Predicting potentially preventable hospital readmissions following bariatric surgery

County health ranking: untangling social determinants of health and other factors associated with short-term bariatric surgery outcomes

BACKGROUND

The complex interplay of the social determinants of health, race/ethnicity, and traditional surgical risk factors on outcomes following metabolic surgery is poorly understood.

OBJECTIVE

To evaluate the relationship between the social determinants of health as measured by county health ranking (CHR) and short-term metabolic surgery outcomes.

SETTING

Five accredited bariatric program sites at a national academic health system.

METHODS

Data were collected from 5 sites of a single health system from 2010 to 2021. Current procedural terminology codes identified primary and revisional cases. Patient characteristics, procedural data, and 30-day occurrences were collected. CHRs for health factors were determined by ZIP Code and stratified into best, middle, and worst terciles. The primary outcome was 30-day complications, readmissions, or reinterventions/reoperations. Logistic regression assessed the correlation between CHR tercile and morbidity.

RESULTS

We analyzed 4,315 primary and 370 revisional metabolic surgery cases. Overall, 64.0%, 27.4%, and 8.6% of patients lived in the best, middle, and worst CHR terciles, respectively. Patients in the middle and worst CHR terciles were more commonly older; non-Hispanic Black or Hispanic; suffered from preexisting chronic obstructive pulmonary disease or hypertension, were dialysis dependence, were on therapeutic anticoagulation, or had inferior vena cava filters. Middle and worst CHR tercile patients were more likely to undergo index sleeve gastrectomy or robotic-assisted surgery and have surgery performed by a self-designated general surgeon. Thirty-day outcomes were similar across CHR terciles. Racial disparity in multiple short-term outcomes persisted despite adjustment for CHR tercile.

CONCLUSION

Higher-risk patients are more likely to be from counties with lower CHRs, but CHR was not independently associated with 30-day outcomes after metabolic surgery.

Gender, BMI, Patient Comorbidities, and Hospital Characteristics Influence 30-Day Readmission Following Vertical Sleeve Gastrectomy

PURPOSE

Obesity impacts 300 million people worldwide and the number continues to increase. Laparoscopic sleeve gastrectomy (LSG) is one of several bariatric procedures offered to help these individuals achieve a healthier life. Here, we report 30-day readmission rates and risk factors for readmission after gastrectomy.

MATERIALS AND METHODS

We used the US Healthcare Utilization Project's Nationwide Readmission Database (NRD) from 2016 to 2019 for patients who underwent laparoscopic gastrectomy and evaluated 30-day readmission rates, comparing readmitted patients to non-readmitted patients. Confounder adjusted and unadjusted analysis were proceeded to the potential factors.

RESULTS

The study population consisted of 235,563 patients, with a 3.0% readmission rate. Factors associated with a higher readmission rate included older age, male gender, higher BMI, Medicare as the primary payer, longer length of stay, higher total charge, higher Charlson Comorbidity Index, higher Elixhauser-Comorbidity Index, lower household income, non-elective admission type, and non-routine disposition. Additionally, larger hospital bed size, and private, invest-own hospital ownership were associated with higher readmission rates. After adjusting for confounders, several comorbidities and complications were found to be significantly associated with readmission, including ileus, abnormal weight loss, postprocedural complications of digestive system, acute posthemorrhagic anemia, and history of pulmonary embolism (all p < 0.001).

CONCLUSIONS

Patient characteristics including age, BMI, and payment source, as well as hospital characteristics, can impact the 30-day readmission after LSG. Such factors should be considered by CMS when deciding on penalties related to readmission.

Difference in 30-Day Readmission Rates After Laparoscopic Sleeve Gastrectomy Versus Laparoscopic Roux-En-Y Gastric Bypass: a Propensity Score Matched Study Using ACS NSQIP Data (2015-2019)

PURPOSE

There are very few studies that have compared the short-term outcomes of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). Among short-term outcomes, hospital readmission after these procedures is an area for quality enhancement and cost reduction. In this study, we compared 30-day readmission rates after LSG and LRYGB through analyzing a nationalized dataset. In addition, we identified the reasons of readmission.

MATERIALS AND METHODS

The current study was a retrospective analysis of data from National Surgical Quality Improvement Program (NSQIP) All adult patients, ≥ 18 years of age and who had LSG or LRYGB during 2014 to 2019 were included. Current Procedural Terminology (CPT) codes were used to identify the procedures. Multivariate logistic regressions were used to calculate propensity score adjusted odds ratios (ORs) for all cause 30-day re-admissions.

RESULTS

There were 109,900 patients who underwent laparoscopic bariatric surgeries (67.5% LSG and 32.5% LRYGB). Readmissions were reported in 4168 (3.8%) of the patients and were more common among RYGB recipients compared to LSG (5.6% versus 2.9%, P < 0.001). The odds of 30-day readmissions were significantly higher among LRYGB group compared to LSG group (AOR, 2.20; 95% CI; 1.83, 2.64). In addition, variables such as age, chronic obstructive pulmonary disease, hypertension, bleeding disorders, blood urea nitrogen, SGOT, alkaline phosphatase, hematocrit, and operation time were significantly predicting readmission rates.

CONCLUSIONS

Readmission rates were significantly higher among those receiving LRYGB, compared to LSG. Readmission was also affected by many patient factors. The factors could help patients and providers to make informed decisions for selecting appropriate procedures.

Incidence, Burden, and Predictors of 11-Month Readmission in Patients Undergoing Bariatric Surgery

BACKGROUND

Bariatric surgery (BSx) is one of the most common surgical procedures performed in the USA. Nonetheless, data regarding 11-month period after BSx remain limited.

METHODS

A retrospective cohort study using the 2016 National Readmission Database. Adult patients admitted for BSx in January were included. The follow-up period was 11 months (February-December). The primary outcome was all-cause 11-month readmission. Secondary outcomes were index admission (IA) and readmission in-hospital mortality rate and healthcare resource use associated with readmission. Multivariate regression was performed to identify independent risk factors for readmission.

RESULTS

A total of 13,278 IA were included. The 11-month readmission rate was 11.1%. The mortality rate of readmission was 1.4% and 0.1% for IA (P < 0.01). The most common cause of readmission was hematemesis. Independent predictors were Charlson comorbidity index (CCI) score ≥ 3 (adjusted hazard ratio [aHR] 1.34; P = 0.05), increasing length of stay (aHR 1.01; P < 0.01), transfer to rehabilitation facilities (aHR 5.02; P < 0.01), undergoing laparoscopic Roux-en-Y gastric bypass (aHR 1.71; P = 0.02), adjustable gastric band (aHR 14.09; P < 0.01), alcohol use disorder (2.10; P = 0.01), and cannabis use disorder (aHR 3.37; P = 0.01). Private insurance as primary payer (aHR 0.65; P < 0.01) and BMI 45-49 kg/m² (aHR 0.72; P < 0.01) were associated with less odds of readmission. The cumulative total hospitalization charges of readmission were $69.9 million.

CONCLUSIONS

The 11-month readmission rate after BSx is 11.1%. Targeting modifiable predictors of readmission may help reduce the burden of readmissions on our healthcare system.

Racial disparity in causes for readmission following bariatric surgery

BACKGROUND

Readmission after bariatric surgery is not cost-effective and is a preventable quality metric within standardized practices. However, reasons for readmission among racial/ethnic bariatric cohorts are less explored and understood.

OBJECTIVE

Our study objective was designed to compare reasons for readmission among racial/ethnic cohorts of bariatric patients.

SETTING

Academic hospital.

METHODS

We performed a retrospective analysis of the 2015-2018 MBSAQIP databases to identify Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) cases. Regression analyses determined predictors of all-cause and bariatric-related readmissions. Reasons for readmission were compared between racial/ethnic cohorts using propensity score matching.

RESULTS

More than 550 000 RYGB and SG cases were analyzed. The readmission rate was 3%-4%. Black race, RYGB, robot-assisted approach, and numerous co-morbidities were independently associated with readmission (P <.05). In RYGB cases, black (versus white) patients were at decreased odds of leak-related (P < .001) and cardiovascular-related (P < .001) readmissions but at increased odds of readmissions related to renal complications (P < .001). Hispanic (versus white) patients had a higher likelihood of venous thromboembolism-related readmissions (P < .001). In SG cases, black (versus white) patients had a similar lower likelihood of readmission related to leaks or cardiovascular complications but higher odds of readmission related to renal complications (P < .001). Hispanic (versus black) patients had a higher likelihood of leak-related readmissions (P < .001).

CONCLUSION

Readmission reasons after bariatric surgery vary by race/ethnicity. Perioperative pathways to mitigate complications, including readmissions, should consider these disparate findings.

An analysis of readmission trends by urgency and race/ethnicity in the MBSAQIP registry, 2015-2018

BACKGROUND

Large-scale analyses stratifying bariatric surgery readmissions by urgency are lacking.

OBJECTIVES

Identify predictors of urgent/nonurgent readmission among "ideal" bariatric candidates, using a national registry.

SETTING

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) national database.

METHODS

We extracted an "ideal" patient cohort from the 2015-2018 Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP) registry, characterized by only typical weight-related comorbidities (hypertension [HTN], obstructive sleep apnea [OSA], gastroesophageal reflux disease [GERD], and diabetes (insulin-dependent diabetes mellitus [IDDM] and non-insulin-dependent diabetes mellitus [NIDDM]) undergoing primary bariatric surgery with an uneventful postoperative course. Readmissions were classified as "urgent" (UR; e.g., leak, obstruction, bleeding) or "nonurgent" (NUR; e.g., dehydration, nonspecific abdominal pain). χ² or t test analyses were used for bivariate significance testing. Multivariate logistic regression models were constructed to assess independent predictors of readmission.

RESULTS

The cohort (N = 292,547) comprised 38.5% of all MBSAQIP patients (mean age [standard deviation] = 43.2 [11.7]; body mass index [BMI] = 44.9 [6.6]; 81% female; 62% White, 17% Black, 14% Hispanic). Total readmission rates were 2.75% (n = 8046) and decreased from 2015-2018 (3.00%-2.63%; P < .001). Independent predictors of readmissions included Roux-en-Y gastric bypass (RYGB) (odds ratio [OR] = 1.97, p < .001), Black (OR = 1.46, P < .001) and Hispanic race (OR = 1.14, P < .001), GERD (OR = 1.27, P < .001), HTN (OR = 1.08, P = .003), and IDDM (OR = 1.39, P < .001). NUR and UR readmission rates were 1.27% (n = 3702) and 1.06% (n = 3090), respectively. NURs decreased over time (1.42%-1.16%, P < .001), with no change in Urs (1.01%-1.06%, P = .51); this trend persisted in multivariate analysis (2017: NUR OR = .85, P < .001; 2018: NUR OR = .82, p < .001). Independent predictors of both URs and NURs included Black (NUR OR = 1.71, p < .001; UR OR = 1.27, p < .001) and Hispanic (NUR OR = 1.15, P < .001; UR OR = 1.19, P < .001) race, RYGB (NUR OR = 1.84, P < .001; UR OR = 2.34, P < .001), and GERD (NUR OR = 1.39, p < .001; UR OR = 1.17, P < .001). Female sex (NUR OR = 1.64, P < .001), age (NUR OR = .98, P < .001), HTN (NUR OR = 1.22, P < .001), and IDDM (NUR OR = 1.41, P < .001) predicted NURs, while higher BMI (UR OR = 1.01, P < .001), and OSA (UR OR = 1.10, P = .02) predicted URs.

CONCLUSION

Readmission rates for "ideal" bariatric patients improved over time, driven by reductions in non-urgent etiologies. Racial disparities persist for both urgent and non-urgent causes of readmission.

Racial disparities in complications and mortality after bariatric surgery: A systematic review

BACKGROUND

Studies have shown racial discrepancies in the rates of postoperative adverse events following bariatric surgery (BS). We aim to systematically review the literature examining racial disparities in postoperative adverse events.

METHODS

PubMed, Embase, and SCOPUS databases were searched for studies that reported race, postoperative adverse events and/or length of stay.

RESULTS

Thirty-five studies were included. Most compared Black and White patients using standardized databases. Racial/ethnic terminology varied. The majority found increased 30-day mortality and morbidity and length of stay in Black relative to White patients. Differences between White and Hipanic patients were mostly non-significant in these outcomes.

CONCLUSIONS

Black patients may experience higher rates of adverse events than White patients within 30 days following bariatric surgery. Given the limitations in the large multicenter databases, explanations for this disparity were limited. Future research would benefit from longer-term studies that include more races and ethnicities and consider socioeconomic factors.

Gender as a Deterministic Factor in Procedure Selection and Outcomes in Bariatric Surgery

Background and Objectives:

With obesity rates rising in the United States, bariatric surgery has become a well-established and effective treatment for morbid obesity and its comorbid conditions. Laparoscopic Roux-en-Y gastric bypass and laparoscopic Sleeve Gastrectomy are two of the more common bariatric procedures. This study analyzes whether gender differences play a role in procedure selection and outcomes following either procedure.

Methods:

Using the American College of Surgeons National Surgical Quality Improvement Program database for years 2015 to 2017, we assessed demographics, postoperative complications, and readmission rates. Chi-square analysis, student t-test, and propensity analyses were performed appropriately.

Results:

Data review found that men presenting for bariatric surgery had a higher incidence of comorbidities and higher body mass index than women. More men than women underwent Sleeve Gastrectomy (68.5% vs 63.0%, P <0.0001), while more women than men underwent Laparoscopic Roux-en-Y gastric bypass (37.0% vs 31.5%, P < 0.0001). In the Laparoscopic Roux-en-Y group, men experienced more postoperative complications, including cardiac arrest (0.2% vs 0.1%, P = 0.02) and unplanned intubation (0.4% vs 0.2%, P = 0.02). In the Sleeve Gastrectomy group, men experienced more postoperative complications, including myocardial infarction (0.2% vs 0.1%, P = 0.006). In both groups, women experienced higher rates of unplanned readmissions (3.5% vs 2.8%, P = 0.0012).

Conclusions:

This study found that men are more likely to undergo Sleeve Gastrectomy than Laparoscopic Roux-en-Y gastric bypass, despite higher complication rates for both. Women have higher rates of unplanned readmission rates regardless of procedure, despite lower postoperative morbidity.

Characterization of urgent versus nonurgent early readmissions (<30 days) following primary bariatric surgery: a single-institution experience

BACKGROUND

Studies on early postoperative readmissions after bariatric surgery (BS) have examined readmissions as a single entity, regardless of urgency. Strategies to lower nonurgent readmissions would reduce unnecessary hospital utilization.

OBJECTIVES

To identify predictors of urgent readmissions (UR) versus nonurgent readmissions (NUR) at 30 days post-BS.

SETTING

Single academic institution.

METHODS

Patients undergoing primary BS over 2 years (n = 589) were retrospectively reviewed. Baseline demographic, medical, and hospitalization data were compared between readmitted patients, stratified by urgency, and nonreadmitted patients. Multivariate regression models of UR and NUR were created using variables with a P value ≤ .2 on univariate analyses. A P value ≤ .05 was considered statistically significant.

RESULTS

There were 39 documented instances of 30-day readmissions, of which 44% (n = 17) were NUR; NUR patients were more likely to be female (100% versus 78.2% male; P = .03) and trended toward being younger, experiencing ≥2 perioperative complications, and having a longer index hospital length of stay (LOS). Patients with URs had a higher baseline BMI (52.5 ± 11.4 kg/m² versus 48.7 ± 8.3 kg/m², respectively; P = .04), were more likely to have sleep apnea (77.3% versus 56.1%, respectively; P = .05), had a longer LOS (3 versus 2 d, respectively; P = .007), and were more likely to have ≥2 postoperative complications (46% versus 17.0%, respectively; P = .003) compared with those with an NUR. Independent predictors of NUR included public insurance (odds ratio [OR] = 3.7; 95% confidence interval [CI], 1.17-11.67; P = .03), younger age (OR = 1.05; 95% CI, 1-1.01; P = .04), and female sex, while URs were independently predicted by LOS (OR = 1.3; 95% CI, 1.04-1.5; P = .02).

CONCLUSIONS

Public insurance appears to be associated with NURs, while LOS predicts URs after BS. This suggests an important dichotomy within readmissions based on urgency, which has important implications for targeted quality initiatives.

Rates and Predictors of 30-Day Readmissions in Patients Undergoing Bariatric Surgery in the US: a Nationwide Study

BACKGROUND

Among various therapeutic options for morbid obesity, bariatric surgery (BS) is now considered one of the most effective methods of weight loss. We decided to perform an analysis to look at 30-day all-cause readmission and independent predictors of readmission in patients undergoing BS.

METHODS

We queried the 2017 Nationwide Readmission Database (NRD) using ICD-10-CM diagnosis codes to identify all adult patients who underwent BS from January 1 to November 30, 2017. Outcomes assessed were 30-day readmission rates, mortality, length of stay (LOS) and hospitalization costs, and independent predictors of readmission.

RESULTS

A total of 182,848 adult patients underwent BS during hospitalization in 2017, with in-hospital mortality rate of 0.52% (951). Of the patients discharged, 4.99% (9088) patients were readmitted within 30 days. The most common primary diagnosis at readmission was "Other complications of other bariatric surgery". When compared with index admission, readmitted patients had higher in-hospital mortality (0.52% vs 2.06%, p < 0.01), increased mean LOS (2.94 days vs 5.94 days, p < 0.01) but lower mean hospitalization charges ($67,763 vs $66,065, p < 0.01). Increasing age (HR 1.01, 95% CI: 1.006-1.014, p < 0.01), longer LOS (HR 1.01, 95% CI: 1.008-1.014, p < 0.01), higher comorbidity score (HR 1.15, 95% CI: 1.12-1.18, p < 0.01), CHF (HR 1.19, 95% CI: 1.01-1.42, p < 0.05), and AKI (HR 1.64, 95% CI: 1.34-2.02, p < 0.01) were independently associated with increased likelihood of 30-day readmission.

CONCLUSION

This study shows that almost 5% patients undergoing bariatric surgery are readmitted within 30 days of discharge in the US. Further studies are needed to assess the high-risk populations to understand the reasons predisposing to early readmission.

Characterizing the preventable emergency department visit after bariatric surgery

BACKGROUND

Patients who present to the emergency department (ED) after bariatric surgery may incur significant costs with no additional benefit.

OBJECTIVES

To characterize patients who presented to the ED but could have been treated in an alternative setting.

SETTING

University hospital, United States.

METHODS

We identified 131 patients who underwent primary bariatric surgery at a single-center academic institution between 2006 and 2016 who also presented to the ED within 30 days of surgery. Preventable ED visits were identified by excluding patients with life-threatening presentations and/or use of emergent ED-specific resources. Patients with preventable ED visits were matched 1:1 to controls (no ED visit) based on procedure type and preoperative patient characteristics. Independent risk factors among patients with preventable ED visits were identified.

RESULTS

A total of 80 patients (61%) were identified as having a preventable ED visit after bariatric surgery. After multivariable logistic regression, independent risk factors associated with preventable ED visits included anxiolytic prescription at discharge (odds ratio [OR] 5.4 [95% confidence interval 1.6-18.6]; P = .007), electrolyte abnormalities (OR 4.3 [1.9-9.6]; P < .0001), and leukocytosis (OR 2.2 [1.0-4.9]; P = .048) at discharge, and number of ED visits preoperatively (OR 2.0 [1.3-3.1]; P = .001). Severe complications, reoperation rates, and 1-year patient reported outcomes did not differ between patients with preventable ED visits and their matched cohort.

CONCLUSIONS

Preventable ED visits are common after bariatric surgery and are associated with risk factors that can be identified perioperatively. Identifying and triaging patients at risk for preventable ED visits may decrease unnecessary and costly visits to the ED after bariatric surgery.

Dehydration risk factors and impact after bariatric surgery: an analysis using a national database

BACKGROUND

Dehydration is a common complication after bariatric surgery and often quoted as the reason for emergency department (ED) visits and readmission.

OBJECTIVE

We sought to investigate risk factors for dehydration after bariatric surgery and evaluate its impact on ED visits and readmission.

SETTING

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.

METHODS

We used the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database to identify patients who underwent laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2016 through 2017. The primary outcome was need for outpatient treatment of dehydration within 30 days postsurgery. Secondary outcomes were association between need for outpatient dehydration therapy and 30-day readmission or ED evaluation not resulting in admission.

RESULTS

Of 256,817 patients, 73% underwent laparoscopic sleeve gastrectomy and 27% LRYGB. Of 9592 patients who required dehydration treatment, they were more often younger than age 40, female, black, had a ≥3-day length of stay during their index admission, and experienced a postoperative complication. More patients receiving LRYGB than laparoscopic sleeve gastrectomy required treatment for dehydration. On multivariable analysis, independent-risk factors for postoperative dehydration treatment included LRYGB, length of stay ≥3 days, gastroesophageal reflux disease, hypertension, previous deep vein thrombosis, chronic steroid/immunosuppression, and a postoperative complication. Patients who developed dehydration requiring treatment compared with those that did not had adjusted odds ratio of 3.7 (95% confidence interval: 3.44-3.96; P < .001) and 22 (95% confidence interval: 21.05-23.06; P < .001) of readmission and ED visit.

CONCLUSION

Dehydration is a strong risk factor for postoperative ED visits and readmission. Closer surveillance and proactive measures for those at higher risk may prevent the development of postoperative dehydration.

Association of Race With Bariatric Surgery Outcomes

Importance

The outcomes of bariatric surgery vary considerably across patients, but the association of race with these measures remains unclear.

Objective

To examine the association of race on perioperative and 1-year outcomes of bariatric surgery.

Design, Setting, and Participants

Propensity score matching was used to assemble cohorts of black and white patients from the Michigan Bariatric Surgery Collaborative who underwent a primary bariatric operation (Roux-en-Y gastric bypass, sleeve gastrectomy, or adjustable gastric banding) between June 2006 and January 2017. Cohorts were balanced on baseline characteristics and procedure. Conditional fixed-effects models were used to evaluate the association of race on outcomes within hospitals and surgeons. Data analysis occurred from June 2006 through August 2018.

Main Outcomes and Measures

Thirty-day complications and health care resource utilization measures, as well as 1-year weight loss, comorbidity remission, quality of life, and satisfaction.

Results

In each group, 7105 patients were included. Black patients had a higher rate of any complication (628 [8.8%] vs 481 [6.8%]; adjusted odds ratio, 1.33 [95% CI, 1.17-1.51]; P = .02), but there were no significant differences in the rates of serious complications (178 [2.5%] vs 135 [1.9%]; adjusted odds ratio, 1.32 [95% CI, 1.05-1.66]; P = .29) or mortality (5 [0.10%] vs 7 [0.10%]; adjusted odds ratio, 0.73 [95% CI, 0.23-2.31]; P = .54). Black patients had a greater length of stay (mean [SD], 2.2 [3.0] days vs 1.9 [1.7] days; adjusted odds ratio, 0.30 [95% CI, 0.20-0.40]; P < .001), as well as a higher rate of emergency department visits (541 [11.6%] vs 826 [7.6%]; adjusted odds ratio, 1.60 [95% CI, 1.43-1.79]; P < .001) and readmissions (414 [5.8%] vs 245 [3.5%]; adjusted odds ratio, 1.73 [95% CI, 1.47-2.03]; P < .001). At 1 year, black patients had lower mean total body weight loss and as a percentage of weight (32.0 kg [26%]; vs 38.3 kg [29%]; P < .001) and this held true across procedures. Remission of hypertension was lower for black patients (564 [40.0%] vs 1096 [56.0%]; P < .001), but the rate of sleep apnea remission (467 [62.6%] vs 615 [56.1%]; P = .005) and gastroesophageal reflux disease (309 [78.6%] vs 453 [75.4%]; P = .049) were higher. There were no significant differences in remission of diabetes with insulin dependence, diabetes without insulin dependence,or hyperlipidemia hyperlipidemia. Fewer black patients than white patients reported a good or very good quality of life (1379 [87.2%] vs 2133 [90.4%]; P = .002) and being very satisfied with surgery (1908 [78.4%] vs 2895 [84.2%]; P < .001) at 1 year.

Conclusions and Relevance

Black patients undergoing bariatric surgery in Michigan had significantly higher rates of 30-day complications and resource utilization and experienced lower weight loss at 1 year than a matched cohort of white patients. While sleep apnea and gastroesophageal reflux disease remission were higher and hypertension remission lower in black patients, comorbidity remission was otherwise similar between matched cohorts. Racial and cultural differences among patients should be considered when designing strategies to optimize outcomes with bariatric surgery.

Preventing Returns to the Emergency Department FollowingBariatric Surgery

BACKGROUND

Unnecessary emergency department (ED) visits following bariatric surgery represent a significant source of inefficient resource utilization. This study aimed to identify potential strategies aimed at preventing unnecessary returns to the ED following bariatric surgery. The study was conducted in University Hospital, USA.

METHODS

The electronic medical records of all patients who underwent bariatric surgery at our institution between January 2011 and October 2015 were retrospectively reviewed. Information regarding procedure, gender, age, preoperative BMI, obesity-related comorbid conditions, postoperative length of stay (LOS), and reasons for ED visits within 90 days of surgery were obtained. Six practitioners (four attending surgeons, one resident physician, and one physician assistant) independently reviewed patient chief complaint and clinical findings at the time of ED returns. Reasons for ED return were scored as either preventable or non-preventable. "Preventable" denoted that an ED return could potentially be avoided by means of a system change in our bariatric practice.

RESULTS

Our institution performed 361 bariatric procedures during the study period. Of these, 65 patients had 91 ED visits, 23 of which resulted in readmissions, and two of which required operative interventions. The ≤90-day all-cause postoperative ED visit rate was 18% (n = 65). Of the 91 ED visits, 47% were deemed preventable (n = 43). The most common preventable reasons for ED returns were nausea, vomiting, dehydration (NVD) (27.9%), postoperative pain (25.6%), wound evaluations (20.9%), and compliance issues (14%).

CONCLUSIONS

Postoperative ED visits following bariatric surgery are prevalent and costly. Many of these visits are potentially preventable. Implementing outpatient strategies to address these causes will likely attenuate inefficient resource utilization.

Preventing Long-term Poor Outcomes in the Bariatric Patient Postoperatively

The obesity epidemic in America continues to rise. People are desperately trying to find ways to lose weight successfully and keep the weight off, and many people are turning to bariatric surgery as the only remaining option for morbid obesity. Bariatric surgery is considered to be a viable treatment option for morbid obesity. However, long-term data are revealing that many postsurgical bariatric patients are regaining the weight after 5 years. The purpose of lifelong follow-up appointments in the bariatric patient is to prevent weight regain and poor outcomes. A case study is used as an example for a poor outcome in a postsurgical bariatric patient. The author of this article provides definitions related to postsurgical bariatric patients, explains the value of early detection and prevention, provides an example of a poor outcome, and concludes with a discussion of evidence-based practice changes that prevent poor outcomes.

Fast track bariatric surgery: safety of discharge on the first postoperative day after bariatric surgery

BACKGROUND

Fast track recovery pathways have resulted in a multidisciplinary approach to enhance postoperative recovery.

OBJECTIVES

To assess feasibility and outcome of early discharge after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB).

SETTING

The American College of Surgeons National Surgical Quality Improvement Program database was analyzed to identify patients with body mass index≥35 kg/m² who underwent LSG or LRYGB in 2012 and 2013.

METHODS

Patients were allocated to early discharge (ED) when discharged on postoperative (POD) 1 and late discharge (LD) when discharged on POD 2 or 3. Baseline characteristics and 30-day outcomes were compared between the 2 groups.

RESULTS

Records of 15,468 LSG and 16,483 LRYGB patients were analyzed; 5220 patients with LSG (33.7%) and 2960 patients with LRYGB (18%) were discharged on POD 1. The early discharge group had significantly fewer co-morbidities and lower rate of complications and readmission. Thirty-day readmission rate in LSG was 2.8% in ED versus 3.6% in LD (P = .008), and in LRGYB, it was 4.3% in ED versus 5.8% in LD (P = .001). Based on multivariate analysis, early discharge was not an independent risk factor for a higher readmission rate after LSG or LRYGB. Predictors of late discharge were age>50 years, body mass index>50 kg/m², Hispanic or non-Hispanic black race/ethnicity, impaired functional status, diabetes on insulin, chronic steroid/immunosuppressant use, bleeding disorder, being on dialysis, chronic obstructive pulmonary disease, albumin<3.5 mg/dL, longer operative time, and concurrent cholecystectomy.

CONCLUSION

Discharge on POD 1 after LSG and LRYGB is feasible in a considerable proportion of patients. In this subgroup, early discharge is well tolerated and may be associated with lower complication and readmission rates.

Readmission Following Laparoscopic Sleeve Gastrectomy

Background and Objectives:

Prior studies have established a 1.7–4.33% readmission rate for laparoscopic sleeve gastrectomy (LSG), a rate that falls within the reported range for other bariatric procedures. The current report describes the incidence of 30-day readmission after primary LSG procedures performed at a single bariatric center of excellence (COE) and examines factors that may be associated with readmission.

Methods:

Data on 343 consecutive LSG operations performed from February 2010 to May 2014 by a single surgeon (PG) were analyzed. Patients readmitted within 30 d were compared to the remaining patients by using Student's t test for continuous variables and the χ² test for categorical variables.

Results:

All LSGs were completed laparoscopically with no conversions to open procedures. There were no reoperations, leaks, perioperative hemorrhages, or mortalities. Twelve patients (3.5%) were readmitted; 1 was readmitted twice. There were no identified risk factors for readmission, including patient demographics, comorbidities, and perioperative factors. Notably, 7 (7%) readmissions occurred in the initial 100 patients and 5 (2%) in the remaining 243 patients (P = .04). Clinical pathways were modified after the initial 100 patients; routine contrast esophagograms were no longer performed, and a 1-day routine postoperative stay was adopted. Operative time also decreased from 94.2 ± 23.8 to 78.2 ± 20.0 min (P < .001).

Conclusions:

Readmission rates after LSG remain in a range similar to those described for other laparoscopic bariatric procedures. Larger prospective studies are needed to identify patterns of complications and readmissions in patients undergoing LSG that may differ from other bariatric procedures.