Greater Adherence to Treatment After Bariatric Surgery by the Implementation of a Standardized Protocol for Delivering Care

Abstract

Bariatric surgery reference centers adopt different protocols of postoperative care including vitamins and minerals supplementation, since there is no consensus in the literature supporting the best approach. We sought to assess the impact of implementing a standardized postoperative care protocol on the adherence to a multidisciplinary team follow-up and the use of vitamin and mineral supplementation for one year after bariatric surgery in a tertiary care public hospital. This study compared a retrospective cohort of patients [n=70; usual care (UC)] who had undergone Roux-en-Y gastric bypass (RYGB) between April 2017 and April 2018 with a prospective cohort of patients [n=64; standardized postoperative protocol (SPP)] who had undergone RYGB between May 2018 and May 2019. The protocol included (1) a pre-scheduled calendar for one-year appointments with surgeons, nutritionists, and endocrinologists, (2) a systematic follow-up trough phone calls by a trained nurse, (3) a standardized vitamins/minerals supplementation during one year, and (4) pre-scheduled laboratory assessment. The initial approach started in the day after the surgery, when the nurse explained post-operative procedures and delivered printed material with the information and schedules. Patients received a standard supplementation free of charge (daily multivitamins with minerals, calcium carbonate 1,500 mg/day, vitramin D 20,000 IU/week, and 5,000 µg of intramuscular vitamin B12 if serum levels were lower than 400 pg/mL). This study was approved by the local Ethics Committee (2018-0183). Among the 134 patients, 86.7% were women, 42.4 ± 10.1 years-old, with preoperative body mass index of 48.5 ± 8.2 kg/m². Adherence to the postoperative care (multidisciplinary team follow-up and laboratory analyses) was 96.9% in the SPP and 81.7% in the UC (p = .003). The SPP attended a greater number of appointments (11 ± 2 vs. 7 ± 2, p <.001), showed a lower prevalence of suboptimal vitamin B12 at 3 months (18.7% vs. 39.5%, p = .03), and had a higher serum vitamin D levels at 3, 6, and 12 months (p <.001). Prevalence of vitamin D deficiency (lower than 20 ng/mL) one year after surgery was 1.6% vs. 24.3% (p <.001) in the SPP and UC, respectively. Only 18.3%, 26.8% and 41% of patients were using vitamin D supplements in the UC after 3, 6 and 12 months, respectively. We conclude that the proposed standardized protocol led to a greater adherence to the postoperative bariatric surgery care, adding attendance to appointments and reducing the incidence of vitamin deficiencies. Further cost-effectivity analysis may be needed to evaluate properly the implementation feasibility of the protocol in other centers. Financial support: CNPq, CAPES, FIPE (HCPA)