Barriers to Bariatric Surgery: A Mixed Methods Study Investigating Obstacles Between Clinic Contact and Surgery

Morbid obesity has emerged as a major public health concern as rates have skyrocketed over the past few decades. Populations most affected by obesity are not reflected in the patients who seek evaluation for and undergo bariatric or weight loss surgery. This study aims to identify patient populations at risk for attrition during bariatric surgery assessment and determine modifiable barriers to combat access inequality to bariatric surgery. We conducted a single institution, retrospective, mixed methods study investigating the compositional differences between adult patients who achieved or withdrew from bariatric surgery. We collected demographic, socioeconomic, and medical data from the electronic medical record between 2012 and 2021. We then performed computer-assisted self-administered interviews of patients who withdrew from surgery, collecting information on patient knowledge, expectations, and barriers to bariatric surgery. Patients who attained bariatric surgery were more likely to be younger (mean age, 42.2 ± 11.9 vs. 43.8 ± 12.5, p<0.0001), female (82.3 vs. 76.5%, p<0.0001), White (81.2% vs. 75.6%, p=0.0002), married (48.5% vs. 44.1%, p=0.004), and employed full-time (48.2% vs. 43.8%, p=0.01). They were less likely to live in an area with a low-income tract (37.1% vs. 40.7%, p=0.01) or poverty (poverty rate 15.8 ± 15.3 vs. 17.4 ± 16.8, p=0.0002). The surgery group had lower frequency of type 2 diabetes (11.1% vs. 15.6%, p<0.0001), hypertension (29.0% vs. 33.7%, p=0.0003), and current everyday tobacco use (5.4% vs. 12.0%). We received 280 completed surveys for a response rate of 8.9%. Respondents were majority female sex (75.5%) with at least some college education (81.8%) and a household income of $50,000 or greater (61.7%). During their clinic visit, patients gained knowledge about bariatric surgery and the insurance process. Fear of complications, length of the insurance approval process, and wait time between initial evaluation and surgery were the most reported barriers. Clinic patients who undergo surgery are more likely to identify with characteristics of historically privileged communities, which do not reflect communities most affected by obesity. Our results suggest the insurance approval process is a major barrier to bariatric surgery for marginalized populations and should be a focus of future healthcare reform

A Program to Reduce Post-Operative Opioid Prescribing at a Veteran’s Affairs Hospital

Variability in surgeon prescribing patterns is common in the post-operative period and can be the nidus for dependence and addiction. This project aims to reduce opioid overprescribing at the Veteran’s Affairs Pittsburgh Healthcare System (VAPHS). The VAPHS Opioid Stewardship Committee collaborated to create prescribing guidelines for inpatient and outpatient general, thoracic, and vascular surgery procedures. We incorporated bundled order sets into the provider workflow in the electronic medical system and performed a retrospective cohort study comparing opioid prescription patterns for Veterans who underwent any surgical procedure for a three-month period pre- and post- guideline implementation. After implementation of opioid prescribing guidelines, morphine milligram equivalents (MME), quantity of pills prescribed, and days prescribed were statistically significantly reduced for procedures with associated guidelines, including cholecystectomy (MME 140.8 vs. 57.5, p = 0.002; quantity 18.8 vs. 8, p = 0.002; days 5.1 vs. 2.8, p = 0.021), inguinal hernia repair (MME 129.9 vs. 45.3, p = 0.002; quantity 17.3 vs. 6.1, p = 0.002; days 5.0 vs. 2.4, p = 0.002), and umbilical hernia repair (MME 128.8 vs. 53.8, p = 0.002; quantity 17.1 vs. 7.8, p = 0.002; days 5.1 vs. 2.5, p = 0.022). Procedures without associated recommendations also preceded a decrease in overall opioid prescribing. Post-operative opioid prescribing guidelines can steer clinicians toward more conscientious opioid disbursement. There may also be reductions in prescribing opioids for procedures without guidelines as an indirect effect of practice change

Omission of axillary dissection following nodal downstaging with neoadjuvant chemotherapy

Importance Data on oncological outcomes after omission of axillary lymph node dissection (ALND) in patients with breast cancer that downstages from node positive to negative with neoadjuvant chemotherapy are sparse. Additionally, the best axillary surgical staging technique in this scenario is unknown. Objective To investigate oncological outcomes after sentinel lymph node biopsy (SLNB) with dual-tracer mapping or targeted axillary dissection (TAD), which combines SLNB with localization and retrieval of the clipped lymph node. Design, Setting, and Participants In this multicenter retrospective cohort study that was conducted at 25 centers in 11 countries, 1144 patients with consecutive stage II to III biopsy-proven node-positive breast cancer were included between April 2013 and December 2020. The cumulative incidence rates of axillary, locoregional, and any invasive (locoregional or distant) recurrence were determined by competing risk analysis. Exposure Omission of ALND after SLNB or TAD. Main Outcomes and Measures The primary end points were the 3-year and 5-year rates of any axillary recurrence. Secondary end points included locoregional recurrence, any invasive (locoregional and distant) recurrence, and the number of lymph nodes removed. Results A total of 1144 patients (median [IQR] age, 50 [41-59] years; 78 [6.8%] Asian, 105 [9.2%] Black, 102 [8.9%] Hispanic, and 816 [71.0%] White individuals; 666 SLNB [58.2%] and 478 TAD [41.8%]) were included. A total of 1060 patients (93%) had N1 disease, 619 (54%) had ERBB2 (formerly HER2)–positive illness, and 758 (66%) had a breast pathologic complete response. TAD patients were more likely to receive nodal radiation therapy (85% vs 78%; P = .01). The clipped node was successfully retrieved in 97% of TAD cases and 86% of SLNB cases (without localization). The mean (SD) number of sentinel lymph nodes retrieved was 3 (2) vs 4 (2) (P &lt; .001), and the mean (SD) number of total lymph nodes removed was 3.95 (1.97) vs 4.44 (2.04) (P &lt; .001) in the TAD and SLNB groups, respectively. The 5-year rates of any axillary, locoregional, and any invasive recurrence in the entire cohort were 1.0% (95% CI, 0.49%-2.0%), 2.7% (95% CI, 1.6%-4.1%), and 10% (95% CI, 8.3%-13%), respectively. The 3-year cumulative incidence of axillary recurrence did not differ between TAD and SLNB (0.5% vs 0.8%; P = .55). Conclusions and Relevance The results of this cohort study showed that axillary recurrence was rare in this setting and was not significantly lower after TAD vs SLNB. These results support omission of ALND in this population