Emergency department utilization and hospital readmission following bariatric surgery

INTRODUCTION: Unplanned hospital visits have emerged as a quality metric encompassing many aspects of postoperative morbidity and deficiencies in the transition from inpatient to outpatient care. This study aims to identify patient, encounter, and organizational factors that may influence Emergency Department (ED) visits and readmissions following bariatric surgery. METHODS: A modified version of a framework initially proposed by Vest et al. in their systematic review of the determinants of preventable readmissions was used as a conceptual framework for this study. The Michigan Bariatric Surgery Collaborative (MBSC) database was used to identify patients undergoing all primary bariatric procedures at 40 centers with >100 patients in the database from 2006–2015. Multivariate logistic regression modeling was used to identify factors associated with unplanned hospital visits. Using an indirect standardization process, each sites’ observed to expected ratio for 30-day readmission was calculated. The association between each site’s adjusted readmission rate with their rate of ED visits, Emergency Department-Sourced readmissions (EDSR), major complications, and compliance with best practices were calculated with Pearson’s correlation coefficients. RESULTS: Younger age, greater comorbidities, increased length of stay, procedure type, and Medicaid/Medicare insurance were significantly associated with readmissions in a multivariate logistic regression model. There was significant variation among sites’ adjusted rates of readmission, EDSR, best practice compliance, and major complications. There was a moderately strong association between each sites’ adjusted readmission rate with their rate of EDSR (r=0.53), major complications (r=0.53), and ED visits (r=0.55). However, the association between bariatric centers’ compliance with best practices to reduce unplanned hospital visits and their readmission rates was fairly weak (r= -0.14). CONCLUSION: Several individual, encounter, and organization-level characteristics are associated with an increased risk of unplanned visits after bariatric surgery. Bariatric centers are more likely to have higher readmission rates if their site has higher rates of major complications and if their ED is less likely to treat and then discharge bariatric patients. Further examination of organizational characteristics of bariatric programs that affect postoperative readmissions, including ED practices, is needed to better guide future initiatives aimed at improving this quality metric

Emergency department utilization and hospital readmission following bariatric surgery

INTRODUCTION: Unplanned hospital visits have emerged as a quality metric encompassing many aspects of postoperative morbidity and deficiencies in the transition from inpatient to outpatient care. This study aims to identify patient, encounter, and organizational factors that may influence Emergency Department (ED) visits and readmissions following bariatric surgery. METHODS: A modified version of a framework initially proposed by Vest et al. in their systematic review of the determinants of preventable readmissions was used as a conceptual framework for this study. The Michigan Bariatric Surgery Collaborative (MBSC) database was used to identify patients undergoing all primary bariatric procedures at 40 centers with >100 patients in the database from 2006–2015. Multivariate logistic regression modeling was used to identify factors associated with unplanned hospital visits. Using an indirect standardization process, each sites’ observed to expected ratio for 30-day readmission was calculated. The association between each site’s adjusted readmission rate with their rate of ED visits, Emergency Department-Sourced readmissions (EDSR), major complications, and compliance with best practices were calculated with Pearson’s correlation coefficients. RESULTS: Younger age, greater comorbidities, increased length of stay, procedure type, and Medicaid/Medicare insurance were significantly associated with readmissions in a multivariate logistic regression model. There was significant variation among sites’ adjusted rates of readmission, EDSR, best practice compliance, and major complications. There was a moderately strong association between each sites’ adjusted readmission rate with their rate of EDSR (r=0.53), major complications (r=0.53), and ED visits (r=0.55). However, the association between bariatric centers’ compliance with best practices to reduce unplanned hospital visits and their readmission rates was fairly weak (r= -0.14). CONCLUSION: Several individual, encounter, and organization-level characteristics are associated with an increased risk of unplanned visits after bariatric surgery. Bariatric centers are more likely to have higher readmission rates if their site has higher rates of major complications and if their ED is less likely to treat and then discharge bariatric patients. Further examination of organizational characteristics of bariatric programs that affect postoperative readmissions, including ED practices, is needed to better guide future initiatives aimed at improving this quality metric

Gastric band is safe and effective at three years in a national study subgroup of non-morbidly obese patients

Aim To analyze the 3-year outcomes of lower body mass index (BMI) (<35 kg/m2) adjustable gastric band (AGB) recipients across multiple sites in the French health insurance system. Methods From prospectively collected data on a cohort of 517 morbidly obese Swedish Adjustable Gastric Band® (SAGB) patients (Clinical Trials Web database, #NCT01183975), a retrospective analysis of a subgroup of 29 low-BMI patients was conducted. Patients had a severe obesity-related comorbidity, had undergone a prior bariatric procedure requiring reintervention, or had a maximum adult BMI≥40. Safety (mortality, adverse events) and effectiveness (BMI change, excess weight loss [EWL, %], total body weight loss [%TBWL], quality of life [QoL], and comorbidities) were evaluated. Results Multiple surgical teams/sites enrolled patients and performed SAGB procedures between September 2, 2007 and April 30, 2008. Of 29 low-BMI patients (mean age, 41.3 ± 10.3 years), 89.7% were female, and obesity duration was 13.6 ± 7.3 years. Mean BMI was 31.5 ± 3.7; there were 37 comorbidities in 15/29 patients. At 3-year follow-up, BMI was 29.4 ± 4.9 (mean change, -2.3 ± 6.2; P = 0.069); total cohort EWL, 7.3 ± 74.8%; TBWL, 6.2 ± 18.8%; BMI≥30 to <35 EWL, 38.8 ± 48.0%; there were 7 comorbidities in 15/29 patients (P < 0.031). There were 20 adverse events in 13 patients (44.8%); SAGBs were retained in 25/29 (86.2%) at 3 years. Conclusions In a retrospective analysis of a subgroup of BMI<35 kg/m2 patients, some following a prior bariatric procedure, SAGB was found to be safe and effective at 3-year follow-up

The Relationship of Physical Activity, Eating Behaviors, and Hunger Control to Weight Loss and Quality of Life in Gastric Banding Patients

Gastric banding as a weight loss surgery has increased in popularity in the United States since its approval by the Food and Drug Administration in 2001. Successful weight loss after weight loss surgery is most frequently defined as greater than 50 percent of excess weight loss (EWL). Systematic reviews show that the band is widely effective in achieving successful weight loss in most patients, however individual studies show more inconsistent outcomes. Although previous research supports gastric bypass surgery as having a positive effect on quality of life after gastric bypass, there is very little data to support this relationship in gastric banding patients. Weight loss outcomes after gastric banding surgery at Virginia Commonwealth Health System were less than 50 per cent EWL at one and two years. A retrospective, descriptive study sought to answer the following questions: 1) What is the relationship between physical activity, eating behaviors and hunger control on weight loss and quality of life after gastric banding surgery and 2) Does successful weight loss at one year predict successful weight loss at two years. The International Physical Activity Questionnaire Sort Form (IPAQ) was used to assess participation in physical activity. The Medical Outcomes Study Short Form (SF-36) was used to determine quality of life. Weight loss outcomes were 34.6 per cent at one year and 39.7 per cent at two years, which was less than the established success rate of greater than 50 per cent EWL, However, most patients lost some weight and demonstrated a significant improvement in most domains of health related quality of life. Participation in physical activity increased fro preoperatively to year one but decreased in year two. Although participation in physical activities overall decreased from year one to year two, there was a significant relationship between participation in greater than 150 minutes per week of moderate or vigorous physical activity and adequate weight loss (p =0.025) and participation in health enhancing physical activities and adequate weight loss (p \u3c 0.05). There was no statistically significant relationship noted between any of these eating behaviors and the percentage of excess weight loss at one or two years. There was a significant relationship between degree of hunger reported by patients and successful weight loss at one year (p \u3c 0.05). There is sufficient statistical evidence of a positive linear relationship between two- year weight loss and one- year weight loss (p \u3c 0.05). That is, one-year weight loss is a significant predictor for two- year weight loss. Based on the results of this study, it is recommended that gastric banding patients participate in at least 150 minutes per week of moderate to vigorous physical activity. Additionally, clinicians should consider development of adjustment protocols that achieve early reduction of hunger in the banding patient

THE EXPERIENCES AND PERCEPTIONS OF BEHAVIORAL FACTORS THAT CONTRIBUTE TO SUCCESSFUL WEIGHT LOSS IN MALE BARIATRIC PATIENTS

The purpose of this study was to examine the experiences and perceptions of behavioral factors that contribute to successful weight loss in male bariatric patients. By analyzing participant experiences and perceptions, this study contributes to a better understanding of which factors are most important in the postoperative phase of gastric bypass in males owing to successful weight loss. Although there is a tremendous amount of quantitative research within the bariatric population, there is a significant gap within the qualitative literature as it relates to male outcomes. As such, by conducting interviews with 10 postoperative male gastric bypass patients, this study was able to further understand how and why these participants obtained successful weight loss. Furthermore, by identifying relevant categories and thematic responses from the participants, this study may serve future researchers in designing other qualitative studies that target best practices in males for successful weight loss outcomes. The findings of this study indicate that participants found greater weight loss success by following proper eating behaviors and engaging in physical activity whereas support group attendance was not found to be an important factor in successful weight loss. This study also revealed that follow up with the bariatric nurse coordinator was greatly viewed as a positive step in adjusting to lifestyle postsurgery. As such, this supportive role by the nurse coordinator may provide further impetus for the ways in which bariatric personnel interact with patients who might not always be able to see their surgeon for follow-up

Management of diabetes across the course of disease: minimizing obesity-associated complications

Obesity increases the risk for developing type 2 diabetes mellitus (T2DM) and this in turn correlates with an elevated probability of long-term diabetes complications once diabetes is established. Interventions aimed at lowering weight via changes in diet and lifestyle have repeatedly been shown to improve glycemic control in patients with T2DM and even to reverse early disease. Weight gain, a potential side effect of treatment for patients with T2DM, is also an important concern, and it has been noted that weight increases associated with antidiabetes therapy may blunt cardiovascular risk reductions achieved by decreasing blood glucose. Among older agents, metformin and acarbose have the lowest risk for weight gain, while sulfonylureas, meglitinides, and thiazolidinediones are all associated with weight increases. Clinical trial results have also consistently demonstrated that treatment with glucagon-like peptide-1 receptor agonists and amylin lowers weight, and that dipeptidyl peptidase-4 inhibitors are weight neutral in patients with T2DM. Conventional human insulin formulations are known to increase weight in patients with T2DM. However, some insulin analogs, particularly insulin detemir, have lower liability for this adverse event. The use of both pharmacologic and surgical therapies aimed at treating obesity rather than lowering blood glucose have the potential to improve glycemic control and even resolve T2DM in some patients

Advanced Bariatric and Metabolic Surgery

Bariatric surgery has gained importance in the last 20 years because of the high prevalence of global obesity, and the vast understating of the physiological and pathological aspects of obesity and associated metabolic syndromes. This book has been written by a number of highly outstanding authors and pioneering bariatric surgeons from all over the world. The intended audience for this book includes all medical professionals involved in caring for bariatric patients. The chapters cover the choice of operation, preoperative preparation including psychological aspect, postoperative care and management of complication. It also extends to concept and result of metabolic surgery and scarless bariatric surgery

Mechanisms maintaining reduced appetite and normoglycaemia after metabolic surgery. The role of bile acids

Obesity is becoming the healthcare epidemic of this century. Weight loss surgery is the only effective treatment for morbid obesity. Furthermore glycaemic control in type 2 diabetic patients is improved after metabolic surgery. Here I observed that with gastric bypass, type 2 diabetes can be improved and even rapidly put into a state of remission irrespective of weight loss. This is achieved via an improvement of both insulin resistance and insulin production. Reduced insulin resistance within the first week after surgery remains unexplained, but increased insulin production in the first week after surgery may be explained by the enhanced postprandial GLP-1 response. In addition, I demonstrate that bile flow changes lead to increased gut hormone response in animal models. Roux-en-Y gastric bypass in humans causes changes in bile flow leading to increased plasma bile acid concentrations. This phenomenon may explain the improved glycaemic control following gastric bypass. In conclusion I investigated the mechanism of diabetes remission after metabolic surgery and explored the role of gut hormones and bile acids in the changes in glucose homeostasis following metabolic surgery

A narrative review on bariatric ERAS

Bariatric/metabolic surgery (BMS) is the most effective treatment of morbid obesity, while Enhanced Recovery After Surgery (ERAS) after BMS represents a multimodal perioperative protocol designed to achieve early recovery for patients with peculiar characteristics. The aim of the current narrative review is to summarize and discuss the current role, the application, and the future developments of ERAS protocols in the field of BMS