- Email: [email protected]
Does patient compliance with preoperative bariatric office visits affect postoperative excess weight loss?
Surgery for Obesity and Related Diseases 7 (2011) 743–748
Integrated health article
Does patient compliance with preoperative bariatric office visits affect postoperative excess weight loss? Maher El Chaar, M.D., Kathleen McDeavitt, Sarah Richardson, Keith S. Gersin, M.D., Timothy S. Kuwada, M.D., Dimitrios Stefanidis, M.D., Ph.D.* Section of Bariatric Surgery, Division of Minimally Invasive Surgery and Bariatric Surgery, Carolinas Medical Center, Charlotte, North Carolina Received May 20, 2010; accepted October 8, 2010
Abstract
Background: The amount of excess weight loss (EWL) achieved after bariatric surgery has varied considerably. Reliable preoperative predictors of the postoperative %EWL do not exist. Patient compliance with the physician recommendations has generally been believed to be important for long-term success after bariatric surgery, especially after gastric banding. We hypothesized that poor preoperative patient compliance with office visits, a likely indicator of overall compliance, would be associated with lower %EWL after bariatric surgery at a teaching hospital in the United States. Methods: We performed an institutional review board-approved review of prospectively collected data from all patients undergoing bariatric surgery from 2007 to 2009. The patients were categorized into 2 groups: those who had missed ⬍25% of all preoperative appointments at our bariatric center and those who had missed ⬎25%. The average %EWL at 12 months between the 2 groups was compared using the unpaired t test separately for the gastric bypass and gastric banding patients. Results: The gastric band patients with ⬎25% missed appointments had lost 23% EWL at 12 months compared with 32% EWL for the gastric band patients who had missed ⬍25% of their appointments (P ⫽ .01). No difference was found in the %EWL for the gastric bypass patients according to the missed preoperative appointments. The postoperative compliance was significantly poorer than preoperatively. Conclusion: The patients with a greater percentage of missed preoperative appointments had a lower postoperative %EWL at 1 year after gastric banding but not after gastric bypass. This information could prove useful during patient selection or when counseling patients about the type of bariatric surgery to pursue. (Surg Obes Relat Dis 2011;7:743–748.) © 2011 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Patient compliance; Weight loss surgery; Gastric bypass; Gastric banding; Outcomes
Obesity has reached epidemic proportions in recent years in the United States [1]. Bariatric surgery is currently the only available and reliable option for the long-term treatment of morbid obesity [2,3]. Laparoscopic Roux-en-Y gasPresented as an oral presentation at the American Society for Metabolic and Bariatric Surgery Annual Meeting, June 21–26, 2010, Las Vegas, Nevada *Correspondence: Dimitrios Stefanidis, M.D., Ph.D., F.A.C.S., Carolinas Simulation Center, Division of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, Carolinas Medical Center, 1000 Blythe Boulevard, MEB 601, Charlotte, NC 28203. E-mail: [email protected].
tric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) have been shown to lead to significant and sustainable weight loss [4]. Nevertheless, the percentage of excess weight loss (EWL) achieved after bariatric surgery has varied considerably, indicating that factors other than procedural effectiveness are likely determinants of longterm weight loss [5,6]. Therefore, a number of studies have attempted to identify the preoperative patient factors that would predict postoperative weight loss; however, no clear predictors have been identified [6 –9]. In addition, patient compliance with dietary restrictions and physician recommendations after bariatric surgery have been considered
1550-7289/11/$ – see front matter © 2011 American Society for Metabolic and Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2010.10.020
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M. El Chaar et al. / Surgery for Obesity and Related Diseases 7 (2011) 743–748
important parameters for successful patient outcomes. The American Society for Metabolic and Bariatric Surgery has recommended that surgeons be a part of an integrated team, including dieticians, fitness experts, and psychologists, that follow-up bariatric patients on a regular basis to improve patient outcomes [10]. Nonetheless, the benefits of such a comprehensive support system will be negated when the patients are not compliant with the recommendations or when their follow-up with the bariatric program is suboptimal. The preoperative visits of bariatric patients will frequently be canceled or postponed, creating efficiency problems in bariatric offices. Such missed appointments not only effect the bariatric center financially but also can delay patient care and the interval to surgery. Because it has generally been accepted that patients who keep their appointments will be responsible and compliant, missed preoperative visits could potentially identify noncompliant patients who might experience suboptimal postoperative outcomes. We, therefore, hypothesized that poor preoperative patient compliance with office visits, a likely indicator of overall compliance, would be associated with poorer %EWL and co-morbidity resolution after bariatric surgery. Methods After institutional review board approval, the data were entered prospectively into an outcomes database containing the data from all patients seen at our multidisciplinary bariatric program, the Carolinas Weight Management and Wellness Center, and undergoing bariatric surgery from 2007 to 2009 at Carolinas Medical Center-Mercy (Charlotte, NC). Our bariatric program was composed of a comprehensive team of professionals including 3 board-certified and fellowship-trained bariatric surgeons, 2 board-certified medical bariatricians, 2 bariatric surgery fellows, 1 hepatologist, 2 midlevel providers, 1 Ph.D. psychologist, 1 center director, 1 nursing team, 3 registered dietitians, 1 fitness trainer and 1 fitness intern, 2 insurance specialists, and several support staff. New potential patients were required to attend an information session given by 1 of the 3 bariatric surgeons, their eligibility for bariatric surgery was determined, and their first appointment was scheduled with 1 of the bariatric surgeons. After this initial visit, all patients met with a dietician for a nutritional evaluation, the psychologist for a psychological evaluation, and the fitness trainer for a fitness assessment. When a patient had an insurance requirement for a preoperative weight loss program, they were followed up for 3– 6 months by our bariatric physicians. When the preoperative assessment was complete, surgery was scheduled, and the patient underwent preoperative counseling with the bariatric surgeon 2 weeks before the surgery date.
After surgery, the patients who had undergone LRYGB were seen in our office at 2 and 6 weeks, 3, 6, and 12 months, and yearly thereafter. After LAGB, the patients were seen at 2 weeks, had their first adjustment at 6 weeks, and were followed up every 3– 4 weeks for adjustments, as needed until they had achieved adequate restriction. At that point, their follow-up visits were scheduled at 6 –12-month intervals. Additional visits with members of our team could be scheduled on an as needed basis for both procedure groups. For the purposes of the present study, all the patients with follow-up data at 1 year after either LRYGB or LAGB were included. The following parameters were recorded at the initial visit to the bariatric office and at 12 months after bariatric surgery: patient weight, body mass index, and co-morbid conditions. We also recorded the type of procedure performed and the number of scheduled and attended preoperative and postoperative appointments with any member of our multidisciplinary team. We defined compliance as the frequency of missed appointments during the preoperative or postoperative period (ie, the percentage of scheduled appointments that were missed). Rescheduled appointments were also considered as missed appointments. The preoperative appointments included the initial bariatric surgery consultation and subsequent visits with the bariatric surgeon and all preoperative visits with the nutritionist, psychologist, and/or fitness specialist. The postoperative appointments included the scheduled visits with the bariatric surgeon and any other visits with other members of our team that might have been required. All patients included in the present study had been seen at 1 year postoperatively in the office and had had their weight measured using the same scale as before surgery. The patients were categorized into 2 groups: group 1 (compliant group) had missed ⬍25% of all preoperative appointments and group 2 (noncompliant group) had missed ⬎25% of their appointments. The LRYGB and LAGB groups were analyzed separately, and only primary procedures were included in our analysis. To calculate the %EWL, we used the following equation: [amount of weight loss/excess body weight] ⫻ 100. The excess body weight was calculated according to the ideal body weight using the medium-frame measurements of the Metropolitan Life insurance tables [11]. Resolution of hypertension was defined as a systolic blood pressure (without antihypertensive medications) of ⱕ140 mm Hg. Resolution of sleep apnea was defined as no need for a positive airway pressure device for a patient previously using one. The resolution of diabetes was determined by a hemoglobin A1c level ⬍6.0, and the resolution of hyperlipidemia was determined by a total cholesterol level ⬍200 mg/dL, low-density lipoprotein level ⬍130 mg/ dL, and triglyceride level ⬍150 mg/dL. The resolution of co-morbidities was determined during the 12-month follow-up visit by the bariatric surgeons after interviewing and
M. El Chaar et al. / Surgery for Obesity and Related Diseases 7 (2011) 743–748
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Table 1 Demographics of LRYGB and LAGB patients by compliance group Demographics
Group 1 (compliant; ⱕ25% missed appointments)
Group 2 (noncompliant; 25% missed appointments)
P value
LRYGB Age (yr) Women (%) BMI (kg/m2) Co-morbidity (%) Hypertension Sleep apnea Hyperlipidemia Type 2 diabetes mellitus LAGB Age (y) Women (%) BMI (kg/m [2]) Co-morbidity (%) Hypertension Sleep apnea Hyperlipidemia Type 2 diabetes mellitus
138 (78) 42.8 ⫾ 9.5 87 45.3 ⫾ 5.3
39 (22) 41.2 ⫾ 9.2 86 44.7 ⫾ 5
62.6 47.5 29.3 30.1 67 (76) 45.3 ⫾ 10 86 43.4 ⫾ 5.1
68.7 39.1 41.6 37 22 (24) 42.5 ⫾ 8.3 87.5 42.4 ⫾ 5.4
.14 .98 .30
67.2 49.1 33.3 26.2
51.6 41.9 36.7 20.7
.09 .46 .72 .52
.27 .82 .52 .42 .29 .09 .35
LRYGB ⫽ laparoscopic Roux-en-Y gastric bypass; BMI ⫽ body mass index; LAGB ⫽ laparoscopic adjustable gastric banding. Data in parentheses are percentages.
examining the patient and after the blood test results were reviewed. To assess the effect of preoperative compliance on outcomes, we compared the average %EWL at 12 months between the compliant and noncompliant groups for each procedure using the Student unpaired t test. We also compared the percentage of missed postoperative appointments between the compliant and noncompliant groups and correlated postoperative compliance with the %EWL at 12 months using Spearman’s correlation. The chi-square test or Fisher’s exact test was used to compare co-morbidity resolution 12 months after surgery between the compliance groups and procedures. P ⬍ .05 was considered statistically significant. The post hoc power analysis revealed that our sample size was adequate to detect an ⱖ7% difference in the %EWL at 12 months after surgery between the compliant and noncompliant groups after either procedure using an ␣ level of .8.
Results A total of 505 patients had undergone bariatric surgery during the study period. Of these, 164 (32%) had a follow-up period of ⬍1 year, 75 (15%) were lost to follow-up, and 266 (53%) had complete follow-up data at 1 year and were included in the present study. Of the 266 patients, 177 had undergone LRYGB and 89 (34%) had undergone LAGB. The patient demographics are listed in Table 1. No differences were seen in the patient demographics at baseline between the compliant and noncompliant patients for
either procedure in terms of age, gender, initial body mass index, or the presence of co-morbidities. The patients attended an average of 5.5 office appointments (range 2–26) and missed 11% of them during their preoperative period. The frequency of missed appointments was similar for the LRYGB and LAGB patients (Tables 2 and 3, respectively). In the LRYGB group, 78% of the patients had missed ⬍25% of their appointments (compliant group) and 22% had missed ⬎25% of their appointments (noncompliant group). In the LAGB group, 76% were compliant and 24% were noncompliant (Table 1). In the LAGB group, the %EWL achieved at 1 year of follow-up by the compliant group was 8% greater than the %EWL achieved by the noncompliant group (P ⫽ .01; Table 3). In the LRYGB group, the difference in the %EWL between the compliant and noncompliant groups was minimal (1%) and statistically insignificant (P ⫽ .76; Table 2). Table 2 Excess weight loss at 12 months and patient compliance for LRYGB patients Variable
Missed appointments (%) Preoperatively Postoperatively %EWL at 12 mo (%)
Group 1 (compliant; ⬍25% missed appointments, n ⫽ 138)
Group 2 (noncompliant; ⬎25% missed appointments, n ⫽ 39)
4.9 37 61.7
41.6 26 60.8
P value
⬍.01
.76
LRYGB ⫽ laparoscopic Roux-en-Y gastric bypass; %EWL ⫽ percentage of excess weight loss.
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Table 3 Excess weight loss at 12 months and patient compliance for LAGB patients Variable
Missed appointments (%) Preoperatively Postoperatively %EWL at 12 mo
Group 1 (compliant; ⬍25% missed appointments, n ⫽ 67)
Group 2 (noncompliant; ⬎25% missed appointments, n ⫽ 22)
P value
5.3 34 31.6
41.3 31 23.4
⬍.01 .35 .01
LAGB ⫽ laparoscopic adjustable gastric banding; %EWL ⫽ percentage of excess weight loss.
The rate of co-morbidity resolution/improvement for both LRYGB and LAGB patients was similar for the compliant and noncompliant patients; however, the LRYGB patients had better resolution/improvement compared with the LAGB patients at 1 year (Table 4). The patients compliant with their preoperative appointments were significantly less compliant with their postoperative appointments after either procedure (P ⬍ .01). The opposite was true for the initially noncompliant patients (Tables 2 and 3). Postoperative compliance demonstrated a weak negative correlation with the %EWL at 12 months after LAGB (r ⫽ ⫺.23; P ⬍ .05) but not after LRYGB (r ⫽ ⫺.09; P ⫽ .2). Discussion In the present study, we elected to use the number of missed preoperative appointments as a reflection of patient compliance to examine the effect of compliance on the %EWL achieved after bariatric surgery. We elected to assess the effect of preoperative compliance, because it provides potentially valuable information before patients undergo surgery. We hypothesized that poor preoperative compliance with scheduled office appointments would result in a lower postoperative EWL 12 months after surgery. Our results have confirmed this hypothesis, but only for the LAGB patients. In addition, we found that better postoperative compliance was associated with improved %EWL at 12 months but only for LAGB patients. The published data support our findings. A recent study by Shen et al. [12] demonstrated a greater %EWL at 1 year after LAGB but not LRYGB in patients who were compliant with their postoperative follow-up appointments. Another study demonstrated that after LAGB, patients compliant with postoperative appointments achieved a significantly greater %EWL (41% versus 31% P ⬍ .05) and resolution/improvement of co-morbidities at 1 year compared with their noncompliant counterparts [13]. Nevertheless, these studies did not assess preoperative compliance and could not provide insight on the effect of preoperative
compliance on weight loss outcomes and its relationship to postoperative compliance. In contrast, our study also provided insight into this relationship. To our surprise, we found postoperative patient compliance with office visits to be significantly worse for the preoperatively compliant patients and slightly better for the initially noncompliant patients. Although this difference was significant between the preoperative compliant and noncompliant groups for the LRYGB patients, it did not seem to influence the weight loss outcomes. In contrast, postoperative compliance for LAGB patients did not differ between the preoperative compliant and noncompliant groups (34% versus 31% missed appointments, respectively; P ⫽ .35); therefore, preoperative compliance remained the main determinant of postoperative weight loss at 1 year after surgery for the LAGB patients. The difference in the effect of compliance on postoperative EWL between the 2 procedures could be explained by the greater need for the LAGB patients to follow-up closely with their bariatric surgeon after surgery to achieve good outcomes [12,13]. Given the need for frequent band adjustments and close patient monitoring, patients who do not keep their appointments would be less likely to be successful, as has been suggested by previous studies [12,13]. Also, the lack of weight loss differences in the LRYGB patients could have been related to the timing of our follow-up. The effect of RYGB appears to be so profound during the first 12–18 months that preoperative and postoperative compliance with dietary and exercise recommendations has a limited effect on weight loss. After this initial period, however, compliance could also be important for these patients, because it has been well documented that in the long term, patients regain ⱖ15% of the nadir weight lost [14]. Thus, if our follow-up period had been longer (⬎2 years), we might have identified differences in weight loss between the compliant and noncompliant LRYGB patients. We found no significant differences, other than compliance, in the patient demographics of the LRYGB and LAGB groups that could explain the differences in weight loss. Furthermore, the percentage of compliant patients, as de-
Table 4 Co-morbidity resolution or improvement at 1 year of follow-up according to preoperative compliance Variable
Group 1 (compliant; ⬍25% missed appointments)
Group 2 (noncompliant; ⬎25% missed appointments)
P value
LRYGB (%) LAGB (%) P value
79 58 ⬍.01
92 50 ⬍.01
.23 .53
Abbreviations as in Table 1. Co-morbidities analyzed included type 2 diabetes mellitus, hypertension, obstructive sleep apnea, and hyperlipidemia; no differences found for individual co-morbidity resolution.
M. El Chaar et al. / Surgery for Obesity and Related Diseases 7 (2011) 743–748
fined in the present study, was similar for both groups and slightly greater than that reported by other studies, probably because our definition of compliance was different [15]. We set 25% of missed appointment as our cutoff for defining compliant versus noncompliant patients. We believed it was appropriate, because rescheduled appointments were also considered missed appointments in our study. Given that the actual average preoperative compliance was distinctly different between the 2 groups (approximately 5% for the compliant groups versus approximately 40% for the noncompliant groups for both procedures; Tables 2 and 3), our choice of a 25% cutoff was appropriate. However, any cutoff point between 5% and 40% would likely have produced very similar results. We found an inferior resolution/improvement rate of co-morbidities at 1 year after LAGB compared with LRYGB. This was likely a consequence of the significantly greater weight loss within the study period after LRYGB. Unlike the study by Dan et al. [13], we did not find a decreased rate of co-morbidity resolution after LAGB between the compliant and noncompliant groups; however, this comparison was likely hampered by our small patient sample. Our study had several limitations. It was a retrospective review of a comprehensive patient database, and, as such, it was subject to the potential errors or omissions during data entry. Nevertheless, the data were entered prospectively by dedicated personnel experienced in outcomes research and database entry. In addition, our analysis was limited to 1 year of follow-up, which as discussed, might have missed important effects of compliance on long-term outcomes in gastric bypass patients. Furthermore, our small sample might have prevented the identification of differences for some of the examined parameters, such as co-morbidity resolution. Nonetheless, it was clear from the present study that less compliant patients had lost less excess weight at 1 year after LAGB. As we continue to collect more data, we hope to fully understand the relationship between EWL and resolution of co-morbidities as it relates to compliance in our patient population. In addition, factors other than compliance and motivation can play a role in patients missing their office appointments. The distance from the office and patients’ socioeconomic status have been previously reported to affect their attendance at office visits [16 –19]. We will examine these data in the future; however, we doubt these factors influenced our results, because most of our patients were of similar socioeconomic status and lived within our city and near locations with little difference in travel distance. Scheduling conflicts or an inconvenient location could also have played a role; however, our office was easily accessible to all patients and very efficient at scheduling patient visits. Thus, it was unlikely that these factors influenced our findings. Furthermore, offering all preoperative appointments at 1 location likely affected attendance positively, making it
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easy for patients to travel repeatedly to the same familiar place. The value of our findings was that noncompliant patients identified preoperatively could be counseled appropriately about the postoperative outcomes. Such counseling could include efforts to improve compliance, change the desired procedure, or even exclude patients from undergoing surgery. In addition, the realization that patients compliant preoperatively become less compliant after surgery provides an opportunity for additional counseling of all patients before surgery and calls for additional studies to investigate this relationship and the underlying reasons. On the basis of our findings, we have started emphasizing to our patients the importance of their compliance with preoperative visits. We have also used the number of missed appointments to counsel patients preoperatively on their expected weight loss outcomes after each procedure and have occasionally steered patients interested in LAGB toward LRYGB. We found this approach helpful in setting appropriate patient expectations, which have often tended to be unrealistic [20]. Conclusion The results of our study have shown that patients with a greater percentage of missed preoperative appointments will have a lower postoperative %EWL 1 year after LAGB but not after LRYGB. This information might prove useful during patient selection or when counseling patients about the type of bariatric surgery to pursue. Additional study is needed to investigate this interesting concept further and is currently underway at our institution. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999 –2008. JAMA. 2010;303:235– 41. [2] Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292:1724 –37. [3] Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007;357:741–52. [4] Kushner RF, Noble CA. Long-term outcome of bariatric surgery: an interim analysis. Mayo Clin Proc 2006;81:S46 –51. [5] Gould JC, Beverstein G, Reinhardt S, Garren MJ. Impact of routine and long-term follow-up on weight loss after laparoscopic gastric bypass. Surg Obes Relat Dis 2007;3:627–30. [6] Elkins G, Whitfield P, Marcus J, Symmonds R, Rodriguez J, Cook T. Noncompliance with behavioral recommendations following bariatric surgery. Obes Surg 2005;15:546 –51. [7] Dixon JB, Laurie CP, Anderson ML, Hayden MJ, Dixon ME, O’Brien PE. Motivation, readiness to change, and weight loss fol-
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[8]
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[10]
[11] [12]
[13]
[14]
M. El Chaar et al. / Surgery for Obesity and Related Diseases 7 (2011) 743–748 lowing adjustable gastric band surgery. Obesity (Silver Spring) 2009;17:698 –705. Balduf LM, Kohn GP, Galanko JA, Farrell TM. The impact of socioeconomic factors on patient preparation for bariatric surgery. Obes Surg 2009;19:1089 –95. Alexander JW, Goodman HR, Martin-Hawver LR, James L. The impact of Medicaid status on outcome after gastric bypass. Obes Surg 2008;18:1241–5. Buchwald H. Consensus conference statement bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers. Surg Obes Relat Dis 2005;1:371– 81. Harrison GG. Height-weight tables. Ann Intern Med 1985;103: 989 –94. Shen R, Dugay G, Rajaram K, Cabrera I, Siegel N, Ren CJ. Impact of patient follow-up on weight loss after bariatric surgery. Obes Surg 2004;14:514 –9. Dan A, Pozsgay M, Pasini D, Zografakis J. Correlation of postoperative office-visit compliance and success after laparoscopic adjustable gastric banding (LAGB). Surg Obes Relat Dis 2009;5:S26. Odom J, Zalesin KC, Washington TL, et al. Behavioral predictors of weight regain after bariatric surgery. Obes Surg 2010;20:349 –56.
[15] Toussi R, Fujioka K, Coleman KJ. Pre- and postsurgery behavioral compliance, patient health, and postbariatric surgical weight loss. Obesity (Silver Spring) 2009;17:996 –1002. [16] Sadhasivam S, Larson CJ, Lambert PJ, Mathiason MA, Kothari SN. Refusals, denials, and patient choice: reasons prospective patients do not undergo bariatric surgery. Surg Obes Relat Dis 2007;3:531– 6. [17] Pontiroli AE, Fossati A, Vedani P, et al. Post-surgery adherence to scheduled visits and compliance, more than personality disorders, predict outcome of bariatric restrictive surgery in morbidly obese patients. Obes Surg 2007;17:1492–7. [18] Lara MD, Baker MT, Larson CJ, Mathiason MA, Lambert PJ, Kothari SN. Travel distance, age, and sex as factors in follow-up visit compliance in the post-gastric bypass population. Surg Obes Relat Dis 2005;1:17–21. [19] Wheeler E, Prettyman A, Lenhard MJ, Tran K. Adherence to outpatient program postoperative appointments after bariatric surgery. Surg Obes Relat Dis 2008;4:515–20. [20] Kaly P, Orellana S, Torrella T, Takagishi C, Saff-Koche L, Murr MM. Unrealistic weight loss expectations in candidates for bariatric surgery. Surg Obes Relat Dis 2008;4:6 –10.
Integrated health article
Does patient compliance with preoperative bariatric office visits affect postoperative excess weight loss? Maher El Chaar, M.D., Kathleen McDeavitt, Sarah Richardson, Keith S. Gersin, M.D., Timothy S. Kuwada, M.D., Dimitrios Stefanidis, M.D., Ph.D.* Section of Bariatric Surgery, Division of Minimally Invasive Surgery and Bariatric Surgery, Carolinas Medical Center, Charlotte, North Carolina Received May 20, 2010; accepted October 8, 2010
Abstract
Background: The amount of excess weight loss (EWL) achieved after bariatric surgery has varied considerably. Reliable preoperative predictors of the postoperative %EWL do not exist. Patient compliance with the physician recommendations has generally been believed to be important for long-term success after bariatric surgery, especially after gastric banding. We hypothesized that poor preoperative patient compliance with office visits, a likely indicator of overall compliance, would be associated with lower %EWL after bariatric surgery at a teaching hospital in the United States. Methods: We performed an institutional review board-approved review of prospectively collected data from all patients undergoing bariatric surgery from 2007 to 2009. The patients were categorized into 2 groups: those who had missed ⬍25% of all preoperative appointments at our bariatric center and those who had missed ⬎25%. The average %EWL at 12 months between the 2 groups was compared using the unpaired t test separately for the gastric bypass and gastric banding patients. Results: The gastric band patients with ⬎25% missed appointments had lost 23% EWL at 12 months compared with 32% EWL for the gastric band patients who had missed ⬍25% of their appointments (P ⫽ .01). No difference was found in the %EWL for the gastric bypass patients according to the missed preoperative appointments. The postoperative compliance was significantly poorer than preoperatively. Conclusion: The patients with a greater percentage of missed preoperative appointments had a lower postoperative %EWL at 1 year after gastric banding but not after gastric bypass. This information could prove useful during patient selection or when counseling patients about the type of bariatric surgery to pursue. (Surg Obes Relat Dis 2011;7:743–748.) © 2011 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Patient compliance; Weight loss surgery; Gastric bypass; Gastric banding; Outcomes
Obesity has reached epidemic proportions in recent years in the United States [1]. Bariatric surgery is currently the only available and reliable option for the long-term treatment of morbid obesity [2,3]. Laparoscopic Roux-en-Y gasPresented as an oral presentation at the American Society for Metabolic and Bariatric Surgery Annual Meeting, June 21–26, 2010, Las Vegas, Nevada *Correspondence: Dimitrios Stefanidis, M.D., Ph.D., F.A.C.S., Carolinas Simulation Center, Division of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, Carolinas Medical Center, 1000 Blythe Boulevard, MEB 601, Charlotte, NC 28203. E-mail: [email protected].
tric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) have been shown to lead to significant and sustainable weight loss [4]. Nevertheless, the percentage of excess weight loss (EWL) achieved after bariatric surgery has varied considerably, indicating that factors other than procedural effectiveness are likely determinants of longterm weight loss [5,6]. Therefore, a number of studies have attempted to identify the preoperative patient factors that would predict postoperative weight loss; however, no clear predictors have been identified [6 –9]. In addition, patient compliance with dietary restrictions and physician recommendations after bariatric surgery have been considered
1550-7289/11/$ – see front matter © 2011 American Society for Metabolic and Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2010.10.020
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important parameters for successful patient outcomes. The American Society for Metabolic and Bariatric Surgery has recommended that surgeons be a part of an integrated team, including dieticians, fitness experts, and psychologists, that follow-up bariatric patients on a regular basis to improve patient outcomes [10]. Nonetheless, the benefits of such a comprehensive support system will be negated when the patients are not compliant with the recommendations or when their follow-up with the bariatric program is suboptimal. The preoperative visits of bariatric patients will frequently be canceled or postponed, creating efficiency problems in bariatric offices. Such missed appointments not only effect the bariatric center financially but also can delay patient care and the interval to surgery. Because it has generally been accepted that patients who keep their appointments will be responsible and compliant, missed preoperative visits could potentially identify noncompliant patients who might experience suboptimal postoperative outcomes. We, therefore, hypothesized that poor preoperative patient compliance with office visits, a likely indicator of overall compliance, would be associated with poorer %EWL and co-morbidity resolution after bariatric surgery. Methods After institutional review board approval, the data were entered prospectively into an outcomes database containing the data from all patients seen at our multidisciplinary bariatric program, the Carolinas Weight Management and Wellness Center, and undergoing bariatric surgery from 2007 to 2009 at Carolinas Medical Center-Mercy (Charlotte, NC). Our bariatric program was composed of a comprehensive team of professionals including 3 board-certified and fellowship-trained bariatric surgeons, 2 board-certified medical bariatricians, 2 bariatric surgery fellows, 1 hepatologist, 2 midlevel providers, 1 Ph.D. psychologist, 1 center director, 1 nursing team, 3 registered dietitians, 1 fitness trainer and 1 fitness intern, 2 insurance specialists, and several support staff. New potential patients were required to attend an information session given by 1 of the 3 bariatric surgeons, their eligibility for bariatric surgery was determined, and their first appointment was scheduled with 1 of the bariatric surgeons. After this initial visit, all patients met with a dietician for a nutritional evaluation, the psychologist for a psychological evaluation, and the fitness trainer for a fitness assessment. When a patient had an insurance requirement for a preoperative weight loss program, they were followed up for 3– 6 months by our bariatric physicians. When the preoperative assessment was complete, surgery was scheduled, and the patient underwent preoperative counseling with the bariatric surgeon 2 weeks before the surgery date.
After surgery, the patients who had undergone LRYGB were seen in our office at 2 and 6 weeks, 3, 6, and 12 months, and yearly thereafter. After LAGB, the patients were seen at 2 weeks, had their first adjustment at 6 weeks, and were followed up every 3– 4 weeks for adjustments, as needed until they had achieved adequate restriction. At that point, their follow-up visits were scheduled at 6 –12-month intervals. Additional visits with members of our team could be scheduled on an as needed basis for both procedure groups. For the purposes of the present study, all the patients with follow-up data at 1 year after either LRYGB or LAGB were included. The following parameters were recorded at the initial visit to the bariatric office and at 12 months after bariatric surgery: patient weight, body mass index, and co-morbid conditions. We also recorded the type of procedure performed and the number of scheduled and attended preoperative and postoperative appointments with any member of our multidisciplinary team. We defined compliance as the frequency of missed appointments during the preoperative or postoperative period (ie, the percentage of scheduled appointments that were missed). Rescheduled appointments were also considered as missed appointments. The preoperative appointments included the initial bariatric surgery consultation and subsequent visits with the bariatric surgeon and all preoperative visits with the nutritionist, psychologist, and/or fitness specialist. The postoperative appointments included the scheduled visits with the bariatric surgeon and any other visits with other members of our team that might have been required. All patients included in the present study had been seen at 1 year postoperatively in the office and had had their weight measured using the same scale as before surgery. The patients were categorized into 2 groups: group 1 (compliant group) had missed ⬍25% of all preoperative appointments and group 2 (noncompliant group) had missed ⬎25% of their appointments. The LRYGB and LAGB groups were analyzed separately, and only primary procedures were included in our analysis. To calculate the %EWL, we used the following equation: [amount of weight loss/excess body weight] ⫻ 100. The excess body weight was calculated according to the ideal body weight using the medium-frame measurements of the Metropolitan Life insurance tables [11]. Resolution of hypertension was defined as a systolic blood pressure (without antihypertensive medications) of ⱕ140 mm Hg. Resolution of sleep apnea was defined as no need for a positive airway pressure device for a patient previously using one. The resolution of diabetes was determined by a hemoglobin A1c level ⬍6.0, and the resolution of hyperlipidemia was determined by a total cholesterol level ⬍200 mg/dL, low-density lipoprotein level ⬍130 mg/ dL, and triglyceride level ⬍150 mg/dL. The resolution of co-morbidities was determined during the 12-month follow-up visit by the bariatric surgeons after interviewing and
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Table 1 Demographics of LRYGB and LAGB patients by compliance group Demographics
Group 1 (compliant; ⱕ25% missed appointments)
Group 2 (noncompliant; 25% missed appointments)
P value
LRYGB Age (yr) Women (%) BMI (kg/m2) Co-morbidity (%) Hypertension Sleep apnea Hyperlipidemia Type 2 diabetes mellitus LAGB Age (y) Women (%) BMI (kg/m [2]) Co-morbidity (%) Hypertension Sleep apnea Hyperlipidemia Type 2 diabetes mellitus
138 (78) 42.8 ⫾ 9.5 87 45.3 ⫾ 5.3
39 (22) 41.2 ⫾ 9.2 86 44.7 ⫾ 5
62.6 47.5 29.3 30.1 67 (76) 45.3 ⫾ 10 86 43.4 ⫾ 5.1
68.7 39.1 41.6 37 22 (24) 42.5 ⫾ 8.3 87.5 42.4 ⫾ 5.4
.14 .98 .30
67.2 49.1 33.3 26.2
51.6 41.9 36.7 20.7
.09 .46 .72 .52
.27 .82 .52 .42 .29 .09 .35
LRYGB ⫽ laparoscopic Roux-en-Y gastric bypass; BMI ⫽ body mass index; LAGB ⫽ laparoscopic adjustable gastric banding. Data in parentheses are percentages.
examining the patient and after the blood test results were reviewed. To assess the effect of preoperative compliance on outcomes, we compared the average %EWL at 12 months between the compliant and noncompliant groups for each procedure using the Student unpaired t test. We also compared the percentage of missed postoperative appointments between the compliant and noncompliant groups and correlated postoperative compliance with the %EWL at 12 months using Spearman’s correlation. The chi-square test or Fisher’s exact test was used to compare co-morbidity resolution 12 months after surgery between the compliance groups and procedures. P ⬍ .05 was considered statistically significant. The post hoc power analysis revealed that our sample size was adequate to detect an ⱖ7% difference in the %EWL at 12 months after surgery between the compliant and noncompliant groups after either procedure using an ␣ level of .8.
Results A total of 505 patients had undergone bariatric surgery during the study period. Of these, 164 (32%) had a follow-up period of ⬍1 year, 75 (15%) were lost to follow-up, and 266 (53%) had complete follow-up data at 1 year and were included in the present study. Of the 266 patients, 177 had undergone LRYGB and 89 (34%) had undergone LAGB. The patient demographics are listed in Table 1. No differences were seen in the patient demographics at baseline between the compliant and noncompliant patients for
either procedure in terms of age, gender, initial body mass index, or the presence of co-morbidities. The patients attended an average of 5.5 office appointments (range 2–26) and missed 11% of them during their preoperative period. The frequency of missed appointments was similar for the LRYGB and LAGB patients (Tables 2 and 3, respectively). In the LRYGB group, 78% of the patients had missed ⬍25% of their appointments (compliant group) and 22% had missed ⬎25% of their appointments (noncompliant group). In the LAGB group, 76% were compliant and 24% were noncompliant (Table 1). In the LAGB group, the %EWL achieved at 1 year of follow-up by the compliant group was 8% greater than the %EWL achieved by the noncompliant group (P ⫽ .01; Table 3). In the LRYGB group, the difference in the %EWL between the compliant and noncompliant groups was minimal (1%) and statistically insignificant (P ⫽ .76; Table 2). Table 2 Excess weight loss at 12 months and patient compliance for LRYGB patients Variable
Missed appointments (%) Preoperatively Postoperatively %EWL at 12 mo (%)
Group 1 (compliant; ⬍25% missed appointments, n ⫽ 138)
Group 2 (noncompliant; ⬎25% missed appointments, n ⫽ 39)
4.9 37 61.7
41.6 26 60.8
P value
⬍.01
.76
LRYGB ⫽ laparoscopic Roux-en-Y gastric bypass; %EWL ⫽ percentage of excess weight loss.
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Table 3 Excess weight loss at 12 months and patient compliance for LAGB patients Variable
Missed appointments (%) Preoperatively Postoperatively %EWL at 12 mo
Group 1 (compliant; ⬍25% missed appointments, n ⫽ 67)
Group 2 (noncompliant; ⬎25% missed appointments, n ⫽ 22)
P value
5.3 34 31.6
41.3 31 23.4
⬍.01 .35 .01
LAGB ⫽ laparoscopic adjustable gastric banding; %EWL ⫽ percentage of excess weight loss.
The rate of co-morbidity resolution/improvement for both LRYGB and LAGB patients was similar for the compliant and noncompliant patients; however, the LRYGB patients had better resolution/improvement compared with the LAGB patients at 1 year (Table 4). The patients compliant with their preoperative appointments were significantly less compliant with their postoperative appointments after either procedure (P ⬍ .01). The opposite was true for the initially noncompliant patients (Tables 2 and 3). Postoperative compliance demonstrated a weak negative correlation with the %EWL at 12 months after LAGB (r ⫽ ⫺.23; P ⬍ .05) but not after LRYGB (r ⫽ ⫺.09; P ⫽ .2). Discussion In the present study, we elected to use the number of missed preoperative appointments as a reflection of patient compliance to examine the effect of compliance on the %EWL achieved after bariatric surgery. We elected to assess the effect of preoperative compliance, because it provides potentially valuable information before patients undergo surgery. We hypothesized that poor preoperative compliance with scheduled office appointments would result in a lower postoperative EWL 12 months after surgery. Our results have confirmed this hypothesis, but only for the LAGB patients. In addition, we found that better postoperative compliance was associated with improved %EWL at 12 months but only for LAGB patients. The published data support our findings. A recent study by Shen et al. [12] demonstrated a greater %EWL at 1 year after LAGB but not LRYGB in patients who were compliant with their postoperative follow-up appointments. Another study demonstrated that after LAGB, patients compliant with postoperative appointments achieved a significantly greater %EWL (41% versus 31% P ⬍ .05) and resolution/improvement of co-morbidities at 1 year compared with their noncompliant counterparts [13]. Nevertheless, these studies did not assess preoperative compliance and could not provide insight on the effect of preoperative
compliance on weight loss outcomes and its relationship to postoperative compliance. In contrast, our study also provided insight into this relationship. To our surprise, we found postoperative patient compliance with office visits to be significantly worse for the preoperatively compliant patients and slightly better for the initially noncompliant patients. Although this difference was significant between the preoperative compliant and noncompliant groups for the LRYGB patients, it did not seem to influence the weight loss outcomes. In contrast, postoperative compliance for LAGB patients did not differ between the preoperative compliant and noncompliant groups (34% versus 31% missed appointments, respectively; P ⫽ .35); therefore, preoperative compliance remained the main determinant of postoperative weight loss at 1 year after surgery for the LAGB patients. The difference in the effect of compliance on postoperative EWL between the 2 procedures could be explained by the greater need for the LAGB patients to follow-up closely with their bariatric surgeon after surgery to achieve good outcomes [12,13]. Given the need for frequent band adjustments and close patient monitoring, patients who do not keep their appointments would be less likely to be successful, as has been suggested by previous studies [12,13]. Also, the lack of weight loss differences in the LRYGB patients could have been related to the timing of our follow-up. The effect of RYGB appears to be so profound during the first 12–18 months that preoperative and postoperative compliance with dietary and exercise recommendations has a limited effect on weight loss. After this initial period, however, compliance could also be important for these patients, because it has been well documented that in the long term, patients regain ⱖ15% of the nadir weight lost [14]. Thus, if our follow-up period had been longer (⬎2 years), we might have identified differences in weight loss between the compliant and noncompliant LRYGB patients. We found no significant differences, other than compliance, in the patient demographics of the LRYGB and LAGB groups that could explain the differences in weight loss. Furthermore, the percentage of compliant patients, as de-
Table 4 Co-morbidity resolution or improvement at 1 year of follow-up according to preoperative compliance Variable
Group 1 (compliant; ⬍25% missed appointments)
Group 2 (noncompliant; ⬎25% missed appointments)
P value
LRYGB (%) LAGB (%) P value
79 58 ⬍.01
92 50 ⬍.01
.23 .53
Abbreviations as in Table 1. Co-morbidities analyzed included type 2 diabetes mellitus, hypertension, obstructive sleep apnea, and hyperlipidemia; no differences found for individual co-morbidity resolution.
M. El Chaar et al. / Surgery for Obesity and Related Diseases 7 (2011) 743–748
fined in the present study, was similar for both groups and slightly greater than that reported by other studies, probably because our definition of compliance was different [15]. We set 25% of missed appointment as our cutoff for defining compliant versus noncompliant patients. We believed it was appropriate, because rescheduled appointments were also considered missed appointments in our study. Given that the actual average preoperative compliance was distinctly different between the 2 groups (approximately 5% for the compliant groups versus approximately 40% for the noncompliant groups for both procedures; Tables 2 and 3), our choice of a 25% cutoff was appropriate. However, any cutoff point between 5% and 40% would likely have produced very similar results. We found an inferior resolution/improvement rate of co-morbidities at 1 year after LAGB compared with LRYGB. This was likely a consequence of the significantly greater weight loss within the study period after LRYGB. Unlike the study by Dan et al. [13], we did not find a decreased rate of co-morbidity resolution after LAGB between the compliant and noncompliant groups; however, this comparison was likely hampered by our small patient sample. Our study had several limitations. It was a retrospective review of a comprehensive patient database, and, as such, it was subject to the potential errors or omissions during data entry. Nevertheless, the data were entered prospectively by dedicated personnel experienced in outcomes research and database entry. In addition, our analysis was limited to 1 year of follow-up, which as discussed, might have missed important effects of compliance on long-term outcomes in gastric bypass patients. Furthermore, our small sample might have prevented the identification of differences for some of the examined parameters, such as co-morbidity resolution. Nonetheless, it was clear from the present study that less compliant patients had lost less excess weight at 1 year after LAGB. As we continue to collect more data, we hope to fully understand the relationship between EWL and resolution of co-morbidities as it relates to compliance in our patient population. In addition, factors other than compliance and motivation can play a role in patients missing their office appointments. The distance from the office and patients’ socioeconomic status have been previously reported to affect their attendance at office visits [16 –19]. We will examine these data in the future; however, we doubt these factors influenced our results, because most of our patients were of similar socioeconomic status and lived within our city and near locations with little difference in travel distance. Scheduling conflicts or an inconvenient location could also have played a role; however, our office was easily accessible to all patients and very efficient at scheduling patient visits. Thus, it was unlikely that these factors influenced our findings. Furthermore, offering all preoperative appointments at 1 location likely affected attendance positively, making it
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easy for patients to travel repeatedly to the same familiar place. The value of our findings was that noncompliant patients identified preoperatively could be counseled appropriately about the postoperative outcomes. Such counseling could include efforts to improve compliance, change the desired procedure, or even exclude patients from undergoing surgery. In addition, the realization that patients compliant preoperatively become less compliant after surgery provides an opportunity for additional counseling of all patients before surgery and calls for additional studies to investigate this relationship and the underlying reasons. On the basis of our findings, we have started emphasizing to our patients the importance of their compliance with preoperative visits. We have also used the number of missed appointments to counsel patients preoperatively on their expected weight loss outcomes after each procedure and have occasionally steered patients interested in LAGB toward LRYGB. We found this approach helpful in setting appropriate patient expectations, which have often tended to be unrealistic [20]. Conclusion The results of our study have shown that patients with a greater percentage of missed preoperative appointments will have a lower postoperative %EWL 1 year after LAGB but not after LRYGB. This information might prove useful during patient selection or when counseling patients about the type of bariatric surgery to pursue. Additional study is needed to investigate this interesting concept further and is currently underway at our institution. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999 –2008. JAMA. 2010;303:235– 41. [2] Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292:1724 –37. [3] Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007;357:741–52. [4] Kushner RF, Noble CA. Long-term outcome of bariatric surgery: an interim analysis. Mayo Clin Proc 2006;81:S46 –51. [5] Gould JC, Beverstein G, Reinhardt S, Garren MJ. Impact of routine and long-term follow-up on weight loss after laparoscopic gastric bypass. Surg Obes Relat Dis 2007;3:627–30. [6] Elkins G, Whitfield P, Marcus J, Symmonds R, Rodriguez J, Cook T. Noncompliance with behavioral recommendations following bariatric surgery. Obes Surg 2005;15:546 –51. [7] Dixon JB, Laurie CP, Anderson ML, Hayden MJ, Dixon ME, O’Brien PE. Motivation, readiness to change, and weight loss fol-
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