Researchers from the University Health Network in Toronto are hoping to improve the operational efficiency of bariatric surgery programs to increase access to care. Studies have shown that bariatric operations can alleviate chronic health issues like diabetes and arthritis for extremely obese people. Now the University Health Network researchers are trying to determine why many patients who are referred for a bariatric operation do not ultimately have the procedure performed, despite being in a publicly funded health care program.  Findings from their single-site study are published in the November issue of the Journal of the American College of Surgeons.

For people who are severely obese, bariatric operations can provide a “treatment modality for obesity,” the study authors noted. Severe obesity means the person has a basal metabolic index (BMI) of 40 or greater. That’s about 240 lbs for a 5-foot, 5-inch person, according to the U.S. Center’s for Disease Control BMI calculator.

“We often see patients who are older in life come to us with a spectrum of co-morbidities, like diabetes and osteoarthritis, as a result of their obesity,” said Fayez Quereshy, MD, MBA, FRCSC, staff surgeon at the University Health Network in Toronto and a senior author on the study. Osteoarthritis, in particular, can make exercise-induced weight loss difficult because patients are often in too much pain to exercise,. People with a BMI of 35 or higher may also be candidates if they also have one or more chronic conditions. The person’s primary care physician may refer him or her for a bariatric surgical procedure for those reasons.

At the University Health Network’s program, patients then go through several assessments, including an orientation followed by a nursing consultation, a nutrition class and dietician assessment, and an evaluation by a social worker. They are then evaluated by a psychologist and have a final consultation with the surgeon before actually undergoing the procedure. At each of these steps in the process, clinical experts evaluate whether the patient is a candidate for the procedure.

However, many patients don’t make it through the orientation process. Dr. Quereshy and his colleagues collaborated with University of Toronto’s Rotman School of Management to identify which patients were more likely to quit the program and when.

The researchers analyzed data on 1,644 patients who were referred to the university’s bariatric surgery program between June 2008 and July 2011. Among them, only 45 percent actually became bariatric surgical patients.  Among those who didn’t, 30 percent didn’t even make it to the patient orientation session, the first step after getting the physician referral.

But it’s not because patients are being turned away. “…The majority of attrition appears to be the result of patient self-removal,” the authors wrote.

Least Likely Candidates

The patients who were least likely to have the operation included:

  Men - Male patients were half as likely as female patients to complete the assessments en route to having the operation performed, even if they attended the orientation. “This finding was surprising because many of the male patients had higher BMIs than the female patients,” Dr. Quereshy said.

  Less obese patients - Patients with a BMI of 35 to 40 were also more likely to drop out, especially after the orientation or the nutritional assessment. Those with a higher BMI of 40 to 49 were 1.5 times more likely to undergo the operation than those with a lower BMI.

  Smokers - Active smokers were 10 percent more likely to drop out after the social work assessment and 26 percent more likely to drop out after the nutrition evaluation than non-smokers. Dr. Quereshy said the fact that smokers were even referred to the program suggests that more education is needed among referring physicians. Smokers generally do not qualify as candidates for bariatric operations because they tend to suffer more complications during and after the procedure.

  Older patients - Patients who were age 60 or older were also 54 percent less likely to undergo the surgical procedure than younger patients. They were more likely to leave the program after orientation or after the surgical consultation, which typically is the final step before the operation.

Next Steps

For this Canadian study, payment is not an issue, since the authors studied surgical candidates for these procedures in a publicly funded program.  So Dr. Quereshy said that the next step is to ask one question about the patients who drop out: Why? This step includes qualitative research to understand which factors lead candidates to not have the operation. Knowing why patients drop out could save resources for the hospital and prevent disappointment for the patients.

Dr. Quereshy and his colleagues are currently testing whether a 40-question patient survey, to be completed before orientation, will help identify patients at risk for not having the operation. Then, the evaluation experts can get the patient the proper support upfront to help them through the process to the procedure. “If a patient has signs and symptoms of depression, for example,” Dr. Quereshy said, “we can make sure he or she sees the psychiatrist first.”

In addition to saving hospital resources, this step could also prevent patients from experiencing a disappointing blow. “This operation is not a cosmetic procedure. It is medically necessary to help with other significant medical issues,” Dr. Quereshy said. “Imagine being told after a year, ‘Sorry, you’re actually not a candidate.’ If that’s going to happen, I’d rather tell the patient at day 10, rather than at day 300.”

Adam Diamant, MSc, Joseph Milner, PhD, Michelle Cleghorn, MSc, Sanjeev Sockalingam, MD, FRCPC, Allan Okrainec, MD, MHPE, FRCSC, FACS, Timothy D Jackson, MD, MPH, FRCSC, FACS, also participated in this study.

Citation: Journal of the American College of Surgeons, November 2014: Vol. 219 (5) 1047-1055.

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About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 79,000 members and is the largest organization of surgeons in the world.

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