Bariatric Services Research Articles

Exploring patient perspectives on shared decision making about bariatric surgery in two healthcare systems.

To assess patient perspectives on the level of shared decision making (SDM) experienced related to bariatric surgery. Severe obesity is common and has serious health implications. Yet, few eligible patients pursue bariatric surgery. Shared decision making could be a useful approach for considering treatment options. Patients were surveyed at Kaiser Permanente and UPMC clinics providing bariatric surgical services. Cross-sectional samples represent three time points: (a) Cohort 1 (C1): following referral; (b) Cohort 2 (C2): after initial bariatric practice appointment; (c) Cohort 3 (C3): following pre-operative visit. Patients completed the electronic survey instruments: CollaboRATE, SDM-Q-9, and National Quality Forum (NQF) SDM process measures. The sample included 167 participants, half from each site. Cohort distribution was 35% C1, 33% C2, and 32% C3. Mean age was 43.8years (SD 13.5), BMI was 48kg/m2 (SD 8.63), 81% were female and 73% were white. Overall, 62% reported CollaboRATE top scores, with a dose-response (C1: 54%, C2: 60%, C3: 72%). Mean (SD) SDM-Q-9 score (possible range: 0-100) was: 79.6 (22.5); with C1: 66.9 (26.5), C2: 83.4 (18.0), and C3: 88.4 (15.9). The average NQF score (possible range: 0-4) was 3.11 (1.14), with C1: 2.71 (1.27), C2: 3.31 (1.09), and C3: 3.28 (0.97). Patients seeking bariatric care reported moderate or high levels of SDM. In general, SDM metrics were highest just before surgery.

BS SO09 - Use of ursodeoxycholic acid in preventing gallstone formation after bariatric surgery – introduction of a new clinical pathway

Abstract Background Rapid weight loss is a risk factor for symptomatic gallstone formation. Managing gallstone disease such as choledocholithiasis can be more challenging after Bariatric Surgery (BS) due to altered anatomy. Ursodeoxycholic acid (UDCA) is a low-cost and low-risk method of reducing the risk of symptomatic gallstone disease and cholecystectomy by almost a third in patients who have had BS. However, it is not yet included in national guidelines for bariatric surgery. We audited prescription rates of UDCA in patients who underwent BS with a view to introducing it into our standard post BS care bundle. Method Data was collected from 30 consecutive patients who underwent a sleeve gastrectomy or Gastric bypass in November and December 2023. The results informed our practice and a UDCA prescribing pathway was developed using evidence from randomized trials. The pathway was circulated to all members of the bariatric service on 17/1/2024 and discussed at the departmental meeting. The audit loop was closed by collecting data from a further 30 consecutive patients. Demographic data, type of operation, BMI, history of gallstone disease, prescribing data and reasons for non-compliance were collected. The compliance rate to the UCDA pathway was expected to be 100%. Results Data was collected from 60 patients (85% female; median BMI 49; median age 45). No patient who could have benefited received UDCA prior to the intervention. After the intervention, 15/30 (50%) of patients were correctly prescribed UDCA. Therefore, correct prescription of UDCA did not meet target compliance rates. No patient was incorrectly prescribed UCDA. Reasons for non-compliance include human error, concern about the size of the tablet, inadequate knowledge about how to administer (e.g. crushing in liquid) and misconceptions of oral intake after BS. Conclusion UCDA can reduce incidence of symptomatic gallstones following BS, yet use of UDCA in bariatric centres in the UK is thought to be low. We discovered that more time should be dedicated to educating the team about administration methods and how it interacts with the current postoperative diet plan. A UCDA pathway and education of bariatric teams can improve compliance with appropriate UDCA prescribing. Further intervention is required and planned in our centre such as utilising e-prescribing as a prompt to include UDCA in the discharge prescription and considering the use of the drug's liquid form in the short term.

Dental team barriers and enablers for the dental management of adults with severe obesity: a qualitative analysis

BackgroundBroad challenges regarding the dental management of people with severe obesity experienced by general dentists have been minimally explored. The perspectives of the dental team regarding these multifaceted issues are currently unknown and they potentially impede the delivery of optimal dental care to this population and contribute to poor oral and general health.AimsOur qualitative study aimed to identify and explore barriers and enablers in the dental management of adults with severe obesity among dental professionals and support staff in Australia.MethodsFocus groups and semi-structured interviews (n = 34 participants) were conducted with dental professionals (n = 23) and support staff (n = 11). Recordings were transcribed verbatim and synthesised using thematic, inductive analysis.ResultsMultiple barriers to adequate provision of dental care for people living with severe obesity in both general and specialist dental settings were identified. Key themes emerged related to the clinical challenges reported by participants in providing dental management for people living with severe obesity, appropriateness of existing bariatric dental service provision and safety of care. Enablers to access were identified, including increased availability of bariatric dental chairs, environmental modifications, education of both patients and the entire dental team and for guideline development.ConclusionThe current study explored multiple barriers to optimal dental management of people living with severe obesity in both general and specialist dental settings. Enablers should be used to inform future practice. The optimisation of existing bariatric dental service provision requires urgent review with solutions guided by systemic change. Study findings suggest a review of current health systems, economics, access barriers, policies and procedures and education and training beyond the individual level are needed. Future directions to improve the dental management of people living with severe obesity are proposed.

Barriers for bariatric surgery in provincial New Zealand: a qualitative analysis.

Bariatric surgery is the most effective treatment for people with obesity. It has been shown that there's is a complex psychosocial overlay in the pathophysiology and treatment, which requires specific consideration when delivering care. There is a significant drop out rate for patients accepted on to bariatric programmes in New Zealand, resulting in failure to progress to surgical intervention. We conducted individual, semi-structured interviews with patients who were accepted onto the bariatric surgery programme but did not complete the programme, or receive an operation between 2015 and 2020. Grounded theory methodology was used to create an exploratory framework to identify and describe the themes encountered. An iterative process of thematic analysis and comparison between participants experiences was used to consolidate the shared key barriers. This study aims to explore patients experiences of a bariatric surgery programme to understand barriers and enablers to complete a bariatric programme and receive an operation. Adding to previous qualitative work investigating patients experience of bariatric surgery programmes in New Zealand. Five themes of barriers that patients face to receiving bariatric surgery were identified. These were preoperative weight loss requirement, experiencing the social stigma of obesity, communication, socioeconomic and geographic barriers, and community support. These five themes often co-exist in patients experiences and combine, to cause patients to disengage with the bariatric service. Many factors contribute to eligible patients not receiving bariatric surgery once accepted onto the programme. Specified weight loss goals was the most significant barrier. Community support and online resources were significant enablers. This study should inform changes to bariatric programmes in New Zealand.

Twenty-year review of the bariatric programme at Te Whatu Ora Waitematā.

Obesity is a significant health issue. Te Whatu Ora Waitematā serves a population of 650,000 patients across the North Shore, Waitākere and Rodney areas. The Waitematā bariatric service at North Shore Hospital was introduced in October 2001. The aim of this study was to review the development and impact of the service over the last 20 years, and identify whether equivalent bariatric services could viably be introduced into other hospitals in Aotearoa New Zealand. A retrospective audit was conducted of the 20-year results of the Waitematā bariatric surgical service to identify the impact of technology, teaching and research on service provision. Since its inception, the Waitematā bariatric service has launched minimally invasive surgery, multiple operative options and an enhanced recovery after surgery (ERAS) protocol. Approximately 100 cases are performed per year. Of these, 3.4% of patients require admission to the intensive care unit/high dependency unit (ICU/HDU), with an average length of stay (LOS) of 0.66 days. The 1-year mortality rate is 0.39%. Eleven surgical fellows have undergone post-fellowship training with the service, which is a recognised training unit for the post-fellowship AANZGOSA/ANZMOSS programme. Bariatric surgery can be performed safely and has good long-term outcomes. The Waitematā bariatric service is dedicated to providing excellent care within the resource constraints of a public healthcare system. The high number of procedures, low requirement for ICU/HDU and low mortality rate suggest that bariatric surgery could be safely performed within a public setting in secondary and regional hospitals across the country.

Intensive pre-operative information course (IPIC) and pre-operative weight loss results in long-term sustained weight loss following bariatric surgery: 11years results from a tertiary referral centre.

Outcomes of long-term (5-10-year) weight loss have not been investigated thoroughly and the role of pre-operative weight loss on long-term weight loss, among other factors, are unknown. Our regional bariatric service introduced a 12week intensive pre-operative information course (IPIC) to optimise pre-operative weight loss and provide education prior to bariatric surgery. The present study determines the effect of pre-operative weight loss and an intense pre-operative information course (IPIC), on long-term weight outcomes and sustained weight loss post-bariatric surgery. Data were collected prospectively from a bariatric center (2008-2022). Excess weight loss (EWL) ≥ 50% and ≥ 70% were considered outcome measures. Survival analysis and logistic regression identified variables associated with overall and sustained EWL ≥ 50% and ≥ 70%. Three hundred thirty-nine patients (median age, 49years; median follow-up, 7years [0.5-11years]; median EWL%, 49.6%.) were evaluated, including 158 gastric sleeve and 161 gastric bypass. During follow-up 273 patients (80.5%) and 196 patients (53.1%) achieved EWL ≥ 50% and ≥ 70%, respectively. In multivariate survival analyses, pre-operative weight loss through IPIC, both < 10.5% and > 10.5% EWL, were positively associated with EWL ≥ 50% (HR 2.23, p < 0.001) and EWL ≥ 70% (HR 3.24, p < 0.001), respectively. After a median of 6.5years after achieving EWL50% or EWL70%, 56.8% (154/271) had sustained EWL50% and 50.6% (85/168) sustained EWL70%. Higher pre-operative weight loss through IPIC increased the likelihood of sustained EWL ≥ 50% (OR, 2.36; p = 0.013) and EWL ≥ 70% (OR, 2.03; p = 0.011) at the end of follow-up. IPIC and higher pre-operative weight loss improve weight loss post-bariatric surgery and reduce the likelihood of weight regain during long-term follow-up.

O80: Intensive pre-operative information course (IPIC) and pre-operative weight loss results in long-term sustained weight loss following bariatric surgery: 11year results from a Tertiary Referral Centre

Abstract Introduction Outcomes of long-term (5-10 year) weight loss have not been investigated thoroughly and the role of pre-operative weight loss on long-term weight loss, among other factors, are unknown. Our regional bariatric service introduced a 12-week intensive pre-operative information course (IPIC) to optimise pre-operative weight loss and provide education prior to bariatric surgery. The present study determines the effect of pre-operative weight loss and an intense pre-operative information course (IPIC), on long-term weight outcomes and sustained weight loss post-bariatric surgery. Methods Data were collected prospectively from a bariatric center (2008-2022). Excess weight loss (EWL) ≥50% and ≥70% were considered outcome measures. Survival analysis and logistic regression identified variables associated with overall and sustained EWL≥50% and ≥70%. Results 339 patients (median age, 49 years; median follow-up, 7 years [0.5-11years]; median EWL%, 49.6%.) were evaluated, including 158 gastric sleeve and 161 gastric bypass. During follow-up 273 patients (80.5%) and 196 patients (53.1%) achieved EWL≥50% and ≥70%, respectively. In multivariate survival analyses, pre-operative weight loss through IPIC, both &amp;lt;10.5% and &amp;gt;10.5%EWL, were positively associated with EWL≥50% (HR2.23,p&amp;lt;0.001) and EWL≥70% (HR 3.24,p&amp;lt;0.001), respectively. After a median of 6.5years after achieving EWL50% or EWL70%, 56.8% (154/271) had sustained EWL50% and 50.6% (85/168) sustained EWL70%. Higher pre-operative weight loss through IPIC increased the likelihood of sustained EWL≥50% (OR,2.36;p=0.013) and EWL≥70% (OR,2.03;p=0.011) at the end of follow up. Conclusions IPIC and higher pre-operative weight loss improve weight loss post-bariatric surgery and reduce the likelihood of weight regain during long-term follow-up.

BS P03 The burden of bariatric tourism on the Health and Social Care System in Northern Ireland: a descriptive analysis

Abstract Background The lack of public bariatric surgical services in Northern Ireland has favoured the growth of bariatric tourism. This retrospective study aimed to analyse the data extracted from the records of bariatric patients who presented with complications to Belfast Health and Social Care Trust following their surgery abroad and investigate the costs associated with managing these complications. It also aimed to explore other factors, such as emotional trauma, that may be associated with bariatric tourism. Methods This was a retrospective study including all patients, who had their bariatric procedure abroad, presenting acutely to our hospital between August 2016 and February 2023. Data were collected from hospital records and included demographic characteristics, type of surgery, nature of complications, and costs associated with managing these complications. Descriptive statistics were used to analyse the data. Results 42 patients included in the study. Majority were female (n=35, 83.3%) with a mean age of 46.6 years. Sleeve gastrectomy was the most common surgery (n=22,52.3%), followed by AGB (n=11,26.1%), Gastric bypass (n=6,14.2%) and Gastric balloon (3,7.1%). Operations were performed in 7 countries, majority were done in Turkey (n= 22). The most common complication was leak (n=14), followed by band erosion (n=7) and nutritional failure (n=7). The total cost was estimated to be (£737,126), which includes hospital-stay costs (£553,179), non-surgical intervention (£55,607), scans (£41,728), and surgical intervention (£75,413). The total cost of dietetic inputs were about £17,390,including 410 hours. Conclusions Most patients experienced emotional trauma related to lack of adequate perioperative care, and difficulties in communication with their overseas surgeons. The results of this study highlight significant costs associated with managing such complications in Northern Ireland. The findings suggest investing in public bariatric surgical services may be more cost-effective than relying on bariatric tourism. Furthermore, Bariatric care is delivered by MDTs which are actively involved in management of these patients throughout their care-pathway. The study highlights lack of perioperative care and follow up needed to minimize complications and associated costs, as well as addressing the emotional trauma of those patients.

BS O08 The burden of bariatric health tourism on publicly funded health services in the UK

Abstract Background Bariatric surgery is a safe and effective treatment for obesity and it's associated co-morbidities. Limited access to surgery in the NHS and a combination of cheaper costs and aggressive advertising by international clinics has led to a surge in people seeking surgery abroad. There is a perception that an indeterminate volume of bariatric health tourism has resulted in increased rate of serious complications in UK. This study aimed to objectively quantify this perceived burden by describing the presentation, management and outcomes of bariatric emergencies in cases undertaken abroad and comparing them to emergency cases originating in the UK. Methods This was a retrospective review of all consecutive non-elective attendances and admissions between January 2018 and April 2023. The setting was a regional bariatric and metabolic surgery centre with a dedicated bariatric on-call service serving Greater Manchester and the North-West of England. Patient demographics, data on index procedures, diagnostic and therapeutic interventions as well as length of hospital and ITU stay was collected. Changes in trends in patients undergoing their index procedure abroad (bariatric health tourist BHT group) were explored and compared to those undergoing surgery in the UK (UK group). Results 373 non-elective episodes were included; 28% related to index procedures abroad. The proportion of admissions related to BHT was 35.5% (17/48), 21% (10/48), 16.5% (9/54), 17% (6/35) and 36.5% (47/128) in years 1 to 5 respectively. BHT patients presented were most likely to present with sleeve complications (33% vs UK 20%) whilst UK patients were most likely to present with band-related problems (46% vs BHT 20%). BHT patients underwent 124 fluoroscopies, 115 CT-scans and 60% required surgical interventions. BHT patients accounted for 37% of total bed days (1610/4311) and had longer median ITU stays (8 v 3 days). Conclusions The total number of emergency episodes related to bariatric surgery undertaken abroad increased eight-fold in the last 12 months compared to the preceding year, and was higher than the total number of episodes in the preceding 4 years. This reflects the ongoing challenges with patient access to publicly funded and affordable bariatric surgery in the UK. Complications arising in this patient group result in longer stays and greater resource burden compared to those patients who have undergone surgery in the UK. This trend has enormous resource implications for service design and an urgent response is needed.

BS P05 The Return to Bariatric Surgery Following the COVID Pandemic 2020- A Single Center Prospective Study

Abstract Background Elective surgical practice was paused in March 2020 to cope with the Covid pandemic. Bariatric surgery was amongst the first specialities to be stopped as resource allocation prioritised lifesaving service for Covid positive patients over what is considered quality of life improving procedures. It was also one of the last to be restarted due to fears of Covid infection in obese patients undergoing surgery both of which are known risk factors of mortality in Covid cases. This study describes outcomes after bariatric surgery since the weight-loss program restarted and the measures to ensure service provision and maintenance of patient safety. Methods Elective bariatric surgery restarted in June 2021; patients were managed within a ‘green’ elective pathway in a new ring-fenced elective surgical hub. All patients who had surgery from June 2021 to January 2023 in a single centre were identified from a prospectively-maintained database of operations. The outcomes were patient safety measured by Covid infection and complication rates post operatively, impacts on hospital resources measured by length of stay in hospital and HDU/ITU bed occupation, impacts on the Bariatric Surgery service measured by waiting time for surgery and cancellations, and benefits to patients measured by remission of diabetes and hypertension. Results 124 patients were included; 42 (34%) had sleeve gastrectomy and 82 (64%) had gastric bypass. There were no Covid infections/complications in this series. Median length of stay after surgery was two days with no admissions to HDU/ICU. Waiting time for surgery was &amp;gt;52 weeks at the start of the study period which has fallen to 15 weeks after listing and no operations were cancelled due to lack of beds. Post-operative outcomes were favorable and in line with national data; 87% of patients had remission of diabetes and 60% of patients were off anti-hypertensive medications one year after surgery. Conclusions The creation of dedicated ring-fenced elective surgical hub allowed the rapid restart of bariatric surgery despite the effects of the Covid-19 pandemic. This model separated elective and acute patients reducing exposure of high-risk patients. This allowed the resumption of weight-loss surgery safely as evident by the zero Covid-related complications, no additional pressure to hospital resources such as beds and intensive care unit capacity, a high-quality service with short waiting times and favorable long term outcomes. This are all signs of good practice in a resilient service and can very easily be replicated in the future whenever required.

BS O05 Resource impacts of bariatric surgery emergencies on the NHS: a 5-year review from a regional bariatric centre

Abstract Background Bariatric surgery is a safe and highly effective treatment for obesity. Whilst the risks of surgery are generally low, emergency presentations can be extremely challenging to manage, particularly in a cohort with complex health needs. In the UK, a large proportion of cases are undertaken outside of the NHS. Little is known about the burden that an indeterminate volume of elective cases has on a publicly funded healthcare system which may need to adapt to better care for this group. This study aimed to explore this topic further by understanding the changing trends of emergency care for bariatric surgery patients. Methods This was a retrospective review of all consecutive non-elective (NE) attendances and admissions between January 2018 and April 2023. The setting was a regional bariatric and metabolic surgery centre with a dedicated bariatric on-call service serving a regional population in the North-West of England. Patient demographics, data on index procedures, diagnostic and therapeutic interventions as well as length of hospital stay (LOS) and intensive therapy unit (ITU) stay was collected. Changing trends in presentations and resource utilization were explored. Results 373 NE episodes resulted in 4311 bed day occupancy; 76% had privately funded surgery accounting for 66.5% of total bed days. Median LOS was 5 days (IQR 2-11). 29 episodes resulted in 176 ITU bed days (median 4 days). Band-related complications were the most frequent cause of episodes (167) versus gastric bypass (104) and gastric sleeve (88). Median time from index procedure was 5 years IQR (2-11). 397 fluoroscopies and 365 CT-scans were undertaken in addition to 270 interventions (186 surgical; 30 radiological; 26 bedside deflations and 28 endoscopic). There was a three-fold increase in episodes between 2021 and 2022. Conclusions Non-elective episodes related to bariatric surgery can occur many years after the index procedure and result in the use of significant diagnostic, therapeutic and system resource. Our results suggest that the landscape of emergency bariatric surgery is changing with more cases that result in greater complex management needs. Most NE episodes are a result of privately funded surgery (likely as a response to limited access in the NHS) which have contributed to this increased resource use. These changes have serious implications for service delivery and design in the NHS which needs to rapidly adapt to these needs.

BS P04 The Legacy of the Adjustable Gastric Band; 5-year study of the presentation and management of gastric band-related complications

Abstract Background Laparoscopic adjustable gastric banding (LAGB), once one of the most popular surgical treatments for obesity, now represents less than 10% of procedures undertaken nationally. No accurate figures exist regarding how many UK patients have undergone LAGB; approximately 5000 procedures were submitted to NBSR between 2013-2015. Alongside procedures undertaken abroad and privately, the total number is likely to be several multiples of this figure over the last 20 years. Currently there is a perception that LAGB-related complications account for a disproportionate volume of non-elective episodes compared to other procedures. This study describes the presentation and management of gastric band dysfunction. Methods This was a retrospective review of all referrals, attendances and admissions to a regional bariatric service with a dedicated bariatric on-call, serving the North West of England between. The study period was January 2018 and April 2023. All elective outpatient (OPC) and non-elective (NE) LAGB-related episodes were included. Patient demographics, band-related data, presentation, investigations, interventions, and related complications were collected and described. Results 375 episodes (212 OPC; 163 NE) accounted for 58% of all OPC and 44% of NE activity. Most patients had LAGB in the independent sector (OPC presentation 73% UK, 18% abroad; NE presentation 80% UK, 20% abroad). Median time from index surgery was 8 years (IQR 5-11, range 0-30 years). Erosions and infections accounted for 4% (14/375) and 5% (20/375) of cases, respectively. LAGB removal was required in 59% of OPC and 60% of NE presentations. LOS for NE presentations was 3 days (IQR 2-6, range 0-41 days). 5 patients required ITU admission (median LOS 2 days). Conclusions Whilst representing only a small proportion of current elective practice, LAGB-related complications represent the majority urgent and non-elective activity in the outpatient and emergency settings. Given that LAGB related complications often present many years after the index procedure, it is likely that this phenomenon will continue to be a challenge for UK surgeons and services for years to come. This has training implications for the future generation of bariatric surgeons and general surgical trainees, many of whom will likely never have seen a gastric band placed, and yet will have to manage complications, a significant proportion of which are complex.

A non-randomised feasibility study of a mHealth follow-up program in bariatric surgery

BackgroundBehavioural support via mobile health (mHealth) is emerging. This study aimed to assess the feasibility, acceptability, cost, and potential effect on weight of a mHealth follow-up program in bariatric surgery.MethodsThis was a non-randomised feasibility study describing intervention development and proof in the concept of a mHealth follow-up program in bariatric surgery. The study compares a prospective cohort with a historical control group and was conducted in a tertiary bariatric surgery service in Australia. The intervention group included individuals who had bariatric surgery (2019–2021) and owned a smart device, and the historical control group received usual postoperative care (2018). The intervention involved usual care plus codesigned biweekly text messages, monthly email newsletters, and online resources/videos over a 6-month period. The primary outcome measures included feasibility (via recruitment and retention rate), acceptability (via mixed methods), marginal costs, and weight 12 months postoperatively. Quantitative analysis was performed, including descriptive statistics and inferential and regression analysis. Multivariate linear regression and mixed-effects models were undertaken to test the potential intervention effect. Qualitative analysis was performed using inductive content analysis.ResultsThe study included 176 participants (n = 129 historical control, n = 47 intervention group; mean age 56 years). Of the 50 eligible patients, 48 consented to participate (96% recruitment rate). One participant opted out of the mHealth program entirely without disclosing their reason (98% retention rate). The survey response rate was low (n = 16/47, 34%). Participants agreed/strongly agreed that text messages supported new behaviours (n = 13/15, 87%); however, few agreed/strongly agreed that the messages motivated goal setting and self-monitoring (n = 8/15, 53%), dietary change (n = 6/15, 40%), or physical activity (n = 5/15, 33%). Interviews generated four main themes (n = 12): ‘motivators and expectations’, ‘preferences and relevance’, ‘reinforced information”, and ‘wanting social support’. The intervention reinforced information, email newsletters were lengthy/challenging to read, and text messages were favoured, yet tailoring was recommended. The intervention cost AUD 11.04 per person. The mean 12-month weight was 86 ± 16 kg and 90 ± 16 kg (intervention and historical control) with no statistically significant difference. Intervention recipients enrolled at 3 months postoperatively demonstrated a statistically significant difference in 12-month weight (p = 0.014).ConclusionAlthough this study observed high rates of recruitment and retention, findings should be considered with caution as mHealth may have been embraced more by the intervention cohort as a result of the 2019 coronavirus pandemic. Of the various digital strategies developed and tested, the text message approach was the most acceptable; however, future intervention iterations could be strengthened through tailoring information when possible. The use of email newsletters and online resources/videos requires further testing of effectiveness to determine their value for continued use in bariatric surgery services.

What is the role of psychology in bariatric surgery? A survey of the differing views of psychologists, the multidisciplinary team, and patients in the UK.

Although psychologists are a key member of the bariatric multidisciplinary team (MDT), there is a lack of clarity about the specific remit of their role. This exploratory study was conducted to identify differences, priorities and clarify how the role of psychology is perceived in the United Kingdom. We conducted surveys of three major stakeholder groups (psychologists, patients, and the bariatric multidisciplinary team) which focused on their perception of psychology in bariatric surgery. The results showed that in UK bariatric services, psychologists are spending the majority of their clinical time providing pre-operative assessments. Differences emerged between psychologists and MDT in how they viewed the purpose of these assessments, with the MDT viewing them as identifying contraindications to surgery whereas psychologists viewed them as identifying readiness for surgery. A total of 51% of patients reported they had not been able to access psychology services when needed and viewed provision of post-operative psychological support to be a key priority. Key themes and tensions emerged around (a) high demand for services yet limited psychology resource, (b) the purpose of the pre-operative assessment and (c) the provision of pre-operative versus post-operative support. These themes combine and interact in a way that currently makes it extremely challenging to provide coherent psychology services. There is clearly a need for education, consensus and adequate resourcing of the psychology role within bariatric surgery services in the United Kingdom.

Improving efficiency and reducing costs in robotic surgery: a Lean Six Sigma approach to optimize turnover time.

Operating room (OR) turnover time (TOT) is the time it takes to prepare an OR for the next surgery after the previous one has been completed. Reducing OR TOT can improve the efficiency of the OR, reduce costs, and improve surgeons' and patients' satisfaction. The objective of this study is to evaluate the effectiveness of an operating room (OR) turnover time (TOT) reduction initiative using the Lean Six Sigma methodology (DMAIC) in the bariatric and thoracic service lines. Performance improvement strategies consist of simplifying steps (surgical tray optimization) and concurrent steps (parallel task execution). We compared 2-month pre-implementation vs. post-implementation. A paired t-test was used to assess whether the difference in the measurements was statistically significant. The study found that TOT was reduced by 15.6% from an average of 35.6 ± 8.1 to minutes 30.09 ± 9.7min (p < 0.05). Specifically, in the bariatric service line, TOT was reduced by 17.15% and in the thoracic service line, TOT was reduced by 9.6%. No adverse events related to the initiative were reported. The results of this study indicate that the TOT reduction initiative was effective in reducing TOT. The efficient use of operating rooms is crucial in hospital management, as it not only impacts finances but also affects the satisfaction of surgical teams and patients. This study shows the effectiveness of Lean Six Sigma methodology in reducing TOT and improving the efficiency in the OR.

A mixed-method study to inform the development and implementation of eHealth in a bariatric surgery service in an Australian public hospital.

This study aimed to explore patient barriers to accessing services, current technology ownership/use and digital device preferences for accessing health information/health service delivery. Additionally, it aimed to explore the Theoretical Domains Framework and the acceptability of future eHealth solutions in bariatric surgery. This mixed-method study (survey and semi-structured interviews) was conducted in a bariatric surgery service in an Australian public hospital. Quantitative data were analysed descriptively, and the qualitative data were deductively and inductively analysed. This study included 117 participants (n = 102 surveyed and n = 15 interviewed). Most participants were aged ≥51 years (n = 70, 60%), and two-thirds were female (n = 76, 65%). One in three participants reported barriers to accessing services (n = 38, 37%), including parking, travel time, and taking time off work. Most participants preferred to receive or access additional health information via email (n = 84, 82%) and were willing to engage with health professionals via email (n = 92, 90%), text messages (n = 87, 85%), and telephone (n = 85, 83%). Deductive analysis of interviews generated three themes: 'Knowledge', 'Social influence' and 'Behavioural regulation, goals and environmental resources'. The inductive analysis generated one theme: 'Seeing a place for eHealth in service delivery'. This study's findings can potentially influence the development of future eHealth solutions. Text message, email, and online approaches may be suitable for delivering further information and resources to patients, particularly regarding diet and physical activity. Online health communities are being used by patients for social support and may be worth further investigation. In addition, developing a bariatric surgery mobile application may be beneficial.

Developing a long-term follow up service for bariatric surgical patients in the community: Patient and professional perspectives.

In the UK, bariatric surgical patients are followed up for 2years post-operatively in hospital settings, before being discharged into General Practice for long-term follow-up. Presently, there is ambiguous guidance as to what should be included in a community-based bariatric surgical follow-up service. The aim of the study was to understand, from both patient and professional perspectives, what is needed to support the long-term management of bariatric surgical patients in community-based settings. Post-surgical bariatric patients and General Practice staff were recruited from an area in the UK which has an National Health Service (NHS) hospital providing a high-volume and established bariatric surgical service. Data was collected through semi-structured interviews. A thematic analytic framework was used to construct eight themes which illuminated the participants' experiences. The study took place between March and December 2021. Thirty participants (14 patients and 16 healthcare professionals) were recruited to the study. The study revealed the lack of a framework for delivery of a long-term follow up service was frustrating to both patients and professionals. Patient participants reported needing more support, especially dietetic and psychological input, and professionals stated they had little knowledge about bariatric surgical care, and what was needed to provide optimal care, but wanted to provide quality patient care. Long-term follow up of bariatric surgical patients is an important issue which needs addressing. This study illuminates both the patient and professional perspectives on developing a pragmatic, community-based service which meets the needs of patients and considers the need to incorporate such a service into existing infrastructures without adding additional demands on General Practice.

"Is it time to throw out the weighing scales?" Implicit weight bias among healthcare professionals working in bariatric surgery services and their attitude towards non-weight focused approaches.

People living with overweight or obesity (PLwO) can be stigmatised by healthcare professionals (HCPs). Reducing focus on weight is a proposed strategy to provide less threatening healthcare experiences. Given the lack of research on weight bias within obesity services, this study aimed to explore implicit bias among obesity specialist HCPs and explore views on non-weight focused approaches. Obesity specialist HCPs were invited to a webinar, "An exploration of non-weight focused approaches within bariatric services", held in October 2021. Implicit weight bias was examined using the BiasProof mobile device test, based on the Implicit Association Test. Poll data was analysed descriptively, and qualitative data was analysed using framework analysis. 82 of the 113 HCPs who attended the webinar consented to contribute data to the study. Over half (51%) had an implicit weight bias against PLwO. Most (90%) agreed/strongly agreed that obesity services are too weight focused and that patients should not be weighed at every appointment (86%). Perceived benefits of taking a non-weight focused approach included patient-led care, reducing stigma and supporting patient wellbeing, while perceived barriers included loss of objectivity, inducing risk and difficulty demonstrating effectiveness. Our findings indicate that half of obesity specialists HCPs in our sample of 82 providers, who are primarily dieticians and psychologists, have an implicit weight bias against PLwO. HCPs feel that a weight-focused approach within services was a barrier to patient care, but that there is a lack of alternative non-weight focused measures. Further research is needed into substitute outcome measures for clinical practice, also seeking the views of PLwO, and into interventions to address implicit weight bias. Johnson & Johnson funded the BiasProof licence and publication open access charge.

Clinical and economic comparative analysis of laparotomy versus laparoscopy in the first gastric bypass surgeries in a bariatric and metabolic surgery service in a city in southern Brazil.

this paper aims to evaluate the main direct and indirect costs of the first laparotomies and laparoscopies in bariatric surgeries with a clinical-economical retrospective and cross-sectional analysis from 2017 to 2020 at a hospital with specialties besides the basic ones in southern Brazil. the study sample included 26 participants. The first 13 laparotomies, and the first 13 laparoscopies performed at the bariatric surgery service of the institution were evaluated. The values evaluated in such comparison analyzed the costs of operation and hospitalization. It is important to highlight that, in addition to the cost benefit, other costs take significance in the health area, such as: cost-utility, cost-effectiveness and cost-minimization, in addition to the cost-opportunity that is reassessed in the observation of the broad context associating all the values raised here. The software used for data analysis was Excel version® 365. The economic analysis was performed evidencing the profile of the patients and the direct and indirect costs involved in each segmentation. the direct and indirect costs of videolaparoscopy amounted to BRL 10,108.10 and laparoscopy to the amount of BRL 12,568.14. it was concluded that laparoscopy presents more savings in the aspects of all health valuations to the detriment of laparotomy. It was concluded that the videolaparoscopy presents more savings in the aspects of all health valuations than the laparotomy.

Clinical and economic comparative analysis of laparotomy versus laparoscopy in the first gastric bypass surgeries in a bariatric and metabolic surgery service in a city in southern Brazil

RESUMO Introdução: o presente estudo tem como objetivo avaliar os principais custos diretos e indiretos das primeiras laparotomias e videolaparoscopias em cirurgias bariátricas em uma análise clínica-econômica, retrospectiva e transversal de 2017 a 2020 em um hospital terciário do sul do Brasil. Métodos: a amostra do estudo incluiu 26 participantes. Foram avaliadas as primeiras 13 laparotomias e as primeiras 13 videolaparoscopias realizadas no serviço de cirurgia bariátrica da instituição. Os valores avaliados em tal comparação analisaram os custos da operação e da internação. É importante ressaltar que além do custo-benefício, outros custos tomam significância na área da saúde. São eles: o custo-utilidade, o custo-efetividade e o custo-minimização, além do custo-oportunidade que é reavaliado na observação do contexto amplo associando todas as valorações aqui levantadas. O software utilizado para a análise dos dados foi o Excel® versão 365. A análise econômica foi realizada evidenciando o perfil dos pacientes e os custos direto e indireto envolvidos em cada segmentação. Resultados: os custos diretos e indiretos da videolaparoscopia somaram o montante de R$ 10.108.10 e da laparoscopia o montante de R$ 12.568,14. Conclusão: concluiu-se que a videolaparoscopia apresenta mais economia nas vertentes de todas as valorizações em saúde em detrimento da laparotomia.