Study Roundup

Published in March Issue             

Association Between Bariatric Surgery and Rates of Continuation, Discontinuation, or Initiation of Antidiabetes Treatment Six Years Later (JAMA Surgery)

To determine rates of discontinuation and initiation of antidiabetes treatment six years after bariatric surgery, records from a French national health insurance database were used to identify 15,650 patients (mean age 38.9, 84.6% female) undergoing primary bariatric surgery between January 1 and December 31, 2009 (48.5% - gastric banding, 27.7% - gastric bypass, and 22.0% - sleeve gastrectomy), and a nonsurgical cohort of patients matched on age, sex, body mass index (BMI) and antidiabetic treatment that were hospitalized for obesity in 2009 but did not have bariatric surgery between 2005 and 2015. Among the 1,633 patients receiving antidiabetic treatment at baseline, the discontinuation rate was higher six years after bariatric surgery than in controls (49.9% vs. 9.0%). The main predictive factors for discontinuation were gastric bypass [odds ratio (OR) 16.7 compared to sleeve gastrectomy-OR 7.30, and gastric banding-OR 4.30] and insulin use (OR 0.17). Other predictive factors included antidepressant treatment (OR 0.67) and age (OR 0.96) per year. Risk factors for initiation of diabetes treatment were higher BMI (OR 2.04 for BMI ≥50.0 vs. 30.0-39.9 and OR 1.68 for 40.0-49.9 vs. 30.0-39.9), antihypertensive treatment (OR 1.49) and low income (OR 1.43). The findings indicate bariatric surgery is associated with a significantly higher
six-year postoperative antidiabetes treatment discontinuation rate.

Emotional Food Cravings Predicts Poor Short-Term Weight Loss Following Laparoscopic Sleeve Gastrectomy (British Journal of Health Psychology)

The study aimed to identify post-surgery eating beliefs and behaviors in response to cravings that are predictive of not achieving excess weight loss (EWL) of greater than 40% at six to eight months after laparoscopic sleeve gastrectomy. In total, 106 patients (80.7% female) completed the Food Cravings Questionnaire-Trait version (FCQ-T) two times, at four to six weeks and six months post-operative, to identify change in nine subscales: intentions to eat, positive reinforcement, negative reinforcement, lack of control, preoccupation with food, feelings of hunger, negative affect, emotions experienced before or during food cravings or eating, and guilty feelings. Study participants had 64% EWL, on average, six to eight months after surgery. Among those that did not achieve greater than 40% EWL, of the nine subscales, emotional food craving was a significant predictor of failure (OR 4.19).

Laparoscopic Sleeve Gastrectomy as a Viable Option for an Ambulatory Surgical Procedure: Our 52-Month Experience (SOARD)

In the study, which is the largest case series of laparoscopic sleeve gastrectomy cases discharged the same day, 821 consecutive patients who had surgery from January 2011 to April 2015 were followed for 52 months to determine if sleeve gastrectomy can be safely performed in the ambulatory setting. Incidence of complications and admission to the hospital after discharge was reviewed up to 30 days from surgery. Follow-up at 30 days was 98.4%. There were 19 30-day complications (seven gastric leaks, four for intra-abdominal abscess, four for dehydration/nausea/vomiting, four for other causes), of which 17 required admission to the hospital. The overall complication and readmission rates at 30 days were 2.3% and 2.1%, respectively. The authors concluded that with stringent patient selection and utilization of enhanced recovery pathways these findings indicate that sleeve gastrectomy may be suitable for the outpatient setting.

Resting Metabolic Rate and Weight Loss after Bariatric Surgery (SOARD)

To determine the relation between the changes in body composition, energy expenditure (EE) and weight loss after bariatric surgery, a cohort of 45 patients were prospectively evaluated by bioelectrical impedance analysis and resting metabolic rate (RMR) by indirect calorimetry before and six months after surgery. Patients were divided into four groups based on patterns of change in the RMR after surgery: decrease (group 1), keep stable
(group 2), had small increase (group 3) or important increase (group 4). A significant relation between Fat-Free Mass (FFM) and RMR for both pre and postoperative periods was observed. EWL had a significant correlation only with post RMR. The pattern of change in RMR was strongly correlated with weight loss, considering an EWL greater than 50% a successful weight loss: in group 1, no patients achieved success; in group 2, 61% of patients achieved success; in group 3, 80% achieved success; and all the patients of group 4 had a successful weight loss. The increase in RMR after surgery is a major factor related to a satisfactory EWL after surgery, according to the authors.

The Readmission Contradiction: Towards Clarifying Common Misconceptions about Bariatric Readmissions and Quality Improvement (SOARD)

This retrospective study analyzed a prospective database of patients undergoing primary gastric bypass or sleeve gastrectomy between May 1, 2007 and April 30, 2015 to determine factors associated with an increased risk for readmissions. Phase I included readmission, demographic and surgical outcomes data. Phase II focused on "nonclinical" data from readmitted patients including payer status (Medicare, Medicaid, Commercial, Geisinger Health Plan), distance from home to the index hospital and utilization of a transfer center.
In total, 2,275 patients were studied and 5.5% were readmitted. Of those readmitted, 48% were preventable and most often associated with nausea, vomiting and dehydration.
Non-preventable readmissions were significantly associated with major complications.
No significant difference was found in overall or preventable readmission rates by payer. Distance from index hospital was not significantly associated with readmissions, however, 28% of readmitted patients were transferred from other health care facilities. With nearly half of all bariatric readmissions identified as preventable, that authors suggest there is a quality improvement opportunity.

Bariatric Surgery Coverage: A Comprehensive Budget Impact Analysis from a Payer Perspective (Obesity Surgery)

The study estimated the impact of covering bariatric surgery under multiple scenarios for a general or type 2 diabetes population under (1) unrestricted, (2) budget-restricted ($500,000/year), and (3) quantity-restricted (100/year) medical benefit plan versus non-coverage over a 10-year period. A model was used to calculate the incremental cost
per-member-per-month by estimating the difference in total non-diabetes and diabetes-related expected costs and savings. The model used a hypothetical payer population of 100,000 members under current real-world trends: BMI-defined obesity groups (31.3% normal/ underweight, 33% overweight, 20.4% obese, 9% severely obese and 6.3% morbidly obese), prevalence of type 2 diabetes (6.7–27.5%; 100% for the type 2 diabetes model), surgery type (gastric banding, BPD/DS, sleeve gastrectomy, and gastric bypass), and differential outcomes (diabetes resolution, costs, and reoperation and complications rates). The impact of covering bariatric surgery for a general and type 2 diabetes population ranged from an additional $0.3 to $3.6 and $0.3 to $10.5 for type 2 diabetes per-member-per-month in year one, respectively. Incremental costs diminished over time, breaking even between years five and nine (type 2 diabetes, years 5 to 6), and by year 10, cost savings were estimated to be between $1.5 and $4.8, and $1.2 and $31.8 for type 2 diabetes. The findings indicate that providing bariatric surgery coverage may have a modest short-term budget impact increase but would lead to long-term net cost savings in a general population model. Moreover, the cost savings would be much more pronounced in a type 2 diabetes population.

A Specialized Medical Management Program to Address Post-operative Weight Regain in Bariatric Patients (Obesity Surgery)

Researchers analyzed the three- and six-month weight outcomes of 48 bariatric patients referred to an individualized, multidisciplinary medical management program at a single center to address weight regain, comparing the patients to a group of matched non-bariatric patients. The multidisciplinary approach to address weight regain included intensive lifestyle management (diet, activity, anti-stress therapy, behavioral counseling, sleep) and medical intervention (one or more anti-obesity medications). The average post-operative weight regain of patients entering the weight management program was 20% above nadir and time since surgery averaged six years with a mean weight loss of -2.3kg and -4.4kg after three months and six months into the program, respectively. The researchers found that individuals most successful with weight loss were those treated with anorexigenic pharmaceuticals, and that weight and percent weight loss were significantly greater for the non-surgical than the surgical patients at three and six months. Overall, the researchers concluded that a medically supervised weight management program is beneficial for the treatment of weight regain after surgery.