The hidden cost of an extensive preoperative work-up: predictors of attrition after referral for bariatric surgery in a universal healthcare system
Bariatric surgery is in high demand and patients generally undergo an extensive work-up process to maximize the success of surgery, especially in universal healthcare systems. Although valuable, this work-up process can lead to attrition before surgery. Therefore, we aim to assess patient and health system factors associated with attrition after bariatric surgery referral in a universal healthcare system.
This was a population-based study of all patients aged ≥ 18 referred for bariatric surgery in Ontario, Canada from 2009 to 2015. Primary outcome was patients who dropped out of bariatric surgery after referral. Predictors of attrition after referral included patient demographics, clinical, institutional, and socioeconomic variables. Odds ratios and 95% CIs were estimated by multilevel logistic regression models.
From 17,703 patients that were referred for bariatric surgery, 4122 patients dropped after the initial referral. Male patients, increasing age, and longer wait times for surgery were significantly (P < 0.0001) associated with higher odds of attrition. Additionally, smoker status, immigration status, unemployment, and disability were significant factors (P < 0.0001) predicting attrition. Patients who lived in lowest income quintile neighborhoods, when compared to those from the richest neighborhoods, had significantly higher odds of attrition (P = 0.02). Sleep apnea was associated with lower odds of attrition while diabetes and heart failure both with higher odds of attrition.
Even in a universal healthcare system, there are various factors that could lead to increased odds of attrition before bariatric surgery. Clear disparities exist for certain marginalized populations. Further studies are warranted to ensure equitable utilization of bariatric surgery for all patients.
KeywordsBariatric surgery Attrition Universal Healthcare Drop out
This work was funded by the Ontario Bariatric Network (OBN) research Grant awarded to Dr. Mehran Anvari.
Compliance with ethical standards
Doumouras, Lee, Babe, Tarride, Gmora, Hong, and Anvari have no conflicts of interest or financial ties to disclose.
- 1.World Health Organization (2016) WHO | Obesity and overweight. In: Obes. overweight (Fact sheet)Google Scholar
- 2.Statistics Canada (2014) Overweight and obese adults (self-reported), 2014. https://www150.statcan.gc.ca/n1/pub/82-625-x/2015001/article/14185-eng.htm
- 4.Colditz GA, Willett WC, Rotnitzky A, Manson JE (1995) Weight gain as a risk factor for clinical diabetes mellitus in women. Ann Intern Med. https://doi.org/10.7326/0003-4819-122-7-199504010-00001 Google Scholar
- 7.Peeters A, Barendregt JJ, Willekens F, Mackenbach JP, Al Mamun A, Bonneux L, Janssen F, Kunst A, Nusselder W (2003) Obesity in adulthood and its consequences for life expectancy: a life-table analysis. Ann Intern Med. https://doi.org/10.7326/0003-4819-138-1-200301070-00008 Google Scholar
- 8.Adams TD, Davidson LE, Litwin SE, Kim J, Kolotkin RL, Nanjee MN, Gutierrez JM, Frogley SJ, Ibele AR, Brinton EA, Hopkins PN, McKinlay R, Simper SC, Hunt SC (2017) Weight and metabolic outcomes 12 years after gastric bypass. N Engl J Med 377:1143–1155. https://doi.org/10.1056/NEJMoa1700459 CrossRefGoogle Scholar
- 25.Juenger J, Schellberg D, Kraemer S, Haunstetter A, Zugck C, Herzog W, Haass M (2002) Health related quality of life in patients with congestive heart failure: comparison with other chronic diseases and relation to functional variables. Heart 87:235–241. https://doi.org/10.1136/HEART.87.3.235 CrossRefGoogle Scholar
- 26.Garza CA, Pellikka PA, Somers VK, Sarr MG, Collazo-Clavell ML, Korenfeld Y, Lopez-Jimenez F (2010) Structural and functional changes in left and right ventricles after major weight loss following bariatric surgery for morbid obesity. Am J Cardiol 105:550–556. https://doi.org/10.1016/j.amjcard.2009.09.057 CrossRefGoogle Scholar
- 28.Owan T, Avelar E, Morley K, Jiji R, Hall N, Krezowski J, Gallagher J, Williams Z, Preece K, Gundersen N, Strong MB, Pendleton RC, Segerson N, Cloward TV, Walker JM, Farney RJ, Gress RE, Adams TD, Hunt SC, Litwin SE (2011) Favorable changes in cardiac geometry and function following gastric bypass surgery. J Am Coll Cardiol 57:732–739. https://doi.org/10.1016/j.jacc.2010.10.017 CrossRefGoogle Scholar