- Email: [email protected]
Improving Follow-Up After Bariatric Surgery
S150
Poster Presentations / Surgery for Obesity and Related Diseases 12 (2016) S76–S232
A5153
BODY COMPOSITION POST SLEEVE GASTRECTOMY Josiah Billing1; Nathaniel Billing2; Brooke Pighin2; Peter Billing3; Dameon Hahn2; Kelsey McFarland2; Debie McSperitt2; Brad Butterfield2; Robert Landerholm4; 1Puget Sound Bariatrics, Edmonds Washington; 2Eviva, Shoreline WA; 3Eviva, Seattle WA; 4 Eviva, Edmonds WA Abstract Background: Sleeve gastrectomy (SG) is currently the most widely performed procedure for the treatment of obesity. SG leads to significant weight loss as well as a reduction in weight related comorbidities. It has been shown that rapid weight loss after bariatric surgery (BS) leads to changes in body composition. However, these changes are not well documented in the early stages post SG when the greatest change in weight occurs. Objective: To identify changes in body composition in the early stages post SG. Setting: Eviva Bariatrics, Seattle, WA Methods: Demographics were gathered for all patients who underwent a SG procedure at Eviva Bariatrics and that also underwent pre and post-operative biometric testing. Changes in fat free mass (FFM) and fat mass (FM) as well as body fat percentage (BF %) were measured using the BodPod. Testing took place on average 74 (37-136) days postoperatively. Testing protocols were followed according to the BodPod guidelines. All testing was done at the same facility and machine to ensure accuracy. Results: Sixty one SG patients from Jan 2014 to April, 2016 underwent biometric testing. They lost an average (avg) 39.9% of their excess body weight (EWL) and 15.2% of their total body weight loss at 74 (37-136) days post op. BF% on average dropped from 49.4% to 45.0%. Patients on average lost 27% of their FFM by 74 days. Three patients (4.9%) maintained or increased their FFM post op. Six patients (9.8%) lost more FFM than fat mass (FM) leading to an increase in BF%. Conclusion: The goal of BS is to reduce weight and weight related comorbidities. However, reduction in weight alone is not sufficient to accurately assess a patient's success post SG. Patients that are losing more FFM than FM need to be identified in order to be successful post BS. Achieving a healthy body composition, rather than just losing weight, should be prescribed to patients. Future studies identifying the factors that influence FFM preservation are needed, as well as long term body composition results in the SG population.
A5154
IMPROVING FOLLOW-UP AFTER BARIATRIC SURGERY Linden Karas1; Lauren DeStefano2; Priya Chhikara3; Linda Doyle2; Piotr Krecioch2; Prashanth Ramachandra2; 1Mercy Catholic Medical Center, Aldan PA; 2Mercy Catholic Medical Center, Darby PA; 3Mercy Catholic Medical Center, Lansdowne PA Background: Bariatric surgery has persistently been proven to be an effective treatment for morbid obesity and its associated comorbid medical conditions. The Mercy Bariatric Center of Excellence in Darby, PA cares for a primarily African American
and publically insured (Medicare or Medicaid) patient population that is significantly different than has been previously examined in the literature. Analysis of weight loss outcomes in our patients has demonstrated adequate but inferior weight loss in African Americans and in patients with publically funded insurance when compared to those with private insurance.[i] Our practice also loses more patients to follow up (54% at six months postoperatively and 20% more at one yeari) than is quoted in the literature. [ii] This study examines the reasons for loss to follow-up after surgery among our patients. Methods: To examine the inferior rates of follow-up in our bariatric surgery patients and the reasons for decreased weight loss outcomes in African American and publically insured patients, we identified forty patients who underwent bariatric surgery from August 2014 - April 2015 who failed to follow-up with their surgeon more than three months post-operatively. We were able to contact twenty-one of the 40 patients over the phone and they all agreed to participate in a 15-minute telephone survey. The remaining 19 patients were either not reachable by phone (due to out of service numbers or failure to pick up) or unable/unwilling to participate. The survey included 22 questions about planned versus actual weight loss, satisfaction with those outcomes, postoperative dietary and exercise regimens, support group attendance, and the perceived value of the education provided in preparation for surgery. We also queried the frequency of follow-up with bariatric surgeon, PCP, and other medical specialists, and the reasons for failure to follow up. Results: Ninety percent (19) of participants were female and 71.4% (15) were African American, which is similar to our overall patient population. However, only 42% (9) were publically insured, which is significantly lower than our overall patient population (nearly 60% Medicare or Medicaid). Fifty-two percent of patients (11) were satisfied with their weight loss, while 48% (10) were either unsatisfied or satisfied but wanted to lose more. Overall, 62% (16) felt that they were well educated about their surgery preoperatively, and 76.2 % (18) felt that nutrition education was the most important component of the preparation. Of the 21 patients interviewed, 16 (76.2%) exercised, 18 (85.7%) felt they maintained a healthy diet after surgery, and only two patients sought other weight loss solutions following inadequate post-surgical weight loss. Although these patients failed to followup with their surgeons as frequently as recommended, 90% (19) did see their primary care physician (PCP) routinely. Patients failed to follow-up with their surgeons postoperatively because of an inability to access office hours due to work/school/child care conflicts or distance (76.2%) and a lack of understanding of the need for long-term follow-up and/or the sentiment that follow-up was unnecessary due to a lack of complications (95.2%). Conclusions: A significant number of patients that fail to followup with their surgeon in the long-term fall short of their weight loss goals after surgery, and many of them desire to continue losing weight but do not have the tools to implement further weight loss. This survey showed that the following interventions should be used to improve post-operative follow-up: increased surgeon interaction with PCPs and referral back to the surgeon, more flexible office hours and/or locations of the surgeons, and pre- and post-operative education about the necessity for long-term follow-up. In addition to increasing surgeon specific follow-up, the use of support groups and information sessions with a nutritionist exclusively for post-operative patients would improve weight loss
Poster Presentations / Surgery for Obesity and Related Diseases 12 (2016) S76–S232
outcomes. Regular and long-term follow-up with bariatric surgery specialists after surgery will improve weight loss outcomes, and help to prevent weight gain. [i] LA Karas, M Siddeswarappa, S Slane, P Ramachandra. Insurance status influence weight loss and complication rates following bariatric surgery. Abstract presented at SAGES 2015, Nashville, TN. [ii] J Harper, AK Madan, C Ternovits, DS Tichansky. What happens to patients who do not follow-up after bariatric surgery? Am Surg. 2007 Feb; 73(2):181-4.
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BODY COMPOSITION OF ASIAN PATIENTS WITH MORBID OBESITY SEEKING BARIATRIC SURGERY Pamela Er1; Chuen Seng Tan2; Pei Zheng Tan2; Yong Xiang Gwee2; Fathimath Naseer1; Si Hooi Lee3; Davide Lomanto1; Jimmy BY4; Asim Shabbir1; Guowei Kim1; 1National University Hospital, Singapore Singapore; 2National University Singapore, Singapore Singapore; 3National University Hospital, Serangoon Singapore; 4National University Hospital, Sosingapore NA Background: Currently, there is a lack of available information on the body composition characteristics of Asian patients with morbid obesity seeking bariatric surgery. The objective of this study is to evaluate the body composition profile of these patients and examine its relationship with ethnicity and diabetic status. Method: A total of 305 bariatric patients were measured presurgically with the body composition analyzer, GAIA 359 PLUS, which utilizes bioelectrical impedance analysis to estimate the body's make up. The data collection included total body weight, body mass index (BMI), excess weight, basal metabolic rate (BMR), fat-free mass (FFM), fat mass, fat percentage and total body water (TBW). Two sub-group analyses (Diabetic versus Non-Diabetic and between the Chinese, Malay, Indian, and Eurasian ethnic groups) were performed to see if there were any differences between the groups for the different body composition variables. The two sample t-test was used to compare the mean body composition variables of diabetics and nondiabetics in the sample, while the F-statistics from simple linear regression was used to compare mean body composition between the different ethnicities. Statistical significance was set at Po0.05. For each of the body composition variable, the mean (SD) was reported. Results: Subjects in this study had a mean BMI of 42.7kg/m2 (7.4) and a mean BMR of 1596kcal (326.3). The mean fat percentage, fat mass and FFM were 42% (8), 48.6kg (13) and 67.5kg (17.9) respectively. Fifty nine percent of the subjects were females and had a mean age of 41.7 years (10.6) while the males subjects were slightly younger with a mean age of 36.5 years (11.5). Ethic Malays form bulk of the group (38.7%) followed by Chinese (28.2%), Indians (24.9%) and Eurasians (8.2%). Malays have the highest mean BMI 45.1kg/m2 (7.8) followed by Eurasians 42.2 kg/ m2 (5.6) while the Chinese and Indians were similar at BMI of 41kg/m2 (SD: 6.6 and 7.1 respectively). Despite having a similar BMI, the mean fat percentage of Chinese was lower in comparison to Indians (39.4% vs. 43.8% respectively, P¼0.003). Additionally, mean FFM and TBW in Chinese was higher than in Indians (72kg vs. 63.8kg, P¼0.031 and 52kg vs. 46.1kg, P¼0.028 respectively). Lastly, Chinese were found to have a higher BMR of 1716.6kcal (334.6) as compared to Malay who had the lowest BMR at 1542.7kcal (313.5). Non-diabetic subjects (n¼213) had a mean of 6.2 absolute percentage point greater FFM (p¼0.003) and a mean
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of 5kg heavier TBW (p¼0.003) as compared to diabetic subjects (n ¼92). In line with the result for FFM, mean fat percentage was lower for non-diabetics [41.4% (8.3) vs. 43.4% (7.3), P¼0.016]. In addition, mean BMR was 114.8kcal higher (p¼0.004) for the nondiabetic subjects. Despite the differences in fat percentage, FFM, TBW and BMR, the diabetic group was significantly lighter than the non-diabetic group [111.9kg (20.9) vs. 118.7kg (25.3) respectively, P¼0.016]. The interaction effect of diabetic status and ethnicity was not looked at for the different body composition variables, due to the small sample size of each stratum. Conclusions: The Chinese ethnic group has a more protective body composition profile. Malays have the highest weight, BMI, percentage of fat and the lowest BMR, which are high risk factors of metabolic diseases. Despite Indians and Chinese having similar BMI, Indians have a higher percentage fat and lower FFM and thus a theoretically higher risk of developing metabolic syndrome.
A5156
BEST PRACTICES FOR REAL-TIME DATA MANAGEMENT WORKFLOW USING MBSAQIP Andrea Stone1; Darren Tishler1; Pavlos Papasavas2; Patricia Sobieski2; Sally Strange2; 1Hartford Healthcare, Glastonbury CT; 2Hartford Healthcare, Hartford CT Background: The healthcare industry is in the midst of substantive transition from a volume-based model to a value-based model, with patients seeking out facilities based on outcomes and safety much like consumers of other services. Additionally, changes in hospital reimbursement have made it necessary for programs to publicly report outcomes as well as implement quality improvement initiatives in order to maintain viability in an increasingly competitive quality-driven market. The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) has provided accredited programs with a standardized Registry through which they are able to monitor safety and quality indicators such as readmissions and complications. This platform has a high level of functionality and provides quantitative feedback to participating programs via the Semi-Annual Report (SAR) and other reports. These data help programs identify areas with potential for quality improvement.In order to provide as much real-time data as possible to centers, MBSAQIP has reduced the amount of time available for the abstractor to complete each case. This has presented a unique challenge to programs whose data entry workflow was not concurrent. As our center was chosen to participate in the Decreasing Readmissions Through Opportunities Provided (DROP) initiative, we were in a position to enhance processes by developing and implementing a concurrent data entry and review process. Our experience at a high volume (Z500 annual cases), acute care teaching hospital in developing best practices with real-time case management and tracking using the MBSAQIP Registry in conjunction with other applications is presented here. Methods: Workflow Our program utilizes multiple tracking systems to augment the Registry and allow for the target 100% case capture required for accreditation. Preoperative surgical pending lists are circulated to the abstractor on a weekly basis, and all new bariatric cases are entered into a spreadsheet which is used to track entry of each case, 30 day follow-up completion, and other procedure and scheduling specific information.Cases are entered into the Registry within 2 weeks of surgery and then
Poster Presentations / Surgery for Obesity and Related Diseases 12 (2016) S76–S232
A5153
BODY COMPOSITION POST SLEEVE GASTRECTOMY Josiah Billing1; Nathaniel Billing2; Brooke Pighin2; Peter Billing3; Dameon Hahn2; Kelsey McFarland2; Debie McSperitt2; Brad Butterfield2; Robert Landerholm4; 1Puget Sound Bariatrics, Edmonds Washington; 2Eviva, Shoreline WA; 3Eviva, Seattle WA; 4 Eviva, Edmonds WA Abstract Background: Sleeve gastrectomy (SG) is currently the most widely performed procedure for the treatment of obesity. SG leads to significant weight loss as well as a reduction in weight related comorbidities. It has been shown that rapid weight loss after bariatric surgery (BS) leads to changes in body composition. However, these changes are not well documented in the early stages post SG when the greatest change in weight occurs. Objective: To identify changes in body composition in the early stages post SG. Setting: Eviva Bariatrics, Seattle, WA Methods: Demographics were gathered for all patients who underwent a SG procedure at Eviva Bariatrics and that also underwent pre and post-operative biometric testing. Changes in fat free mass (FFM) and fat mass (FM) as well as body fat percentage (BF %) were measured using the BodPod. Testing took place on average 74 (37-136) days postoperatively. Testing protocols were followed according to the BodPod guidelines. All testing was done at the same facility and machine to ensure accuracy. Results: Sixty one SG patients from Jan 2014 to April, 2016 underwent biometric testing. They lost an average (avg) 39.9% of their excess body weight (EWL) and 15.2% of their total body weight loss at 74 (37-136) days post op. BF% on average dropped from 49.4% to 45.0%. Patients on average lost 27% of their FFM by 74 days. Three patients (4.9%) maintained or increased their FFM post op. Six patients (9.8%) lost more FFM than fat mass (FM) leading to an increase in BF%. Conclusion: The goal of BS is to reduce weight and weight related comorbidities. However, reduction in weight alone is not sufficient to accurately assess a patient's success post SG. Patients that are losing more FFM than FM need to be identified in order to be successful post BS. Achieving a healthy body composition, rather than just losing weight, should be prescribed to patients. Future studies identifying the factors that influence FFM preservation are needed, as well as long term body composition results in the SG population.
A5154
IMPROVING FOLLOW-UP AFTER BARIATRIC SURGERY Linden Karas1; Lauren DeStefano2; Priya Chhikara3; Linda Doyle2; Piotr Krecioch2; Prashanth Ramachandra2; 1Mercy Catholic Medical Center, Aldan PA; 2Mercy Catholic Medical Center, Darby PA; 3Mercy Catholic Medical Center, Lansdowne PA Background: Bariatric surgery has persistently been proven to be an effective treatment for morbid obesity and its associated comorbid medical conditions. The Mercy Bariatric Center of Excellence in Darby, PA cares for a primarily African American
and publically insured (Medicare or Medicaid) patient population that is significantly different than has been previously examined in the literature. Analysis of weight loss outcomes in our patients has demonstrated adequate but inferior weight loss in African Americans and in patients with publically funded insurance when compared to those with private insurance.[i] Our practice also loses more patients to follow up (54% at six months postoperatively and 20% more at one yeari) than is quoted in the literature. [ii] This study examines the reasons for loss to follow-up after surgery among our patients. Methods: To examine the inferior rates of follow-up in our bariatric surgery patients and the reasons for decreased weight loss outcomes in African American and publically insured patients, we identified forty patients who underwent bariatric surgery from August 2014 - April 2015 who failed to follow-up with their surgeon more than three months post-operatively. We were able to contact twenty-one of the 40 patients over the phone and they all agreed to participate in a 15-minute telephone survey. The remaining 19 patients were either not reachable by phone (due to out of service numbers or failure to pick up) or unable/unwilling to participate. The survey included 22 questions about planned versus actual weight loss, satisfaction with those outcomes, postoperative dietary and exercise regimens, support group attendance, and the perceived value of the education provided in preparation for surgery. We also queried the frequency of follow-up with bariatric surgeon, PCP, and other medical specialists, and the reasons for failure to follow up. Results: Ninety percent (19) of participants were female and 71.4% (15) were African American, which is similar to our overall patient population. However, only 42% (9) were publically insured, which is significantly lower than our overall patient population (nearly 60% Medicare or Medicaid). Fifty-two percent of patients (11) were satisfied with their weight loss, while 48% (10) were either unsatisfied or satisfied but wanted to lose more. Overall, 62% (16) felt that they were well educated about their surgery preoperatively, and 76.2 % (18) felt that nutrition education was the most important component of the preparation. Of the 21 patients interviewed, 16 (76.2%) exercised, 18 (85.7%) felt they maintained a healthy diet after surgery, and only two patients sought other weight loss solutions following inadequate post-surgical weight loss. Although these patients failed to followup with their surgeons as frequently as recommended, 90% (19) did see their primary care physician (PCP) routinely. Patients failed to follow-up with their surgeons postoperatively because of an inability to access office hours due to work/school/child care conflicts or distance (76.2%) and a lack of understanding of the need for long-term follow-up and/or the sentiment that follow-up was unnecessary due to a lack of complications (95.2%). Conclusions: A significant number of patients that fail to followup with their surgeon in the long-term fall short of their weight loss goals after surgery, and many of them desire to continue losing weight but do not have the tools to implement further weight loss. This survey showed that the following interventions should be used to improve post-operative follow-up: increased surgeon interaction with PCPs and referral back to the surgeon, more flexible office hours and/or locations of the surgeons, and pre- and post-operative education about the necessity for long-term follow-up. In addition to increasing surgeon specific follow-up, the use of support groups and information sessions with a nutritionist exclusively for post-operative patients would improve weight loss
Poster Presentations / Surgery for Obesity and Related Diseases 12 (2016) S76–S232
outcomes. Regular and long-term follow-up with bariatric surgery specialists after surgery will improve weight loss outcomes, and help to prevent weight gain. [i] LA Karas, M Siddeswarappa, S Slane, P Ramachandra. Insurance status influence weight loss and complication rates following bariatric surgery. Abstract presented at SAGES 2015, Nashville, TN. [ii] J Harper, AK Madan, C Ternovits, DS Tichansky. What happens to patients who do not follow-up after bariatric surgery? Am Surg. 2007 Feb; 73(2):181-4.
A5155
BODY COMPOSITION OF ASIAN PATIENTS WITH MORBID OBESITY SEEKING BARIATRIC SURGERY Pamela Er1; Chuen Seng Tan2; Pei Zheng Tan2; Yong Xiang Gwee2; Fathimath Naseer1; Si Hooi Lee3; Davide Lomanto1; Jimmy BY4; Asim Shabbir1; Guowei Kim1; 1National University Hospital, Singapore Singapore; 2National University Singapore, Singapore Singapore; 3National University Hospital, Serangoon Singapore; 4National University Hospital, Sosingapore NA Background: Currently, there is a lack of available information on the body composition characteristics of Asian patients with morbid obesity seeking bariatric surgery. The objective of this study is to evaluate the body composition profile of these patients and examine its relationship with ethnicity and diabetic status. Method: A total of 305 bariatric patients were measured presurgically with the body composition analyzer, GAIA 359 PLUS, which utilizes bioelectrical impedance analysis to estimate the body's make up. The data collection included total body weight, body mass index (BMI), excess weight, basal metabolic rate (BMR), fat-free mass (FFM), fat mass, fat percentage and total body water (TBW). Two sub-group analyses (Diabetic versus Non-Diabetic and between the Chinese, Malay, Indian, and Eurasian ethnic groups) were performed to see if there were any differences between the groups for the different body composition variables. The two sample t-test was used to compare the mean body composition variables of diabetics and nondiabetics in the sample, while the F-statistics from simple linear regression was used to compare mean body composition between the different ethnicities. Statistical significance was set at Po0.05. For each of the body composition variable, the mean (SD) was reported. Results: Subjects in this study had a mean BMI of 42.7kg/m2 (7.4) and a mean BMR of 1596kcal (326.3). The mean fat percentage, fat mass and FFM were 42% (8), 48.6kg (13) and 67.5kg (17.9) respectively. Fifty nine percent of the subjects were females and had a mean age of 41.7 years (10.6) while the males subjects were slightly younger with a mean age of 36.5 years (11.5). Ethic Malays form bulk of the group (38.7%) followed by Chinese (28.2%), Indians (24.9%) and Eurasians (8.2%). Malays have the highest mean BMI 45.1kg/m2 (7.8) followed by Eurasians 42.2 kg/ m2 (5.6) while the Chinese and Indians were similar at BMI of 41kg/m2 (SD: 6.6 and 7.1 respectively). Despite having a similar BMI, the mean fat percentage of Chinese was lower in comparison to Indians (39.4% vs. 43.8% respectively, P¼0.003). Additionally, mean FFM and TBW in Chinese was higher than in Indians (72kg vs. 63.8kg, P¼0.031 and 52kg vs. 46.1kg, P¼0.028 respectively). Lastly, Chinese were found to have a higher BMR of 1716.6kcal (334.6) as compared to Malay who had the lowest BMR at 1542.7kcal (313.5). Non-diabetic subjects (n¼213) had a mean of 6.2 absolute percentage point greater FFM (p¼0.003) and a mean
S151
of 5kg heavier TBW (p¼0.003) as compared to diabetic subjects (n ¼92). In line with the result for FFM, mean fat percentage was lower for non-diabetics [41.4% (8.3) vs. 43.4% (7.3), P¼0.016]. In addition, mean BMR was 114.8kcal higher (p¼0.004) for the nondiabetic subjects. Despite the differences in fat percentage, FFM, TBW and BMR, the diabetic group was significantly lighter than the non-diabetic group [111.9kg (20.9) vs. 118.7kg (25.3) respectively, P¼0.016]. The interaction effect of diabetic status and ethnicity was not looked at for the different body composition variables, due to the small sample size of each stratum. Conclusions: The Chinese ethnic group has a more protective body composition profile. Malays have the highest weight, BMI, percentage of fat and the lowest BMR, which are high risk factors of metabolic diseases. Despite Indians and Chinese having similar BMI, Indians have a higher percentage fat and lower FFM and thus a theoretically higher risk of developing metabolic syndrome.
A5156
BEST PRACTICES FOR REAL-TIME DATA MANAGEMENT WORKFLOW USING MBSAQIP Andrea Stone1; Darren Tishler1; Pavlos Papasavas2; Patricia Sobieski2; Sally Strange2; 1Hartford Healthcare, Glastonbury CT; 2Hartford Healthcare, Hartford CT Background: The healthcare industry is in the midst of substantive transition from a volume-based model to a value-based model, with patients seeking out facilities based on outcomes and safety much like consumers of other services. Additionally, changes in hospital reimbursement have made it necessary for programs to publicly report outcomes as well as implement quality improvement initiatives in order to maintain viability in an increasingly competitive quality-driven market. The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) has provided accredited programs with a standardized Registry through which they are able to monitor safety and quality indicators such as readmissions and complications. This platform has a high level of functionality and provides quantitative feedback to participating programs via the Semi-Annual Report (SAR) and other reports. These data help programs identify areas with potential for quality improvement.In order to provide as much real-time data as possible to centers, MBSAQIP has reduced the amount of time available for the abstractor to complete each case. This has presented a unique challenge to programs whose data entry workflow was not concurrent. As our center was chosen to participate in the Decreasing Readmissions Through Opportunities Provided (DROP) initiative, we were in a position to enhance processes by developing and implementing a concurrent data entry and review process. Our experience at a high volume (Z500 annual cases), acute care teaching hospital in developing best practices with real-time case management and tracking using the MBSAQIP Registry in conjunction with other applications is presented here. Methods: Workflow Our program utilizes multiple tracking systems to augment the Registry and allow for the target 100% case capture required for accreditation. Preoperative surgical pending lists are circulated to the abstractor on a weekly basis, and all new bariatric cases are entered into a spreadsheet which is used to track entry of each case, 30 day follow-up completion, and other procedure and scheduling specific information.Cases are entered into the Registry within 2 weeks of surgery and then