Analysis of patient attrition in a publicly funded bariatric surgery program.

Diamant, Adam; Milner, Joseph; Cleghorn, Michelle; Sockalingam, Sanjeev; Okrainec, Allan; Jackson, Timothy D; Quereshy, Fayez A

BACKGROUND Obesity is a global epidemic, and several surgical programs have been created to combat this public health issue. Although demand for bariatric surgery has grown, so too has the attrition rate. In this study we identify patient characteristics and operational interventions that have contributed to high attrition in a multistage, multidisciplinary bariatric surgery program. STUDY DESIGN A retrospective study was conducted of 1,682 patients referred for bariatric surgery at the University Health Network in Toronto, Canada, from June 2008 to July 2011. Demographic information, presurgical assessment dates, and records describing operational changes were collected. Several penalized likelihood and mixed effects multivariable logistic regression models were used to determine whether patient characteristics, operational changes, and previous experience affected program completion and intermediate transitions between assessments. RESULTS Although the majority of attrition appears to be the result of patient self-removal, males (odds ratio [OR] 0.511, 95% CI 0.392 to 0.663, p < 0.001), and individuals with active substance use (OR 0.223, 95% CI 0.096 to 0.471, p < 0.001) were less likely to undergo surgery. Operational practices had a detrimental effect on program completion (OR 0.590, 95% CI 0.456 to 0.762, p < 0.001). Conversely, patients with a BMI > 40 kg/m(2) (OR 1.756, 95% CI 1.233 to 2.515, p = 0.002) and those who lived within 25 to 300 km of the center (OR > 1.633, p < 0.001) were more likely to undergo surgery. CONCLUSIONS Certain subgroups in the referral population were found to be at a higher risk of noncompletion. Specialized care pathways must be implemented to address this issue. Furthermore, careful consideration must be given to operational decisions because they may negatively affect access to care, as we have shown.