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

Doumouras, Aristithes G.; Lee, Yung; Babe, Glenda; Gmora, Scott; Tarride, Jean‐Éric; Hong, Dennis; Anvari, Mehran

doi:10.1007/s00464-019-06894-9

Cited by 28 publications

(44 citation statements)

References 28 publications

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“…Achieving a goal of reducing wait times across Canada toward those seen in Ontario will be influenced by multiple factors. The expedited pathway in Ontario sees earlier surgery but a higher dropout rate (11,25,26) compared to the Alberta pathway used in this study as the Canadian average (15). A key difference between the two is the inclusion of a weight management program in the Alberta pathway, but whether the addition of weight management or a higher degree of patient engagement is responsible for higher retention is unclear.…”

Section: Discussionmentioning

confidence: 92%

“…Patient non-completion of surgery is another potential area to address. Predictors of patient attrition have been investigated (11,25), but the reasons are unclear. Non-completion for many patients is self-directed, rather than physician-advised, and the patients no longer engage with the bariatric surgery program to explain why they have left (25).…”

Section: Discussionmentioning

confidence: 99%

“…The improvements in wait time and post-surgical trajectory assessed are hypothetical, but within reason. Surgical delivery at 1 year post-referral occurs in the Ontario care pathway (11,25,26), and there is considerable overlap in the weight trajectories of the two care pathways (Figure 1) demonstrating non-significance of the weight loss improvements under consideration.…”

Section: Discussionmentioning

confidence: 99%

“…Patient attrition during the wait for bariatric surgery has been identified as an issue in the care of patients with obesity (8,11,25). Among the studies analyzed for the present investigation, attrition data were identified for the provinces of Alberta and Ontario.…”

Section: Pre-surgical Periodmentioning

confidence: 99%

“…After referral for surgery, some patients in Canada do not complete the program for various reasons including dropout or seeking surgery elsewhere. Recent studies in the province of Ontario have found significant predictors of non-completion of surgery to include male sex, increasing age, the occurrence of diabetes, longer wait times, and non-white race ( 11 , 12 ).…”

Section: Introductionmentioning

confidence: 99%

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Earlier Provision of Gastric Bypass Surgery in Canada Enhances Surgical Benefit and Leads to Cost and Comorbidity Reduction

Davis

Saunders

2020

Front. Public Health

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Background: Effective provision of bariatric surgery for patients with obesity may be impeded by concerns of payers regarding costs or perceptions of patients who drop out of surgical programs after referral. Estimates of the cost and comorbidity impact of these inefficiencies in gastric bypass surgery in Canada are lacking but would aid in informing healthcare investment and resource allocation. Objectives: To estimate total and relative public payer costs for surgery and comorbidities (diabetes, hypertension, and dyslipidemia) in a bariatric surgery population. Methods: A decision analytic model for a 100-patient cohort in Canada (91% female, mean body mass index 49.2 kg/m 2 , 50% diabetes, 66% hypertension, 59% dyslipidemia). Costs include surgery, surgical complications, and comorbidities over the 10-year post-referral period. Results are calculated as medians and 95% credibility intervals (CrIs) for a pathway with surgery at 1 year ("improved") compared with surgery at 3.5 years ("standard"). Sensitivity analyses were performed to test independent contributions to results of shorter wait time, better post-surgical weight loss, and randomly sampled cohort demographics. Results: Compared to standard care, the improved path was associated with reduction in patient-years of treatment for each of the three comorbidities, corresponding to a reduction of $1.1 (0.68-1.6) million, or 34% (26-41%) of total costs. Comorbidity treatment costs were 9.0-and 4.7-fold greater than surgical costs for the standard and improved pathways, respectively. Relative to non-surgical bariatric care, earlier surgery was associated with earlier return on surgical investment and 2-fold reduction in risk of prevalence of each comorbidity compared to delayed surgery. Conclusions: Comorbidity costs represent a greater burden to payers than the costs of gastric bypass surgery. Investments may be worthwhile to reduce wait times and dropout rates and improve post-surgical weight loss outcomes to save overall costs and reduce patient comorbidity prevalence.

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Section: Discussionmentioning

confidence: 92%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Pre-surgical Periodmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Earlier Provision of Gastric Bypass Surgery in Canada Enhances Surgical Benefit and Leads to Cost and Comorbidity Reduction

Davis

Saunders

2020

Front. Public Health

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Comparison of 4-Year Health Care Expenditures Associated With Roux-en-Y Gastric Bypass vs Sleeve Gastrectomy

et al. 2021

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IMPORTANCE Data on the long-term health care expenditures associated with bariatric surgery consisting of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy are lacking.OBJECTIVE To compare 4-year health care expenditures after RYGB vs sleeve gastrectomy, identify factors independently associated with 4-year health care expenditures, and compare the procedures in terms of subsequent hospitalizations, bariatric procedures, and all-cause mortality. DESIGN, SETTING, AND PARTICIPANTSIn this propensity score-matched cohort study, all residents of Ontario, Canada, who underwent publicly funded surgery with RYGB (n = 6301) or

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Association Between Bariatric Surgery and Major Adverse Diabetes Outcomes in Patients With Diabetes and Obesity

et al. 2021

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IMPORTANCEThere are high-quality randomized clinical trial data demonstrating the effect of bariatric surgery on type 2 diabetes remission, but these studies are not powered to study mortality in this patient group. Large observational studies are warranted to study the association of bariatric surgery with mortality in patients with type 2 diabetes. OBJECTIVE To determine the association between bariatric surgery and all-cause mortality among patients with type 2 diabetes and severe obesity. DESIGN, SETTING, AND PARTICIPANTS This retrospective, population-based matched cohort study included patients with type 2 diabetes and body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) 35 or greater who underwent bariatric surgery from January 2010 to December 2016 in Ontario, Canada. Multiple linked administrative databases were used to define confounders, including age, baseline BMI, sex, comorbidities, duration of diabetes diagnosis, health care utilization, socioeconomic status, smoking status, substance abuse, cancer screening, and psychiatric history. Potential controls were identified from a primary care electronic medical record database. Data were analyzed in 2020.EXPOSURE Bariatric surgery (gastric bypass and sleeve gastrectomy) and nonsurgical management of obesity provided by the primary care physician. MAIN OUTCOMES AND MEASURESThe primary outcome was all-cause mortality. Secondary outcomes were cause-specific mortality and nonfatal morbidities. Groups were compared through a multivariable Cox proportional Hazards model. RESULTSA total of 6910 patients (mean [SD] age at baseline, 52. 04 [9.45] years; 4950 [71.6%] women) were included, with 3455 patients who underwent bariatric surgery and 3455 match controls and a median (interquartile range) follow-up time of 4.6 (3.22-6.35) years. In the surgery group, 83 patients (2.4%) died, compared with 178 individuals (5.2%) in the control group (hazard ratio [HR] 0.53 [95% CI, 0.41-0.69]; P < .001). Bariatric surgery was associated with a 68% lower cardiovascular mortality (HR, 0.32 [95% CI, 0.15-0.66]; P = .002) and a 34% lower rate of composite cardiac events (HR, 0.68 [95% CI, 0.55-0.85]; P < .001). Risk of nonfatal renal events was also 42% lower in the surgical group compared with the control group (HR, 0.58 [95% CI, 0.35-0.95], P = .03).Of the groups that had the highest absolute benefit associated with bariatric surgery, men had an absolute risk reduction (ARR) of 3.7% (95% CI, 1.7%-5.7%), individuals with more than 15 years of diabetes had an ARR of 4.3% (95% CI, 0.8%-7.8%), and individuals aged 55 years or older had an ARR of 4.7% (95% CI, 3.0%-6.4%).

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

Cited by 28 publications

References 28 publications

Earlier Provision of Gastric Bypass Surgery in Canada Enhances Surgical Benefit and Leads to Cost and Comorbidity Reduction

Earlier Provision of Gastric Bypass Surgery in Canada Enhances Surgical Benefit and Leads to Cost and Comorbidity Reduction

Comparison of 4-Year Health Care Expenditures Associated With Roux-en-Y Gastric Bypass vs Sleeve Gastrectomy

Association Between Bariatric Surgery and Major Adverse Diabetes Outcomes in Patients With Diabetes and Obesity

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