAL suggested that the delivery logistics and content of TOTAL were acceptable to Veterans. Attitudes toward behavioral weight management and bariatric surgery and weight loss improved in TOTAL vs. usual care patients (Cohen's d ranging from 0.3 to 0.6). CONCLUSIONS: TOTAL was feasible to implement, acceptable to Veterans, and has the potential to increase obesity treatment participation in VHA. An adequately powered RCT is warranted to assess its impact on population-level weight loss. TRIAL REGISTRATION: ClinicalTrials.gov NCT03856320.

pH Impedance Parameters Associated with Improvement in GERD Health-Related Quality of Life Following Anti-reflux Surgery.

INTRODUCTION: pH impedance testing is the most sensitive diagnostic test for detecting gastroesophageal reflux disease (GERD). The literature remains inconclusive on which preoperative pH impedance testing parameters are associated with an improvement in heartburn symptoms after anti-reflux surgery. The objective of this study was to evaluate which parameters on preoperative pH impedance testing were associated with improved GERD health-related quality of life (GERD-HRQL) following surgery. METHODS: Data from a single-institution foregut database were used to identify patients with reflux symptoms who underwent anti-reflux surgery between 2014 and 2020. Acid and impedance parameters were extracted from preoperative pH impedance studies. GERD-HRQL was assessed pre- and postoperatively with a questionnaire that evaluated heartburn, dysphagia, and the impact of acid-blocking medications on daily life. Patient characteristics, fundoplication type, and four pH impedance parameters were included in a multivariable linear regression model with improvement in GERD-HRQL as the outcome. RESULTS: We included 108 patients (59 Nissen and 49 Toupet fundoplications), with a median follow-up time of 1 year. GERD-HRQL scores improved from 22.4 (SD ± 10.1) preoperatively to 4.2 (± 6.2) postoperatively. In multivariable analysis, a normal preoperative acid exposure time (p = 0.01) and Toupet fundoplication (vs. Nissen; p = 0.03) were independently associated with greater improvement in GERD-HRQL. CONCLUSIONS: Of the four pH impedance parameters that were investigated, a normal preoperative acid exposure time was associated with greater improvement in quality of life after anti-reflux surgery. Further investigation into the critical parameters on preoperative pH impedance testing using a multi-institutional cohort is warranted.