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.

Identifying Young Adults at High Risk for Weight Gain Using Machine Learning.

INTRODUCTION: Weight gain among young adults continues to increase. Identifying adults at high risk for weight gain and intervening before they gain weight could have a major public health impact. Our objective was to develop and test electronic health record-based machine learning models to predict weight gain in young adults with overweight/class 1 obesity. METHODS: Seven machine learning models were assessed, including three regression models, random forest, single-layer neural network, gradient-boosted decision trees, and support vector machine (SVM) models. Four categories of predictors were included: 1) demographics; 2) obesity-related health conditions; 3) laboratory data and vital signs; and 4) neighborhood-level variables. The cohort was split 60:40 for model training and validation. Area under the receiver operating characteristic curves (AUC) were calculated to determine model accuracy at predicting high-risk individuals, defined by ≥ 10% total body weight gain within 2 y. Variable importance was measured via generalized analysis of variance procedures. RESULTS: Of the 24,183 patients (mean [SD] age, 32.0 [6.3] y; 55.1% females) in the study, 14.2% gained ≥10% total body weight. Area under the receiver operating characteristic curves varied from 0.557 (SVM) to 0.675 (gradient-boosted decision trees). Age, sex, and baseline body mass index were the most important predictors among the models except SVM and neural network. CONCLUSIONS: Our machine learning models performed similarly and had modest accuracy for identifying young adults at risk of weight gain. Future models may need to incorporate behavioral and/or genetic information to enhance model accuracy.

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.

National Databases for Assessment of Quality.

With the rise in the availability of large health care datasets, database research has become an important tool for colorectal surgeon to assess health care quality and implement practice changes. In this chapter, we will discuss the benefits and drawbacks of database research for quality improvement, review common markers of quality for colorectal surgery, provide an overview of frequently used datasets (including Veterans Affairs Surgical Quality Improvement Program, National Surgical Quality Improvement Project, National Cancer Database, National Inpatient Sample, Medicare Data, and Surveillance, Epidemiology, and End Results), and look ahead to the future of database research for the improvement of quality.

Obesity and "obesity-related" cancers: are there body mass index cut-points?

BACKGROUND: Despite compelling links between excess body weight and cancer, body mass index (BMI) cut-points, or thresholds above which cancer incidence increased, have not been identified. The objective of this study was to determine if BMI cut-points exist for 14 obesity-related cancers. SUBJECTS/METHODS: In this retrospective cohort study, patients 18-75 years old were included if they had ≥2 clinical encounters with BMI measurements in the electronic health record (EHR) at a single academic medical center from 2008 to 2018. Patients who were pregnant, had a history of cancer, or had undergone bariatric surgery were excluded. Adjusted logistic regression was performed to identify cancers that were associated with increasing BMI. For those cancers, BMI cut-points were calculated using adjusted quantile regression for cancer incidence at 80% sensitivity. Logistic and quantile regression models were adjusted for age, sex, race/ethnicity, and smoking status. RESULTS: A total of 7079 cancer patients (mean age 58.5 years, mean BMI 30.5 kg/m2) and 270,441 non-cancer patients (mean age 43.8 years, mean BMI 28.8 kg/m2) were included in the study. In adjusted logistic regression analyses, statistically significant associations were identified between increasing BMI and the incidence of kidney, thyroid, and uterine cancer. BMI cut-points were identified for kidney (26.3 kg/m2) and uterine (26.9 kg/m2) cancer. CONCLUSIONS: BMI cut-points that accurately predicted development kidney and uterine cancer occurred in the overweight category. Analysis of multi-institutional EHR data may help determine if these relationships are generalizable to other health care settings. If they are, incorporation of BMI into the screening algorithms for these cancers may be warranted.

Racial disparities in selected micronutrient deficiencies after bariatric surgery: A systematic review.

BACKGROUND: Bariatric surgery has been associated with numerous micronutrient deficiencies. Several observational studies have found that these deficiencies are more common in racially/ethnically minoritized patients. OBJECTIVES: To conduct a systematic review to investigate whether racially/ethnically minoritized patients experience worse nutritional outcomes after bariatric surgery. SETTING: University of Wisconsin-Madison. METHODS: PubMed, CINAHL, PsychINFO, and Cochrane databases were queried. We searched for manuscripts that reported micronutrient levels or conditions related to micronutrient deficiencies according to race/ethnicity (White, African American/Black, and Hispanic) after laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass between 2002 and 2022. Eleven micronutrients (vitamins A, B1 [thiamine], B12, D, E, K, calcium, copper, folate, iron, and zinc), and four conditions (anemia, bone loss, fractures, and hyperparathyroidism) were assessed. RESULTS: Abstracts from 953 manuscripts were screened; 18 full-text manuscripts were reviewed for eligibility, and ten met the inclusion criteria. Compared to White patients, African Americans had a higher prevalence of thiamine, vitamin D, and vitamin A deficiencies. There were no differences in calcium and vitamin B12 deficiencies. The other six micronutrients were not assessed according to race/ethnicity. Hyperparathyroidism was more prevalent in African Americans than White patients in the three studies that evaluated it. The prevalence of fractures was mixed. Anemia and bone loss were not evaluated according to race/ethnicity. CONCLUSIONS: Although the literature on micronutrient outcomes following bariatric surgery according to race/ethnicity is limited, African Americans appear to experience a higher prevalence of vitamin deficiencies and associated conditions. Qualitative and quantitative research to explore these disparities is warranted.

Optimization of the Electronic Health Record for Research.

Mini Abstract This surgical perspective highlights the current limitations of utilizing the electronic health record for research and discusses directions for future optimization.

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.

Association between neighborhood food environments and bariatric surgery outcomes.

BACKGROUND: Individual characteristics associated with weight loss after bariatric surgery are well established, but the neighborhood characteristics that influence outcomes are unknown. OBJECTIVES: The objective of this study was to determine if neighborhood characteristics, including social determinants and lifestyle characteristics, were associated with weight loss after bariatric surgery. SETTING: Single university healthcare system, United States. METHODS: In this retrospective cohort study, all patients who underwent primary bariatric surgery from 2008 to 2017 and had at least 1 year of follow-up data were included. Patient-level demographics and neighborhood-level social determinants (area deprivation index, urbanicity, and walkability) and lifestyle factors (organic food use, fresh fruit/vegetable consumption, diet to maintain weight, soda consumption, and exercise) were analyzed. Median regression with percent total body weight (%TBW) loss as the outcome was applied to examine factors associated with weight loss after surgery. RESULTS: Of the 647 patients who met inclusion criteria, the average follow-up period was 3.1 years, and the mean %TBW loss at the follow-up was 22%. In adjusted median regression analyses, Roux-en-Y gastric bypass was associated with greater %TBW loss (11.22%, 95% confidence interval [8.96, 13.48]) compared to sleeve, while longer follow-up time (-2.42% TBW loss per year, 95% confidence interval [-4.63, -0.20]) and a preoperative diagnosis of diabetes (-1.00% TBW loss, 95% confidence interval [-1.55, -0.44]) were associated with less. None of the 8 neighborhood level characteristics was associated with weight loss. CONCLUSIONS: Patient characteristics rather than neighborhood-level social determinants and lifestyle factors were associated with weight loss after bariatric surgery in our cohort of bariatric surgery patients. Patients from socioeconomically deprived neighborhoods can achieve excellent weight loss after bariatric surgery.

Perioperative Cost Differences Between Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-en-Y Gastric Bypass: A Single Institutional Review.

Background: Minimizing bariatric surgery care costs is important since more than 250,000 patients undergo bariatric surgery annually in the United States. The study objective was to compare perioperative costs for the two most common bariatric procedures: laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). In addition, we sought to identify predictors of high-cost perioperative care. Methods: Adult patients who underwent LSG or LRYGB from 2012 to 2017 were identified using our institutional bariatric surgery database. Perioperative costs, defined as costs incurred from the time of entering the preoperative unit until exiting the postanesthesia care unit, were obtained through billing data. Median perioperative cost components of LSG and LRYGB were compared using Mann-Whitney tests. Multivariable logistic regression was performed to investigate patient-level predictors of high-cost care, defined as the top tercile of perioperative costs. Results: We included 546 bariatric surgery patients with a mean age and body mass index (BMI) of 49.7 years and 45.9 kg/m2, respectively. There were no significant differences in median perioperative costs between LSG and LRYGB ($14,942 versus $15,016; P = .80). Stapler use was the largest cost contributor for both procedures, accounting for 27.7% and 29.2% of costs for LSG and LRYGB, respectively. In multivariable analyses, preoperative patient characteristics, including BMI, were not associated with high-cost perioperative care. Conclusions: Perioperative costs for LSG and LRYGB were similar in our single institution study. Reducing costs outside of the operating room, including those related to ED visits and complications, may be more impactful than focusing on cost reduction directly related to perioperative care.