Advertisement

The hidden cost of an extensive preoperative work-up: predictors of attrition after referral for bariatric surgery in a universal healthcare system

  • Aristithes G. Doumouras
  • Yung Lee
  • Glenda Babe
  • Scott Gmora
  • Jean-Eric Tarride
  • Dennis HongEmail author
  • Mehran Anvari
2019 SAGES Oral

Abstract

Background

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.

Methods

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.

Results

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.

Conclusion

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.

Keywords

Bariatric surgery Attrition Universal Healthcare Drop out 

Notes

Funding

This work was funded by the Ontario Bariatric Network (OBN) research Grant awarded to Dr. Mehran Anvari.

Compliance with ethical standards

Disclosures

Doumouras, Lee, Babe, Tarride, Gmora, Hong, and Anvari have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    World Health Organization (2016) WHO | Obesity and overweight. In: Obes. overweight (Fact sheet)Google Scholar
  2. 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
  3. 3.
    Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ (2003) Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med.  https://doi.org/10.1056/NEJMoa021423 Google Scholar
  4. 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
  5. 5.
    Must A, Spadano J, Coakley E, Field A, Colditz G, Dietz W (1999) The disease burden associated with overweight and obesity. JAMA 282:1523–1529.  https://doi.org/10.1001/jama.282.16.1523 CrossRefGoogle Scholar
  6. 6.
    Fontaine KR, Barofsky I (2001) Obesity and health-related quality of life. Obes Rev 25:256.  https://doi.org/10.1046/j.1467-789x.2001.00032.x Google Scholar
  7. 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. 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
  9. 9.
    Courcoulas AP, Yanovski SZ, Bonds D, Eggerman TL, Horlick M, Staten MA, Arterburn DE (2014) Long-term outcomes of bariatric surgery. JAMA Surg 149:1323.  https://doi.org/10.1001/jamasurg.2014.2440 CrossRefGoogle Scholar
  10. 10.
    Diamant A, Milner J, Cleghorn M, Sockalingam S, Okrainec A, Jackson TD, Quereshy FA (2014) Analysis of patient attrition in a publicly funded bariatric surgery program. J Am Coll Surg.  https://doi.org/10.1016/j.jamcollsurg.2014.08.003 Google Scholar
  11. 11.
    Pitzul KB, Jackson T, Crawford S, Kwong JC, Sockalingam S, Hawa R, Urbach D, Okrainec A (2014) Understanding disposition after referral for bariatric surgery: when and why patients referred do not undergo surgery. Obes Surg.  https://doi.org/10.1007/s11695-013-1083-z Google Scholar
  12. 12.
    Sadhasivam S, Larson CJ, Lambert PJ, Mathiason MA, Kothari SN (2007) Refusals, denials, and patient choice: reasons prospective patients do not undergo bariatric surgery. Surg Obes Relat Dis.  https://doi.org/10.1016/j.soard.2007.07.004 Google Scholar
  13. 13.
    Chawla AS, Hsiao CW, Romney MC, Cohen R, Rubino F, Schauer P, Cremieux P (2015) Gap between evidence and patient access: policy implications for bariatric and metabolic surgery in the treatment of obesity and its complications. Pharmacoeconomics 33(7):629–641CrossRefGoogle Scholar
  14. 14.
    Fuchs HF, Broderick RC, Harnsberger CR, Chang DC, Sandler BJ, Jacobsen GR, Horgan S (2015) Benefits of bariatric surgery do not reach obese men. J Laparoendosc Adv Surg Tech 25:196–201.  https://doi.org/10.1089/lap.2014.0639 CrossRefGoogle Scholar
  15. 15.
    Wee CC, Davis RB, Huskey KW, Jones DB, Hamel MB (2013) Quality of life among obese patients seeking weight loss surgery: the importance of obesity-related social stigma and functional status. J Gen Intern Med 28:231–238.  https://doi.org/10.1007/s11606-012-2188-0 CrossRefGoogle Scholar
  16. 16.
    Funk LM, Jolles S, Fischer LE, Voils CI (2015) Patient and referring practitioner characteristics associated with the likelihood of undergoing bariatric surgery: a systematic review. JAMA Surg 150:999–1005.  https://doi.org/10.1001/jamasurg.2015.1250 CrossRefGoogle Scholar
  17. 17.
    Padwal RS, Sharma AM (2009) Treating severe obesity: morbid weights and morbid waits. CMAJ 181:777–778.  https://doi.org/10.1503/cmaj.081508 CrossRefGoogle Scholar
  18. 18.
    Martin AR, Klemensberg J, Klein LV, Urbach D, Bell CM (2011) Comparison of public and private bariatric surgery services in Canada. Can J Surg 54:154–169.  https://doi.org/10.1503/cjs.048909 CrossRefGoogle Scholar
  19. 19.
    Khawali C, Ferraz MB, Zanella MT, Ferreira SRG (2014) Willingness to pay as patient preference to bariatric surgery. Health Expect 17:73–81.  https://doi.org/10.1111/j.1369-7625.2011.00738.x CrossRefGoogle Scholar
  20. 20.
    Sarkhosh K, Switzer NJ, El-Hadi M, Birch DW, Shi X, Karmali S (2013) The impact of bariatric surgery on obstructive sleep apnea: a systematic review. Obes Surg 23:414–423.  https://doi.org/10.1007/s11695-012-0862-2 CrossRefGoogle Scholar
  21. 21.
    Engleman HM, Martin SE, Douglas NJ (1994) Compliance with CPAP therapy in patients with the sleep apnoea/hypopnoea syndrome. Thorax 49:263–266.  https://doi.org/10.1136/THX.49.3.263 CrossRefGoogle Scholar
  22. 22.
    Glasgow RE, Ruggiero L, Eakin EG, Dryfoos J, Chobanian L (1997) Quality of life and associated characteristics in a large national sample of adults with diabetes. Diabetes Care 20:562–567.  https://doi.org/10.2337/DIACARE.20.4.562 CrossRefGoogle Scholar
  23. 23.
    Goldney RD, Phillips PJ, Fisher LJ, Wilson DH (2004) Diabetes, depression, and quality of life: a population study. Diabetes Care 27:1066–1070.  https://doi.org/10.2337/DIACARE.27.5.1066 CrossRefGoogle Scholar
  24. 24.
    Zambroski CH, Moser DK, Bhat G, Ziegler C (2005) Impact of symptom prevalence and symptom burden on quality of life in patients with heart failure. Eur J Cardiovasc Nurs 4:198–206.  https://doi.org/10.1016/j.ejcnurse.2005.03.010 CrossRefGoogle Scholar
  25. 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. 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
  27. 27.
    Valezi AC, Machado VHS (2011) Morphofunctional evaluation of the heart of obese patients before and after bariatric surgery. Obes Surg 21:1693–1697.  https://doi.org/10.1007/s11695-011-0431-0 CrossRefGoogle Scholar
  28. 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
  29. 29.
    Gill RS, Karmali S, Hadi G, Al-Adra DP, Shi X, Birch DW (2012) Predictors of attrition in a multidisciplinary adult weight management clinic. Can J Surg.  https://doi.org/10.1503/cjs.035710 Google Scholar
  30. 30.
    Kuwada TS, Richardson S, El Chaar M, Norton HJ, Cleek J, Tomcho J, Stefanidis D (2011) Insurance-mandated medical programs before bariatric surgery: do good things come to those who wait? Surg Obes Relat Dis 7:526–530.  https://doi.org/10.1016/J.SOARD.2010.08.017 CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of General SurgeryMcMaster UniversityHamiltonCanada
  2. 2.Centre for Minimal Access Surgery (CMAS), St. Joseph’s HealthcareMcMaster UniversityHamiltonCanada
  3. 3.Michael G. DeGroote School of MedicineMcMaster UniversityHamiltonCanada
  4. 4.Institute for Clinical Evaluative SciencesMcMaster UniversityHamiltonCanada
  5. 5.Programs for Assessment of Technology in Health Research Institute, St Joseph’s HealthcareMcMaster UniversityHamiltonCanada
  6. 6.Department of Clinical Epidemiology and Biostatistics, Faculty of Health SciencesMcMaster UniversityHamiltonCanada
  7. 7.Division of General SurgerySt. Joseph’s HealthcareHamiltonCanada

Personalised recommendations