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Psychological Predictors of Bariatric Surgery Attrition

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David Mahony at Northside Psychology PLLC
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Objective: An estimated 30.8 to 63.4 percent of obese patients that enroll in bariatric surgery programs drop out before receiving surgery. The present study was designed to identify psychological barriers to surgery including surgical anxiety and the patients’ belief that they can lose weight on their own. Design and Methods: 123 patients were randomly selected and administered telephone interviews to assess factors considered to be relevant to surgical completion/attrition. The patients included 105 (85.4%) females and 18 (14.6%) males and consisted of 90 (73.2%) Caucasians, 7 (5.7%) Latinos, 24 (19.5%) African-Americans, and 2 (1.6%) self-identified as “other” race. Results: Of the 123 patients, 57.7% completed surgery and 42.3% dropped out. Patients were more likely to complete surgery when they reported lower levels of surgical anxiety (p = .014, r = -.221) and less confidence in their ability to lose weight on their own (p = .022, r = -.207). Medical co-morbidities did not predict surgical completion. Conclusions: Bariatric surgery candidates often drop out of the surgical process because they experience surgical anxiety and/or they believe that they can lose weight on their own, without surgery. Motivators such as medical co-morbidities are not sufficient for surgical completion.
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Abstract
DOI http://dx.doi.org/10.13070/rs.en.1.1196
Date 2014-11-18
Cite as Research 2014;1:1196
License CC-BY
Psychological predictors of bariatric surgery attrition
David Mahony1 (DrDavidMahony at Gmail dot com) #, Henry Alder2, Jeff Eha2
1 PsyBari, 30 Bayard St., Suite 1F, Brooklyn, NY 11211, USA. 2 Ethicon Endo-Surgery, 4545 Creek Rd., Blue Ash, OH 45242, USA
# : corresponding author
Objective: An estimated 30.8 to 63.4 percent of obese patients that enroll in bariatric surgery
programs drop out before receiving surgery. The present study was designed to identify psychological barriers to
surgery including surgical anxiety and the patients’ belief that they can lose weight on their own. Design and
Methods: 123 patients were randomly selected and administered telephone interviews to assess factors
considered to be relevant to surgical completion/attrition. The patients included 105 (85.4%) females and 18
(14.6%) males and consisted of 90 (73.2%) Caucasians, 7 (5.7%) Latinos, 24 (19.5%) African-Americans, and 2
(1.6%) self-identified as “other” race. Results: Of the 123 patients, 57.7% completed surgery and 42.3% dropped
out. Patients were more likely to complete surgery when they reported lower levels of surgical anxiety (p = .014, r
= -.221) and less confidence in their ability to lose weight on their own (p = .022, r = -.207). Medical co-morbidities
did not predict surgical completion. Conclusions: Bariatric surgery candidates often drop out of the surgical
process because they experience surgical anxiety and/or they believe that they can lose weight on their own,
without surgery. Motivators such as medical co-morbidities are not sufficient for surgical completion.
Introduction
When compared to traditional weight loss interventions, bariatric surgery is considered to be a clinically effective
treatment for obesity with multiple comprehensive reviews concluding that it effectively achieves weight loss as well
as a reduction in co-morbid medical conditions [1] [2]. These results have led an increasing number of medically
eligible patients to seek out the procedure with most reporting that their motivation is the elimination of medical co-
morbidities [3] [4]. In spite of the documented benefits of bariatric surgery, and the increasing number of patients
receiving the procedure, the American Society for Metabolic and Bariatric Surgery estimates that less than 1 percent
of the obese individuals in the U.S, who have medical indications for bariatric surgery, receive it [5]. Even amongst
patients with adequate BMI’s (≥40 or ≥35 with a medical co-morbidity), that enroll in bariatric surgery programs, it is
reported that only 49 to 69 percent complete the procedure [6] [7] [8]. This low number of patients completing
bariatric surgery is surprising given the severity of their co-morbid medical conditions, the effectiveness of bariatric
surgery, and the relative ineffectiveness of other weight approaches.
Researchers have begun to investigate the reasons for this low completion rate and found that many patients drop
out of the surgical process due to financial, medical and/or psychological concerns. For example, Sadhasivam et al.
found that 9.9 to 19.9 percent of their patients did not complete bariatric surgery due to inadequate health coverage
while 13 percent did not complete surgery due to medical or psychological contraindications [7]. Merrell et al. found
that 24.4 percent of their surgical drop outs, dropped out due to inadequate health insurance [9]. In addition to these
barriers, several studies reported high drop out rates even amongst patients that were financially, medically, and
psychologically eligible for surgery. For example, Sadhasivam et al. found that 44.7 percent of their patients were
eligible for surgery but simply “decided against it” or failed to follow-up with pre-surgical requirements. Merrell et al.
reported that 70.7 percent of their surgical drop outs failed to follow-up with pre-surgical requirements, withdrew from
the surgical program, or sought different weight loss approaches.
There is little published evidence as to why patients that begin the surgical process, and are financially, medically,
and psychologically eligible, do not complete the procedure, although researchers have begun to explore this issue.
For example, Merrell et al. found that many of the patients that dropped that out of the surgical process had
psychological or substance/alcohol abuse problems [8] ; a finding that is consistent with attrition study results of non
surgical weight loss treatments [10]. Mahony found that patients were not completing surgery due to a global surgical
Topi cs
bariatric surgery
morbid obesity
[enlarge]
Figure 1. Questionnaire items.
anxiety [8]. Jakobsen et al. and Mahony found that patients with a higher age of obesity onset were more likely to
drop out of the surgical process [6] [8]. Additionally, Jakobsen et al. and Mahony found that in spite of patient reports
that medical co-morbidities are their primary motivation for surgery, patients with more co-morbidities were not more
likely to complete surgery. While the available data on this topic is limited, these studies offer support that
psychological factors are involved in bariatric surgery attrition.
Given that considerable time, effort, and expense are devoted to pre-surgical screenings, the cost-effectiveness of
these screenings may be improved by advancing our understanding of the psychological factors that predict surgical
attrition. Furthermore, if psychological barriers that impede surgical completion can be identified, interventions to
manage these barriers could be implemented so that a greater number of patients could receive the benefits of
bariatric surgery.
The present study was conducted to identify the psychological barriers to bariatric surgery. As such, our first
hypothesis is that patients with lower levels of surgical anxiety will be more likely to complete surgery. Our second
hypothesis is that patients with lower levels of confidence in their ability to lose weight on their own, without surgery,
will be more likely to complete surgery. Our third hypothesis is that patients with a higher number of weight loss
attempts, and who experience weight re-gain after dieting, will be more likely to complete surgery. Our forth
hypothesis is that patients with more medical co-morbidities will not be more likely to complete surgery.
Methods and Procedures
Participants
This study had access to a database of 23,917 patients that attended an informational seminar on bariatric surgery.
These patients were also enrolled in a health insurance benefits verification service to verify that their health
insurance benefits included coverage for bariatric surgery. All of the patients used in this study were medically
eligible and had no medical/psychological contraindications for surgery. Patients were randomly selected from the
database and the first 203 were contacted by phone. Of the 203 patients that were contacted, 123 were available
and agreed to complete the interview. The sample included 105 females (85.4%) and 18 males (14.6%). Of these, 90
(73.2%) identified themselves as Caucasian, 24 (19.5%) as African-American, 7 (5.7%) as Latino, and 2 (1.6%) as
“other” race. They had a mean BMI (±SD) of 47.7 (±7.31) and mean age (±SD) of 48.82 (±11.45), when they enrolled
in a bariatric program.
Instruments
A semi-structured clinical
telephone interview that
assessed demographic,
psychological, and medical
factors considered to be
relevant to surgical attrition
was developed for this study
(Figure 1). All questions were
qualified with “prior to having
surgery” or “when you were
considering bariatric surgery,”
in an attempt to capture the
patient’s medical/psychological
status, and beliefs about
themselves and bariatric
surgery, when they were
actively involved in a surgical
program. Patients were asked
about their anxiety about
surgical risks, history of weight loss attempts, confidence in their ability to lose weight on their own, presence of
obesity related co-morbidities, and their psychological status. Items were responded to with yes/no or rated on a 7
point Likert scale.
Procedures
Institutional review board permission was obtained. Patients were randomly selected, contacted by telephone, and
[enlarge]
Figure 2. Attrition due to psychological
variables. Note: All variables measured on a
7-point Likert Scale. All comparisons p < .05
[enlarge]
Figure 3. Number of dieting attempts and
weight re-gain.
[enlarge]
Figure 4. Completion rates with/without
co-morbidities. All chi square test results
were non-significant.
administered a structured interview by a professional marketing-research organization in 2011. Patients were sent
$20 for their participation.
Data Analysis
All variables were examined through various SPSS programs for
accuracy of data entry and fit between their distributions and the
assumptions of multivariate analysis [11]. Data was checked for
multivariate outliers, normality, linearity and homoscedasticity. Almost all
of the Likert items were found to be skewed and did not improve with
square root, log, or inverse transformation. For this reason, non
parametric tests, the chi square and Mann-Whitney U, were used.
Missing data were excluded using the analysis by analysis option in
SPSS. Patients that reported that they completed surgery were
compared to those that reported that they had not completed surgery on
all variables.
Results
Out of 122 patients (one patient had missing data), 70 (57.7%)
completed bariatric surgery while 52 (42.3%) dropped out and did not
receive surgery. Of the 70 patients that completed surgery, 31 (44.3%)
received the gastric band, 28 (40.0%) received the gastric bypass, 5
(7.1%) received the sleeve gastrectomy, and 6 (8.6%) received
another procedure. Results of the chi square and Mann-Whitney U
tests are as follows; completers were more comfortable with surgical
risks, (Mdn = 6), U(121) = 1395, p = .014, r = -.221; had less
confidence in their ability to lose weight on their own, (Mdn = 3),
U(121) = 1406, p = .022, r = -.207, felt as though they were less able
to control their weight, (Mdn = 6), U(121) = 1341, p = .006, r = -.247; and were more likely to believe that bariatric
surgery was the only way for them to lose weight, (Mdn = 7), U(121) = 1322, p = .003, r = -.264 (Figure 2).
Completers had more previous weight loss attempts, X2(1, N = 123) = 6.77, p = .009) and were more likely to
experience weight re-gain after dieting, X2(1, N = 123) = 12.59, p < .001, Figure 3). No significant differences were
found on chi square tests for completers vs. non-completers on medical and/or psychological co-morbidities including
type 2 diabetes, hypertension, hypercholesterolemia, sleep apnea, asthma, back pain, heart disease and depression
(Figure 4).
Discussion
The present study found that 57.7 percent of the patients that enrolled in a
bariatric surgery program completed surgery while 42.3 percent dropped out.
This drop out rate is lower than the 51 percent drop out rates reported
independently by both Jakobsen et al. [6] and Sadhasivam et al. [7]. These
differences may be due to methodological differences amongst the studies.
In specific, both Jakobsen et al. and Sadhasivam et al. included patients that
did not complete surgery due to inadequate health insurance coverage
and/or medical/psychological contraindications while the current study
excluded these patients. In comparison to the results of the Mahony [8]
study, the current study found a higher drop out rate (30.8% vs. 42.3%,
respectively). These two studies both excluded patients with inadequate
health insurance coverage and medical/psychological contraindications
although they used different methods to identify these patients. The Mahony study used medical records while the
current study used a combination of patient reports and the records of a health insurance benefits verification
program. In spite of these differences, the results of these studies show that a large percentage of patients that begin
the process of bariatric surgery do not complete the procedure.
Our first hypothesis, that patients with lower levels of surgical anxiety are more likely to complete surgery, was
supported. Patients were asked if they were “comfortable taking the medical risks associated with surgery?” and
responded on a seven point Likert scale. Patients that completed surgery endorsed lower levels of surgical anxiety.
This finding adds support to the Mahony [8] results that patients are at risk for dropping out of the surgical process
due to surgical anxiety and these patients can be identified by asking about global anxiety about surgery instead of
specific surgical risks (e.g., infections).
Our second hypothesis, that patients who are confident that they can lose weight on their own, without surgery, will
be more likely to drop out, was supported. Patients were asked several questions about this variable including: “were
you confident about your ability to lose weight on your own?,” “did you feel like you had no control over your
weight?,” and “were you thinking about bariatric surgery because you realized that there was no other way for you to
lose the weight on your own?” Patients that completed surgery indicated that they felt less confident about losing
weight on their own and had less control over their weight when compared to surgical drop outs. Additionally, surgical
completers gave higher ratings on the belief that bariatric surgery is the only way that they can lose weight. This
finding supports the hypothesis that patients will complete bariatric surgery only when they no longer believe that
they can lose weight on their own.
Our third hypothesis, that patients with a higher number of weight loss attempts, and weight re-gain, will be more
likely to complete surgery, was supported. Patients that reported more attempts at dieting and experienced weight re-
gain after previous weight loss were more likely to complete surgery. These findings offer support to the hypothesis
that patients are more likely to complete surgery after they have “given up” on their ability to lose weight on their own.
Conversely, patients that do not complete surgery are more likely to hold onto the belief that they can lose weight,
without surgery.
Our fourth hypothesis, that patients with higher rates of medical co-morbidities were not more likely to have surgery
was supported. This is an interesting finding since almost all patients report medical co-morbidities as their primary
motivation for seeking bariatric surgery. This result supports the previous findings by Jakobsen et al. [6] and Mahony
[8] and suggests the possibility that medical co-morbidities are a necessary, but not sufficient motivator for bariatric
surgery. It also suggests that patients may benefit from further education about the lethality of these co-morbidities.
Overall, these findings offer insights into some of the psychological factors involved in determining whether or not a
bariatric surgery candidate completes surgery. Most importantly, the results show that the motivators that patients
usually report as their primary reasons for seeking bariatric surgery, such as medical co-morbidities, are not
sufficient. Conversely, factors that are not traditionally assessed in the pre-surgical workup, such as their level of
surgical anxiety and their beliefs about their ability to lose weight without surgery, may lead them to decide against
surgery. Realistically, patients are weighing all of these factors when deciding whether or not they should go through
with bariatric surgery. Given these findings, future research can focus on addressing these barriers. Bariatric surgery
candidates may benefit from further education about the severity and potential lethality of their co-morbid conditions
and the safety and benefits of bariatric surgery. They may also benefit from information on the difficulties involved in
losing weight, and keeping it off, without bariatric surgery. Future studies can determine if these barriers are also the
reason why so many obese individuals that are eligible for bariatric surgery do not even seek out the procedure.
The results of this study are limited by some methodological concerns. As this was a retrospective study, it is
unknown if patients were able to accurately report their psychological/medical status during the time that they were
considering surgery. Subject participation may have been affected by the subject’s surgical status, i.e., surgical
completers may have been more likely to participate in the study. The study is also limited by the lack of validated
instruments that can be administered over the telephone. As no such instruments existed, a questionnaire was
created specifically for this study and may have reliability/validity concerns.
Declarations
Acknowledgments
This research involved in this study was supported by Ethicon Endo-Surgery, Inc.
Conflicts of interest statement
David Mahony is an obesity research consultant for Ethicon Endo-Surgery.
Henry Alder is an employee of Ethicon Endo-Surgery.
Jeff Eha is an employee of Ethicon Endo-Surgery.
Authors' contribution
DM conceived of experiments. JE and HA carried out experiment. DM, HA, and JE analyzed data. DM was involved
in writing the paper and had final approval of the submitted and published versions
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Article
  • Sep 2009
OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of bariatric surgery for obesity. DATA SOURCES Seventeen electronic databases were searched [MEDLINE; EMBASE; PreMedline In-Process & Other Non-Indexed Citations; The Cochrane Library including the Cochrane Systematic Reviews Database, Cochrane Controlled Trials Register, DARE, NHS EED and HTA databases; Web of Knowledge Science Citation Index (SCI); Web of Knowledge ISI Proceedings; PsycInfo; CRD databases; BIOSIS; and databases listing ongoing clinical trials] from inception to August 2008. Bibliographies of related papers were assessed and experts were contacted to identify additional published and unpublished references. REVIEW METHODS Two reviewers independently screened titles and abstracts for eligibility. Inclusion criteria were applied to the full text using a standard form. Interventions investigated were open and laparoscopic bariatric surgical procedures in widespread current use compared with one another and with non-surgical interventions. Population comprised adult patients with body mass index (BMI) > or = 30 and young obese people. Main outcomes were at least one of the following after at least 12 months follow-up: measures of weight change; quality of life (QoL); perioperative and postoperative mortality and morbidity; change in obesity-related comorbidities; cost-effectiveness. Studies eligible for inclusion in the systematic review for comparisons of Surgery versus Surgery were RCTs. For comparisons of Surgery versus Non-surgical procedures eligible studies were RCTs, controlled clinical trials and prospective cohort studies (with a control cohort). Studies eligible for inclusion in the systematic review of cost-effectiveness were full cost-effectiveness analyses, cost-utility analyses, cost-benefit analyses and cost-consequence analyses. One reviewer performed data extraction, which was checked by two reviewers independently. Two reviewers independently applied quality assessment criteria and differences in opinion were resolved at each stage. Studies were synthesised through a narrative review with full tabulation of the results of all included studies. In the economic model the analysis was developed for three patient populations, those with BMI > or = 40; BMI > or = 30 and or = 30 and or = 30 and 40, ICERs were 18,930 pounds at two years and 1397 pounds at 20 years, and for BMI > or = 30 and < 35, ICERs were 60,754 pounds at two years and 12,763 pounds at 20 years. Deterministic and probabilistic sensitivity analyses produced ICERs which were generally within the range considered cost-effective, particularly at the long twenty year time horizons, although for the BMI 30-35 group some ICERs were above the acceptable range. CONCLUSIONS Bariatric surgery appears to be a clinically effective and cost-effective intervention for moderately to severely obese people compared with non-surgical interventions. Uncertainties remain and further research is required to provide detailed data on patient QoL; impact of surgeon experience on outcome; late complications leading to reoperation; duration of comorbidity remission; resource use. Good-quality RCTs will provide evidence on bariatric surgery for young people and for adults with class I or class II obesity. New research must report on the resolution and/or development of comorbidities such as Type 2 diabetes and hypertension so that the potential benefits of early intervention can be assessed.
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Bariatric surgery attrition secondary to psychological barriers
Article
  • Mar 2013
Despite the effectiveness of bariatric surgery only 49% of the patients that enroll in bariatric surgery programmes complete the surgery. This study attempts to identify psychological barriers to bariatric surgery. A sample of 471 patients who were screened for medical indications for surgery, adequate health insurance and medical/psychological contraindications, were used. Participants were predomi-nantly female (71.8%) and Caucasian (68.4%) with a mean body mass index (standard deviation [SD]) of 47.84 (7.53) and mean age (SD) of 40.59 (10.79). A total of 69.2% completed surgery (63.2% gastric bypass, 35.6% gastric band, 1.2% gastric sleeve). Participants with lower levels of global surgical anxiety, a preference for the gastric bypass, a childhood or adolescent onset of obesity, and more experience dieting, were more likely to complete surgery. No significant differences were found among groups for specific surgical anxieties or medical comorbidities. These findings suggest that factors that patients routinely report as surgical motivators, including comorbidities, may be necessary, but are not sufficient, for surgical completion. Other factors, such as a global surgical anxiety, and the patient's belief in their ability to lose weight without surgery, may play a large role in surgical attrition.
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Psychological risk may influence drop-out prior to bariatric surgery
Article
  • Feb 2012
Factors necessitating a delay before psychological clearance for bariatric surgery have been previously identified; however, research has not examined why patients who begin the preoperative evaluation fail to complete surgery or drop-out of bariatric programs. This study sought to explore the potential psychosocial reasons for a failure to reach bariatric surgery. The setting was an academic medical center. Data were analyzed from 129 patients psychologically evaluated for bariatric surgery who had failed to reach surgery after 15 months. Medical records were reviewed for demographics, body mass index, and psychiatric variables. The most common reasons for not reaching surgery included withdrawal from the program, outstanding program requirements, self-canceled surgery, moving out of the area, insurance denial, switching to non-surgical weight management, or death. Patients with outstanding program requirements were psychosocially different from patients who had not achieved surgery for other reasons. They were significantly more likely to be involved in outpatient behavioral health treatment (chi-square = 12.90, P < .05), to be taking psychotropic medications (chi-square = 15.17, P < .05), and to have met the criteria for current or past alcohol abuse/dependence (chi-square = 23.70, P < .01), and there was a trend for previous inpatient hospitalizations (chi-square = 11.59, P < .07). Patients who failed to complete outstanding program requirements often had significant psychiatric and/or substance abuse/dependence issues that required additional treatment. It is possible that these patients drop-out of the program due to unwillingness to complete psychiatric treatment recommendations. Continued screening of high-risk patients and the education of patients on the importance of managing these risks is indicated. However, patients may choose to leave programs once education has been provided or treatment mandated.
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Bariatric Surgery: A Systematic Review and Meta-Analysis
Article
  • Nov 2004
  • J Am Med Assoc
About 5% of the US population is morbidly obese. This disease remains largely refractory to diet and drug therapy, but generally responds well to bariatric surgery. To determine the impact of bariatric surgery on weight loss, operative mortality outcome, and 4 obesity comorbidities (diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea). Electronic literature search of MEDLINE, Current Contents, and the Cochrane Library databases plus manual reference checks of all articles on bariatric surgery published in the English language between 1990 and 2003. Two levels of screening were used on 2738 citations. A total of 136 fully extracted studies, which included 91 overlapping patient populations (kin studies), were included for a total of 22,094 patients. Nineteen percent of the patients were men and 72.6% were women, with a mean age of 39 years (range, 16-64 years). Sex was not reported for 1537 patients (8%). The baseline mean body mass index for 16 944 patients was 46.9 (range, 32.3-68.8). A random effects model was used in the meta-analysis. The mean (95% confidence interval) percentage of excess weight loss was 61.2% (58.1%-64.4%) for all patients; 47.5% (40.7%-54.2%) for patients who underwent gastric banding; 61.6% (56.7%-66.5%), gastric bypass; 68.2% (61.5%-74.8%), gastroplasty; and 70.1% (66.3%-73.9%), biliopancreatic diversion or duodenal switch. Operative mortality (< or =30 days) in the extracted studies was 0.1% for the purely restrictive procedures, 0.5% for gastric bypass, and 1.1% for biliopancreatic diversion or duodenal switch. Diabetes was completely resolved in 76.8% of patients and resolved or improved in 86.0%. Hyperlipidemia improved in 70% or more of patients. Hypertension was resolved in 61.7% of patients and resolved or improved in 78.5%. Obstructive sleep apnea was resolved in 85.7% of patients and was resolved or improved in 83.6% of patients. Effective weight loss was achieved in morbidly obese patients after undergoing bariatric surgery. A substantial majority of patients with diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea experienced complete resolution or improvement.
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Refusals, denials, and patient choice: reasons prospective patients do not undergo bariatric surgery
Article
  • Sep 2007
  • SURG OBES RELAT DIS
Many prospective laparoscopic gastric bypass (LGB) surgery patients ultimately do not undergo the procedure. We analyzed the reasons patients did not undergo LGB surgery. All prospective LGB patients at our institution are required to attend an informational seminar. Our multidisciplinary team then evaluates each patient's suitability for surgery. The medical records of all patients evaluated at our institution from 2001 through 2005 were retrospectively reviewed for age, body mass index, gender, co-morbidities, initial evaluation date, and, if applicable, the reasons for not undergoing surgery. The Mantel-Haenszel test was used to test for trends over time. Of the 1054 patients evaluated, 515 (48.8%) underwent LGB at our institution. The percentage of women did not differ significantly between the LGB and non-LGB groups (82.3% and 78.5%, respectively; P = .116), nor was the difference in mean body mass index significant (48 kg/m(2) versus 49 kg/m(2); P = .074). From 2001 to 2005, the percentage of prospective patients not undergoing LGB increased from 36.6% to 53.7% (P = .001). The percentage of patients not undergoing LGB because of insurance denials or unattainable coverage prerequisites increased from 9.9% in 2001 to 19.9% in 2005 (P = .012). The most common reasons patients did not undergo LGB surgery were insurance denial and unattainable coverage prerequisites. Also, the percentage of prospective LGB patients who did not undergo surgery because of denial or unattainable coverage prerequisites increased over time.
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