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Surgical delays

US paper examines why bariatric patients face surgical delays

Many insurance companies require them to lose weight before the surgery, even though there's no data or evidence to prove preoperative weight loss affects long-term success

Patients eligible for bariatric surgery are increasingly facing longer waits for their operations, according to a study by researchers from the Michigan Bariatric Surgery Collaborative (MBSC), Michigan, IL. The investigators - who were examining the amount of time between initial bariatric surgery clinic visit and operative date and identifying the factors associated with longer wait times – reported that over a ten-year period patient’s waiting time had nearly doubled from 86 days in 2006 to 159 days in 2016.

About 95 percent of patients undergoing bariatric surgery in Michigan are enrolled in the MBSC registry used for the study. Surgeons across the state share information about their cases via MBSC with the intent of recognising practice trends and patient outcomes in a way that a single doctor or even a hospital would be able to do on their own, namely whether suitable patients receive bariatric surgery in a timely fashion.

The study, ‘Factors Associated With Long Wait Times for Bariatric Surgery’, published in the Annals of Surgery, is believed by the authors to be the first multi-institutional look at bariatric surgery wait times in the US. The researchers examined data collected by the Michigan Bariatric Surgery Collaborative (MBSC) on 60,791 patients who had bariatric surgery in Michigan.

Oliver Varban (Credit: Bryan McCullough/Michigan Medicine)

"Prolonged wait times can be discouraging and increase the chance that patients will drop their pursuit of surgery," said study author, Dr Oliver Varban, an assistant professor of surgery at the University of Michigan and director of the Adult Bariatric Surgery Program.

Outcomes

Factors independently associated with longer wait times included Medicaid insurance [odds ratio (OR) 3.02; 95% confidence interval (CI): 2.58–3.53], sleep apnoea (OR 1.49; 95% CI: 1.41–1.58), psychological disorder (OR 1.25; 95% CI: 1.18–1.32), hyperlipidaemia (OR 1.21; 95% CI: 1.14–1.28), smoking history (OR 1.11; 95% CI: 1.05–1.17) and white race (OR 0.665; 95% CI: 0.614–0.720). Pre-operative weight loss, risk adjusted complication rates, postoperative self-reported weight loss, and comorbidity remission were similar between groups.

Therefore, patients with complex medical histories enrolled in Medicaid experienced the longest delays. Non-white patients also waited longer, but in Michigan they are more often enrolled in Medicaid. Smokers and patients with high cholesterol or psychological disorders also had longer wait times for bariatric surgery.

Interestingly, because more surgeons have begun performing bariatric surgery in Michigan over the past decade, finding an available doctor had minimal impact on scheduling, authors confirmed.

Researchers used the data to create two study groups: a shorter wait time group that had a median wait of 67 days and a longer wait time group that waited 204 days or more for surgery. After one year, patients in the longer wait time group had lost 56.6lbs compared with the shorter wait time group in which average weight loss was 58.lbs. Among all recipients, serious complications occurred in just 2 percent of patients in the first month after surgery.

Some insurers, including Medicaid, want documentation of supervised diet attempts and some patients may lose some weight that improves their health conditions, but the benefits will not last unless the patients can keep the weight off. However, the benefit of such policies is unclear and should be re-examined, said the authors.

The authors did acknowledge that cautious doctors may overestimate surgery risk and that patients can get cold feet and intentionally delay surgery. In addition, the study was not able to measure the availability of other specialists such as registered dietitians, who are needed to guide patients through a successful health transformation.

"Showing that patients waiting longer are not experiencing fewer complications or better comorbidity resolution than those with shorter wait times argues for streamlining the preoperative optimisation process and against insurance-mandated weight-loss documentation," said U-M general surgery resident, Dr Rafael Alvarez, lead author of the study.

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