Discussing Bariatric Surgery Linked to Increased Weight Loss Whether or Not Patients Undergo Surgery

Alexander Turchin, MD, MS

A new study from Brigham and Women’s Hospital is highlighting the importance of patient-provider discussions related to weight loss options, specifically bariatric surgery, in patients with obesity.

A look at more than 30,000 patients with obesity over a 15-year period, results suggest increased frequency of patient-provider discussions related to bariatric surgery was associated with increased weight loss in patients with obesity, regardless of whether or not they underwent a subsequent bariatric procedure.

"Usually, when we talk about clinical outcomes, we look at whether we changed a patient's medication or started a new treatment," said senior investigator Alexander Turchin, MD, MS, Director of Quality in Diabetes in the Division of Endocrinology, Diabetes and Hypertension at Brigham and Women’s Hospital, in a statement. "What we miss, though, is that the first step in reaching a treatment goal is to talk to the patient. We need to talk to our patients more about the options available and help them to become better informed about their care."

With the obesity epidemic already placing a significant burden on society and healthcare systems as a whole, and the problem expected to continue growing, avenues of attenuating this burden have become a top priority among clinicians in multiple specialties. With research indicating patient-provider discussion have a significant impact on patients’ decision-making, Turchin and a team of colleagues designed the current study to assess whether patient-provider discussions related to bariatric surgery influence rate of procedure and BMI change in patients with severe obesity.

With this in mind, investigators designed a retrospective cohort study using data from adult patients with class 2-3 obesity treated at practices affiliated with Mass General Brigham from 2000-2015. For the purpose of analysis, patients were included if they were between 18-65 years of age, had a BMI of 35 or more to less than 60 kg/m2 on 2 consecutive visits, no history of bariatric surgery, and with follow-up data for at least 24 months.

Investigators noted the lower cutoff was chosen as many of these patients are eligible due to the presence of comorbidities and the upper cutoff was chosen as these patients are often not considered candidates for bariatric surgery.

The primary outcome of interest for the investigators’ analyses was weight changes over 2 years after study entry. The secondary outcome of interest was the receipt of bariatric surgery over 2 years after study entry.

A total of 37,220 patients were followed for at least 24 months during the study period. After exclusion of those with missing information and those who underwent bariatric surgery within 30 days of study entry, investigators identified a cohort of 30,560 patients for inclusion in the study. From these patients, investigators obtained data related to 692,057 notes from clinics for inclusion.

The final patient population had a median age of 45.0 years and a median baseline BMI of 37.3 kg/m2, with 71.6% of patients having a baseline BMI between 35-40 kg/m2. Investigators pointed out 41.3% had a history of hypertension and 16.9% had a history of diabetes.

Among the 30,560 patients included in the study, only 2659 (8.7%) discussed bariatric surgery with their clinicians within the first year following study entry. Of these, 1462 (4.8%) had a single discussion and 1197 (3.9%) had at least 2 discussions. In comparison to those who did not discuss bariatric surgery with their clinicians, patients who did discuss bariatric surgery were more likely to be younger, female, non-White, and have a higher BMI.

Analysis of notes suggested clinicians practicing in endocrinology were the most likely to discuss bariatric surgery with patients, with documented bariatric surgery discussions comprising 3.47% of notes from within that specialty compared to an overall rate of 1.50%. Following endocrinology, those practicing in cardiology (2.72%) and OBGYN (2.28%) were the most likely to discuss bariatric surgery while orthopedic specialists were the least likely (0.62%).

In univariate analysis, bariatric surgery discussion was associated with a mean decrease in BMI of 2.18 compared to a mean decrease of 0.21 among patients who did not undergo such a discussion (P <.001). Investigators highlighted increased frequency of discussions was associated with a greater decrease in BMI.

In multivariate analysis, patients who discussed bariatric surgery with their providers lost more weight than those who did not take part in such a discussion (change in BMI: -1.43; 95% CI, 1.29-1.57). Additionally, these patients also had greater odds of undergoing subsequent bariatric surgery (OR, 10.2; 95% CI, 9.0-11.6; P <.001).

"Even without surgery, such discussions emphasize the seriousness of obesity and may prompt patients to explore ways to lose weight," said Turchin. "It's important for clinicians to initiate these discussions but also support them when patients bring them up themselves."

This study, “Patient-provider discussions of bariatric surgery and subsequent weight changes and receipt of bariatric surgery,” was published in Obesity.