Understanding the psychosocial impact of weight loss following bariatric surgery: a qualitative study

Abstract Background Bariatric surgery leads to changes in mental health, quality of life and social functioning, yet these outcomes differ among individuals. In this study, we explore patients’ psychosocial experiences following bariatric surgery and elucidate the individual-level factors that may drive variation in psychosocial outcomes. Methods Eleven semi-structured focus groups with Michigan Bariatric Surgery Collaborative (MBSC) patients (n = 77). Interviews were audio recorded, transcribed verbatim, and analyzed using a grounded theory approach. Data on participant demographic characteristics were abstracted from the MBSC clinical registry. Results Most focus group participants were female (89%), white (64%), and married (65%). We identified three major themes: (1) change in self-perception; (2) change in perception by others; and (3) change in relationships. Each theme includes 3 sub-themes, demonstrating a range of positive and negative psychosocial experiences. For example, weight loss led to increased self-confidence among many participants while others described a loss of self-identity. Some noted improved relationships with family or friends while others experienced worsening or even loss of relationships due to perceived jealousy. Conclusion Weight loss following bariatric surgery leads to complex changes in self-perception and inter-personal relationships, which may be proximal mediators of commonly assessed mental health outcomes such as depression. Individuals considering bariatric surgery may benefit from anticipatory guidance about these diverse experiences, and post-surgical longitudinal monitoring should include evaluation for adverse psychosocial events.https://deepblue.lib.umich.edu/bitstream/2027.42/146725/1/40608_2018_Article_215.pd

Am I on Track? Evaluating Patient-Specific Weight Loss After Bariatric Surgery Using an Outcomes Calculator

PURPOSE: Individual weight loss outcomes after bariatric surgery can vary considerably. As a result, identifying and assisting patients who are not on track to reach their weight loss goals can be challenging. MATERIALS AND METHODS: Using a bariatric surgery outcomes calculator, which was formulated using a state-wide bariatric-specific data registry, predicted weight loss at 1 year after surgery was calculated on 658 patients who underwent bariatric surgery at 35 different bariatric surgery programs between 2015 and 2017. Patient characteristics, postoperative complications, and weight loss trajectories were compared between patients who met or exceeded their predicted weight loss calculation to those who did not based on observed to expected weight loss ratio (O:E) at 1 year after surgery. RESULTS: Patients who did not meet their predicted weight loss at 1 year (n = 237, 36%) had a mean O:E of 0.71, while patients who met or exceeded their prediction (n = 421, 63%) had a mean O:E = 1.14. At 6 months, there was a significant difference in the percent of the total amount of predicted weight loss between the groups (88% of total predicted weight loss for those that met their 1-year prediction vs 66% for those who did not, p \u3c 0.0001). Age, gender, procedure type, and risk-adjusted complication rates were similar between groups. CONCLUSION: Using a bariatric outcomes calculator can help set appropriate weight-loss expectations after surgery and also identify patients who may benefit from additional therapy prior to reaching their weight loss nadir

Factors associated with completion of patient surveys 1 year after bariatric surgery

BACKGROUND: Patient-reported outcomes (PRO) obtained from follow-up survey data are essential to understanding the longitudinal effects of bariatric surgery. However, capturing data among patients who are well beyond the recovery period of surgery remains a challenge, and little is known about what factors may influence follow-up rates for PRO. OBJECTIVES: To assess the effect of hospital practices and surgical outcomes on patient survey completion rates at 1 year after bariatric surgery. SETTING: Prospective, statewide, bariatric-specific clinical registry. METHODS: Patients at hospitals participating in the Michigan Bariatric Surgery Collaborative are surveyed annually to obtain information on weight loss, medication use, satisfaction, body image, and quality of life following bariatric surgery. Hospital program coordinators were surveyed in June 2017 about their practices for ensuring survey completion among their patients. Hospitals were ranked based on 1-year patient survey completion rates between 2011 and 2015. Multivariable regression analyses were used to identify associations between hospital practices, as well as 30-day outcomes, on hospital survey completion rankings. RESULTS: Overall, patient survey completion rates at 1 year improved from 2011 (33.9% ± 14.5%) to 2015 (51.0% ± 13.0%), although there was wide variability between hospitals (21.1% versus 77.3% in 2015). Hospitals in the bottom quartile for survey completion rates had higher adjusted rates of 30-day severe complications (2.6% versus 1.7%, respectively; P = .0481), readmissions (5.0% versus 3.9%, respectively; P = .0157), and reoperations (1.5% versus .7%, respectively; P = .0216) than those in the top quartile. While most hospital practices did not significantly impact survey completion at 1 year, physically handing out surveys during clinic visits was independently associated with higher completion rates (odds ratio, 13.60; 95% confidence interval, 1.99-93.03; P =.0078). CONCLUSIONS: Hospitals vary considerably in completion rates of patient surveys at 1 year after bariatric surgery, and lower rates were associated with hospitals that had higher complication rates. Hospitals with the highest completion rates were more likely to physically hand surveys to patients during clinic visits. Given the value of PRO on longitudinal outcomes of bariatric surgery, improving data collection across multiple hospital systems is imperative

Effect of Surgeon Age on Bariatric Surgery Outcomes

OBJECTIVE: This study sought to explore the relationship of bariatric surgeon age and patient outcomes. BACKGROUND: Regulators, policy makers, and patient advocacy groups have recently been pushing to establish clear guidelines for physician retirement in the United States. Although it is often assumed that increasing physician age leads to worse patient outcomes, the relationship is lacking robust evidence, and is still unclear. METHODS: We conducted a study analyzing all bariatric surgeons in Michigan who participated in a statewide collaborative quality improvement program (n = 71) who performed primary laparoscopic Roux-en-Y Gastric Bypass, or sleeve gastrectomy operations, and data on their patients (n = 60430) over the past 10 years. Our primary outcomes were 30-day postoperative complications. Odds ratios for overall complications and serious complications were calculated for each age group, and surgery type. RESULTS: Late career surgeons had more bariatric surgery experience and had a higher average annual case volume than early career surgeons. Considering all cases in the past 10 years, older surgeons performed more Roux-en-Y Gastric Bypass (40%) and less sleeve gastrectomy (38.8%) than younger surgeons (34.7% and 51.5%). When adjusting for patient and surgeon characteristics, there were no statistically significant differences in overall or serious complication rates for either procedure among surgeon age groups. CONCLUSIONS: When evaluating bariatric surgeons in the State of Michigan, we found no statistically significant association between surgeon age and patient outcomes. Our findings do not provide evidence for age-specific retirement cut-offs, but support the development of guidelines which are holistic, and focus on evaluating and improving physician outcomes at all career levels

Factors that influence discharge opioid prescribing among bariatric surgeons across Michigan

BACKGROUND: Opioid prescribing following bariatric surgery has been a focus due to its association with new persistent opioid use (NPOU) and worse outcomes. Guidelines have led to a reduction in opioids prescribed, but there remains variation in prescribing practices. METHODS: We conducted interviews with 20 bariatric surgeons across Michigan. Transcripts were analyzed using descriptive content analysis. RESULTS: At the patient level, surgeons described the role of surgical history and pain tolerance. At the provider level, surgeons discussed patient dissatisfaction, reputation, and workload. At the institution level, surgeons discussed colleagues, resources, and administration. At a collaborative level, surgeons described the role of evidence and performance measures. There was lack of consensus on whether NPOU is a problem facing patients undergoing bariatric surgery. CONCLUSION: Despite efforts aimed at addressing opioid prescribing, variability exists in prescribing practices. Understanding determinants that impact stakeholder alignment is critical to increasing adherence to guideline-concordant care

Am I on Track? Evaluating Patient-Specific Weight Loss after Bariatric Surgery Using an Outcomes Calculator

Introduction: Individual weight loss outcomes after bariatric surgery can vary considerably. As a result, identifying and assisting patients who are not on track to reach their weight loss goals can be challenging. Methods: Using a bariatric surgery outcomes calculator formulated by the Michigan Bariatric Surgery Collaborative (MBSC), 1-year predicted weight loss was calculated for patients who underwent primary sleeve gastrectomy and gastric bypass between 2015 and 2018 and also had a minimum of 3 follow-up weights reported (n = 658). Observed to expected (O:E) ratios were calculated for all patients and weight loss trajectories were compared between patients who met or exceeded their predicted weight loss calculation (O:E ≥1) to those who did not (O:E\u3c1). Results: Patients who did not meet their 1-year predicted weight loss (n = 237, mean O:E = 0.71) had a lower mean preoperative BMI (46.7 kg/m2 vs 48.5 kg/m2, p = 0.0079), were more likely to be black (13.9% vs 8.2%, p = 0.023) and had higher rate of hypertension (59.1% vs 48.9%, p = 0.0124) when compared with patients who either met or exceeded their weight loss prediction (n = 421,mean O:E = 1.14). Patients who did not meet their weight loss prediction also had less mean total body weight loss (19.8% vs 29.6%, p \u3c 0.0001) and were noted to have a lower O:E ratio as early as 3 months after surgery (0.50 vs 0.58, p \u3c 0.0001). Conclusion: Using a bariatric-specific weight-loss calculator, individuals can determine if they are on track to meeting their predicted weight loss calculation as early as three months after surgery

A Longitudinal Analysis of Variation in Psychological Well-being and Body Image in Patients Before and After Bariatric Surgery

MINI: In this multicenter, prospective cohort study we conducted a longitudinal assessment of a bariatric-specific, patient-reported outcome instrument. We assessed psychological well-being and satisfaction with body image before and after bariatric surgery, and its association with clinical outcomes. OBJECTIVE: We sought to use a bariatric-tailored patient-reported outcome (PRO) instrument to assess psychological well-being and satisfaction with body image before and after bariatric surgery, and its association with clinical outcomes. BACKGROUND: Weight loss after bariatric surgery has the potential to improve body image and psychological well-being. Traditional instruments used to measure these PROs have, however, not been tailored to patients who have undergone bariatric surgery. METHODS: In this multicenter, prospective, longitudinal cohort study we administered the Body-Q survey (a validated, customized PRO instrument) to patients in the Michigan Bariatric Surgery Collaborative just before bariatric surgery and at 1-year postoperatively. We linked the survey data to prospectively collected clinical outcome data to assess associations between body image or psychological well-being and patient characteristics and clinical outcomes (ie, percent excess body weight loss and complications). RESULTS: The preoperative and postoperative surveys were completed by 4068 patients for body image and 4062 patients for psychological well-being. Overall mean scores for body image and psychological well-being improved significantly from 26.2 ± 21.4 and 70.8 ± 20.1, respectively, before surgery to 57.7 ± 21.1 and 78.1 ± 22.1 after surgery. For both body image and psychological well-being, we found several patient-level factors such as sex, race, income level, and baseline body mass index that were statistically significant predictors of increases in scores. All P values less than 0.05. CONCLUSIONS: Psychological well-being and body image vary widely across patients before bariatric surgery with significant increases in both measures 1 year postoperatively. Some patient populations do not experience the same increases at 1 year. Recognition of these differences and factors contributing to lower reported levels of psychological well-being and body image may help providers provide appropriate counseling in the postoperative period

Evaluating the effect of operative technique on leaks after laparoscopic sleeve gastrectomy: a case-control study

OBJECTIVE: To assess the effect of operative technique on staple line leaks after laparoscopic sleeve gastrectomy (LSG). BACKGROUND: Staple-line leaks after LSG are a major source of morbidity and mortality. Variations in operative technique exist; however, their effect on leaks is poorly understood. METHODS: We analyzed data from the Michigan Bariatric Surgery Collaborative (MBSC) to perform a case-control study comparing patients who had a clinically significant leak after undergoing a primary LSG to those who did not. A total of 45 patients with leaks were identified between January 2007 and December 2013. The leak group was matched 1:2 to a control group based on procedure type, age, body mass index, sex, and year the procedure was performed. Technique-specific factors were assessed by reviewing operative notes from all primary bariatric procedures in our study population. Conditional logistic regression was used to identify techniques associated with leaks. To increase the power of our analysis, we used a significance level of .10. RESULTS: Leak rates with LSG have decreased over the past 5 years (1.18% to .36%) as annual case volume has increased (846 cases/yr to 4435 cases/yr). Surgeons who performed 43 or more cases per year had a leak rate CONCLUSION: Despite considerable variation in operative technique, leak rates with laparoscopic sleeve gastrectomy have decreased over time as operative volume has increased. Oversewing of the staple line was associated with fewer leaks, but specific suturing technique was not uniform and oversewing was performed routinely by more experienced surgeons with higher case volumes and less complication rates overall. Before standardizing surgical technique one must take into account variations in surgeon skill and experience

Site-specific Approach to Reducing Emergency Department Visits Following Surgery

OBJECTIVE: The aim of this study was to explore the efficacy of current bariatric perioperative measures at reducing emergency department (ED) visits following bariatric surgery in the state of Michigan. SUMMARY OF BACKGROUND DATA: Many ED visits following bariatric surgery do not result in readmission and may be preventable. Little research exists evaluating the efficacy of perioperative measures aimed at reducing ED visits in this population. Therefore, understanding the driving factors behind these preventable ED visits may be a fruitful approach to prevention. Furthermore, evaluating the efficacy of current perioperative measures may shed light on how to achieve meaningful reductions in ED visits. METHODS: We studied 48,035 eligible bariatric surgery patients across 37 Michigan Bariatric Surgical Collaborative (MBSC) sites between January 2012 and October 2015. Hospitals were ranked according to their risk- and reliability-adjusted ED visit rates. For hospitals in each ED visit rate tercile, several patient, surgery, and hospital summary characteristics were compared. We then studied whether a hospital\u27s compliance with specific perioperative measures was significantly associated with reduced ED visit rates. RESULTS: Only 3 of the 30 surgery, hospital, and patient summary characteristics studied were significant predictors of a hospital\u27s ED visit rate: rate of sleeve gastrectomies, rate of readmissions, and rate of venous thromboembolism complications (P = 0.04, P = 0.0065, and P = 0.0047, respectively). Also, a hospital\u27s compliance with the perioperative measures evaluated was not a significant predictor of ED visit rates (P = 0.12). CONCLUSIONS: Current practices aimed at reducing ED visits appear to be ineffective. Due to heterogeneity in patient populations and local infrastructure, a more tailored approach to ED visit reduction may be more successful

Association Between Surgeon Practice Knowledge and Venous Thromboembolism

BACKGROUND: The most common cause of mortality following bariatric surgery is venous thromboembolism. Our study aimed to (1) determine the practice patterns of venous thromboembolism (VTE) chemoprophylaxis among bariatric surgeons participating in a large statewide quality collaborative and (2) compare the results of surgeon self-reported chemoprophylaxis practices to actual practices from abstracted chart data. METHODS: We administered a 13-question survey to 66 surgeons across a statewide collaborative aimed at revealing VTE practice patterns such as medication type, dosage, timing, duration, and level of trainee involvement (response rate 93%). We conducted on-site data audits to examine the charts of all patients that had developed VTE during the study period and 15 other randomly selected patient charts per site. We then evaluated both the ordered perioperative chemoprophylaxis and the actual administered chemoprophylaxis from nursing and electronic records. RESULTS: There was 31% overall discordance between self-reported and abstracted chart data for pre-operative VTE dosing regimens. Among patients who had a VTE, 39% of administered chemoprophylaxis did not match surgeon responses. Conversely, among patients who did not have a VTE, only 29% were discordant (p = 0.03). In contrast, for post-operative VTE dosing, there was no significant difference in the rate of discordance in patients with and without a VTE (47% discordance vs 38%, p = 0.0552, respectively). CONCLUSIONS: Greater discordance between surgeon self-reported and actual perioperative VTE chemoprophylaxis is associated with significantly increased risk of VTE. Further understanding of the system characteristics associated with these practices may yield insights into how best to improve appropriate VTE chemoprophylaxis