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Study Roundup

Published in July/August Issue             

Hospital Quality and Medicare Expenditures for Bariatric Surgery in the United States   (Annals of Surgery)

A retrospective review of 38,374 Medicare beneficiaries that had bariatric surgery between 2011 and 2013 examined the relationship between hospital outcomes and expenditures. Hospitals were ranked into quintiles by their risk and reliability-adjusted postoperative serious complications, following which an examination of the relationship between upper and lower outcome quintiles with risk-adjusted total episode payments was performed. Additionally, patients were stratified by their risk (low, medium, high) of developing a complication to understand how this impacted payment. A strong correlation was found between hospital complication rates and episode payments. Hospitals in the lowest quintile of complication rates had average total episode payments that were $1,321 per patient less than hospitals in the highest quintile ($11,112 vs $12,433). Cost savings was more prominent amongst high-risk patients where the difference of total episode payments per patient between lowest and highest quintile hospitals was $2,160 ($12,960 vs $15,120). In addition to total episode payment savings, hospitals with the lowest complication rates also had decreased costs for index hospitalization, readmissions, physician services, and postdischarge ancillary care compared with hospitals with the highest complication rates. Medicare payments for bariatric surgery are significantly lower at hospitals with low complication rates. These findings suggest that efforts to improve bariatric surgical quality may ultimately help reduce costs. Additionally, the authors note that these cost savings may be most prominent amongst the patients at the highest risk for complications.

New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults
(JAMA Surgery)

A population-based study of 36,177 surgical patients who had elective procedures aimed to determine the incidence of new persistent opioid use after minor and major procedures. Using a nationwide insurance claims data set from 2013 to 2014, researchers identified U.S. adults aged 18 to 64 years without opioid use in the year prior to surgery (i.e. no opioid prescription fulfillments from 12 months to 1 month prior to the procedure). For patients filling a perioperative opioid prescription, researchers calculated the incidence of persistent opioid use for more than 90 days among opioid-naive patients after both minor surgical procedures (ie, varicose vein removal, laparoscopic cholecystectomy, laparoscopic appendectomy, hemorrhoidectomy, thyroidectomy, transurethral prostate surgery, parathyroidectomy, and carpal tunnel) and major surgical procedures (ie, ventral incisional hernia repair, colectomy, reflux surgery, bariatric surgery, and hysterectomy). Among the patient cohort, 29,068 (80.3%) had minor surgical procedures and 7,109 (19.7%) had major procedures. By comparison, the incidence in the nonoperative control cohort was only 0.4%. Risk factors independently associated with new persistent opioid use included preoperative tobacco use, alcohol and substance abuse disorders, mood disorders, anxiety and preoperative pain disorders. The authors concluded that new persistent opioid use after surgery is common and is not significantly different between minor and major surgical procedures but rather associated with behavioral and pain disorders. The findings suggest opioid use is not due to surgical pain but addressable patient-level predictors.

Changes in Dietary Intake and Eating Behavior in Adolescents After Bariatric Surgery:
an Ancillary Study to the Teen-LABS Consortium
(Obesity Surgery)

To investigate changes in dietary intake and eating behavior of adolescents with obesity who underwent bariatric surgery (n = 119) or lifestyle modification (LM), (n = 169), a prospective investigation of 288 patients were assessed at 6, 12, and 24 months after treatment. At 1 year follow-up, adolescents who underwent bariatric surgery experienced significantly greater weight loss than those who received LM. The two groups differed in self-reported intake of a number of macronutrients at 6 and 12 months from baseline, but not total caloric intake. Patients treated with surgery, compared to those treated with LM, also reported significantly greater reductions in a number of disordered eating symptoms. After bariatric surgery, greater weight loss from postoperative month 6 to 12 was associated with self-reported weight consciousness, craving for sweets, and consumption of zinc.

The Standardized Postoperative Checklist for Bariatric Surgery; a Tool for Safe
Early Discharge?
(Obesity Surgery)

A pilot study evaluating the effect of a postoperative checklist in bariatric surgery that addressed regularly measured parameters on the occurrence and early recognition of complications during the first postoperative day after bariatric surgery. The checklist included information on nausea, pain, temperature, heart rate, and laboratory markers. Patients were divided into three groups were formed: no complications, minor complications, and major complications. Of the 694 patients, 29 developed major complications within 30 days postoperatively. There were no significant differences in baseline characteristics between groups. Subjects with major complications were less willing to be discharged due to complaints, compared to subjects with no or minor complications (14.8 vs. 3.6 and 4.6%, respectively) and had a higher decrease of hemoglobin level (0.8 vs. 0.6 and 0.65 mmol/l, respectively). The findings indicate that the patientís willingness for discharge, in combination with hemoglobin decrease, may be the best early predictors of major complications after bariatric surgery. The authors suggested that the postoperative checklist used in the study may be an adequate instrument to identify patients who can be safely discharged home on the first postoperative day.

Dietary Intake and Weight Changes 5 Years After Laparoscopic Sleeve Gastrectomy
(Obesity Surgery)

To investigate long-term dietary intake and weight status after laparoscopic sleeve gastrectomy, 40 patients were followed for more than 5 years, during which complete clinical data and food frequency questionnaires were analyzed. Mean BMI was 37.9 kg/m2. Mean BMI loss at 5 years after surgery as 10.6 kg/m2. Weight regain appeared in 20% of patients. Dietary composition analysis at 5 years showed mean calorie intake of 1,230 kcal/day, protein 70 g/day (22.5% of calorie), fat 50 g/day (36.1%), carbohydrate 126 g (41.4%), iron 7.5 mg/day, calcium 536.2 mg/day, and fiber 11.7 g/day. Calorie intake at 5 years after sleeve gastrectomy is correlated with weight loss but weight regain is not related to a higher calorie intake. All comorbidities were significantly improved after surgery but hemoglobin and parathyroid hormone significantly changed. Incidence of iron deficiency anemia increased from 7.5% at pre-operation to 41.2% after sleeve gastrectomy. Incidence of secondary hyperparathyroidism increased from 17.5 to 60.7%.

Weight Regain in Patients with Symptoms of Post-Bariatric Surgery Hypoglycemia (SOARD)

To determine whether patients with post-bariatric surgery hypoglycemia (PBSH) symptoms have greater odds for Weight regain (WR), a mail survey was conducted among 1,119 patients who underwent gastric bypass or sleeve gastrectomy at a tertiary academic hospital from Augist 2008 to August 2012, from which weight trajectory and PBSH symptoms were assessed. Of those surveyed, 428 respondents (40.6%) were eligible for analysis. The primary outcome was WR>=10% between dates of survey completion and bariatric surgery, as reflection of the median WR among respondents. WR was observed in 79.2% (N=339), while 20.8% (N=89) experienced either weight loss or no weight regain, at a mean of 40.6 Ī 14.5 months. Median WR was 10.8%. Odds of WR>=10% was significantly increased in those who experienced PBSH symptoms, reported less adherence to nutritional guideline and had longer time since surgery.