Table 4.

Factors associated with comfort in initiating conversations about bariatric surgery and managing eligible patients

Author	Initiating discussions and providing referrals	Providing postoperative management and follow-up care	Statistical test
Avidor et al., 2007	• Initiate conversation: BARI (26.1%), OBGYN (11.9%), IM (8.8%), ENDO (17.9%), CARD (8.0%), FM (21.9%), All Specialties (15.4%) • Top reasons for not referring eligible patients: lack of acquaintance with local bariatric surgeons (37.4%), perception that patient lacked interest (23.6%) • All specialists who had previously referred patients for bariatric surgery were more familiar with local bariatric surgeons than providers who had not previously referred		• Descriptive statistics
Balduf et al., 2008		• Reported competence in addressing medical complications: Previously referred (54.2%), non-referring (15.4%) (p < 0.001)	• Chi-squared test or Student’s t-test
Ferrante et al., 2009	• Higher knowledge associated with increased frequency of recommendations: p < 0.0001 • Greater percentage of patients with obesity seen in practice associated with decreased likelihood of recommending BSY: OR 0.38, p = 0.0002		• Odds ratio • Chi-squared test
Salinas et al., 2011	• Very confident discussing LAGB: 34.2% agree   ○ 34.7% FP, 33.8% IM • Very confident discussing Roux-en-Y gastric bypass: 32.1% agree   ○ 31.3% FP, 32.9% IM	• Confident managing patients after LAGB: 14.4% agree   ○ 13.5% FP, 15.4% IM	• Descriptive statistics
Glauser et al., 2015	• “Very significant” barriers in communicating with patients who are obese   ○ Lack of Training on how to discuss obesity: 13% bariatricians, 14% cardiologists, 11% endocrinologists, 11% PCPs   ○ Lack of resources to refer overweight and obese patients to: 24% cardiologists, 33% endocrinologists, 29% PCPs   ○ Low likelihood of succeeding in helping patients achieve or maintain healthy weight: 33% cardiologists, 41% endocrinologists, 32% PCPs		• Descriptive statistics
Kim et al., 2015	• GPs decision to refer patients strongly influenced by patients’ expectation or request • GPs that refer patients for BSY were often influenced by “positive feedback from patients”		• Qualitative
Stanford et al., 2015	• Barriers to evaluating/managing patients:   ○ Prior obesity training: Insufficient time (61%), not being part of professional role (63%), inadequate training (71%), fear of offending patient (100%), too difficult for patients to change (59%), lack of effective tools and information to give to patients (65%), long wait times for referrals to obesity medicine specialists (54%)   ○ No obesity training: Inadequate reimbursement (75%), lack of adequate referral services (57%), patients being generally not interested in improving their weight status (58%), lack of effective treatment options (52%) • Statistically significant factor associated with physician confidence in treating obesity: prior obesity training	• Statistically significant factors associated with physician confidence in treating obesity: younger physician age, physician’s own BMI being higher	• Descriptive statistics • Chi-square analyses and Fisher’s exact tests
Tork et al., 2015	• Do not feel competent to discuss BSY as a treatment option for morbidly obese patients: 70% PCPs strongly disagree/disagree	• Not comfortable managing postoperative patients: 45% PCPs strongly disagree/disagree	• Descriptive statistics • 5-point Likert Scale
Auspitz et al., 2016	• Initiate conversation: 73.1% FPs • Reasons for non-referral: Disagree with the procedure (7.6%), concerned with follow-up care (24.5%), discomfort within own practice to manage patients with obesity (7.6%)	• “I feel comfortable providing care to patients who have received BSY:” All FPs (46.5%)   ○ Previously referred (64.2%), non-referring (26.7%) (p = 0.005)	• Descriptive statistics • Chi-squared or Fisher’s exact test
Funk et al., 2016	• Requirement of PCPs to address postoperative issues contributed to hesitation to refer patients for BSY		• Qualitative
Hirpara et al., 2016	• Comfortable explaining procedure: All Surgeons (37%)   ○ BS (100%), non-BS (50%) (p < 0.001) • Initiate conversation: All Surgeons (59.6%)   ○ BS (94.7%), non-BS (51.3%) (p = 0.001)	• Managed > 20 patients with previous BSY (past 12 months): All Surgeons (16.8%)   ○ BS (70%), non-BS (3.7%) (p < 0.001) • Managed complications (past 12 months): All Surgeons (82.2%)   ○ BS (100%), non-BS (77.7%) (p < 0.001) • Confident managing common early complications: All Surgeons (38.6%)   ○ BS (95%), non-BS (24.7%) (p < 0.001) • Confident managing common late complications: All Surgeons (41.6%)   ○ BS (95%), non-BS (28.4%) (p < 0.001) • Able to transfer patients effectively: All Surgeons (32.7%)   ○ BS (42.1%), non-BS (34.6%) (p = 0.18)	• Descriptive statistics • Pearson chi-square test
Jung et al., 2016	• Factors related to frequency of recommendation:   ○ Perceived expertise (p < 0.001)   ○ Rating of BSY as “useful” (p < 0.001)   ○ Attitude towards BSY as an “easy way out” (p < 0.001)		• Linear regression • Logistic regression
Major et al., 2016	• Have previously referred a patient: 72.2% PCPs		• Descriptive statistics
Stolberg et al., 2017	• Had extensive experience: 45% disagree/strongly disagree • Reluctant to refer patients due to negative experiences: ~ 30% • Discuss referral on their own initiative with a patient with severe obesity and type-2 diabetes: 22% PCPs agree/strongly agree		• Descriptive statistics • 5-point Likert Scale
Zacharoulis et al., 2017	• Highest rates of non-referral: cardiologists (90.2%), endocrinologists (90.0%) • Lowest rates of non-referral: general surgeons (58.3%)		• Descriptive statistics
Falvo et al., 2018	• Initiate conversation: 76.6% PCPs frequently, 17.8% PCPs always		• Descriptive statistics
Martini et al., 2018	• Open discussion: 36.1% GPs • Refer eligible patients: 56.6%   ○ 46.6% post-university obesity education, 19.6% university education (p < 0.05)   ○ 46.2% with BSY recommendations knowledge, 31.3% without knowledge (p < 0.05)	• Available for post-operative follow-up: 83.7% • Want education in post-operative follow-up: 86.1%	• Descriptive statistics • Pearson chi-square test
McGlone et al., 2018		• Confident with providing long-term postoperative care: 34%   ○ 30% PCPs with ≤ 8 years of experience, 36% PCPs with > 8 years of experience, p = 0.99 • Feels well-supported in managing postoperative medical problems: 17%   ○ 10% PCPs with ≤ 8 years of experience, 20% PCPs with > 8 years of experience, p = 0.63 • Feels well-supported managing postoperative surgical problems: 8%   ○ 10% PCPs with ≤ 8 years of experience, 8% PCPs with > 8 years of experience, p = 0.99	• Pearson chi-square test • Descriptive statistics
Simon et al., 2018	• In patients with BMI 30–39 kg/m2, 40.7% discuss BSY • In patients with BMI ≥ 40 kg/m2, 76.4% discuss BSY • Reason for not offering:   ○ Limited experience on when to offer BSY: 26.6%		• Descriptive statistics
Conaty et al., 2020		• Comfortable managing long-term care of postoperative patient: 59.5% PCPs strongly agree/agree	• Descriptive statistics • 5-point Likert Scale
El-Beheiry et al., 2020	• Comfortable counseling patients: All FPs (45.4%)   ○ Referring (56.8%), non-referring (17.1%), p < 0.001	• Comfortable with post-operative care: 9.4% strongly agree, 50.4% agree   ○ Referring (67.4%), non-referring (38.2%), p = 0.004	• Descriptive statistics • Student’s t-test
Lopez et al., 2020	• Obstacles to referral among PCPs:   ○ Lack of patient interest/engagement (61%)   ○ Time restriction during patient visits (14.6%)   ○ Prior experiences of poor patient outcomes (12.2%)   ○ Feeling unclear how to refer (2.4%) • Initiate discussions regarding weight loss management greater than 50% of the time: 51.2% PCPs   ○ Male provider (76.5%), Female provider (37.5%), p = 0.01		• Descriptive statistics • ANOVA and chi-squared tests
Egerer et al., 2021	• Average confidence in approaching obese patients concerning their weight and related risks (5 point scale)   ○ Normal weight PCP (4.44 $\pm$ 0.7), Overweight PCP (4.47 $\pm$ 0.7), p = 0.756   ○ Male PCP (4.45 $\pm$ 0.7), Female PCP (4.46 $\pm$ 0.7), p = 0.947   ○ Younger PCP (4.35 $\pm$ 0.8), Older PCP (4.48 $\pm$ 0.7), p = 0.538 • Confidence in educating obese patients regarding their obesity (5 point scale)   ○ Normal weight PCP (4.22 $\pm$ 0.9), Overweight PCP (4.32 $\pm$ 0.8), p = 0.549   ○ Male PCP (4.30 $\pm$ 0.8), Female PCP (4.24 $\pm$ 0.9), p = 0.783   ○ Younger PCP (3.90 $\pm$ 1.0), Older PCP (4.38 $\pm$ 0.8), p = 0.009	• Average number of patients provided with follow-up care after BSY (1 = 0 patients, 5 = more than 5 patients)   ○ Normal weight PCP (3.20 $\pm$ 1.3), Overweight PCP (3.53 $\pm$ 1.4), p = 0.089   ○ Male PCP (3.59 $\pm$ 1.4), Female PCP (3.06 $\pm$ 1.2), p = 0.014   ○ Younger PCP (2.77 $\pm$ 1.2), Older PCP (3.49 $\pm$ 1.2), p = 0.007	• Descriptive statistics • Two-sample t-test • Mann–Whitney U test
Memarian et al., 2021	• Felt competent to discuss: 59% PCPs • Initiate conversation: 7% PCPs	• Felt competent to take care of patients post-op: 63% PCPs	• Descriptive statistics
Sbraccia et al., 2021	• Correlation between PCP weight and likelihood of reviewing BSY options with patients: 58% normal weight HCPs, 44% overweight or obese HCPs • Agree that patients trust them to recommend BSY if appropriate: 62% normal weight HCPs, 48% overweight or obese HCPs		• Descriptive statistics
Zevin et al., 2021	• Percentage of PCPs who initiate conversation based on number of years in practice   ○ 0–10 years (29.6%), 11–20 years (100%), 21–30 years (70%), 31 + years (76.9%)   ○ 0–10 years vs 11–20 years (p = 0.002)   ○ 0–10 years vs 21–30 years (p = 0.016)   ○ 0–10 years vs 31 + years (p = 0.013) • Agree they initiate conversation: 44.8% PCPs • Correlation between PCP age and likelihood of initiating discussion (r = 0.363, p = 0.003)	• Felt competent in addressing post-op medical complications: 18.4% PCPs • Felt comfortable providing long-term follow up: 25% PCPs	• Descriptive statistics • Independent sample t-tests • Pearson’s correlation coefficient
Alenezi et al. 2022	• Do not feel confident discussing BSY as a treatment option for obesity: 20% PCPs agree, 42.1% PCPs disagree	• Do not feel comfortable providing postoperative management care: 28.6% agree, 27.9% disagree	• Descriptive statistics
Carrasco et al., 2022	• Greater confidence discussing BSY with patients associated with:   ○ Greater knowledge (p = 0.002)   ○ Positive attitude towards BSY (p = 0.008) • Obstacles to discussing weight loss management with patients with obesity   ○ Doctors lack knowledge about weight management: 31% • Confident suggesting BSY: 81%		• Multiple linear regression
Holmes et al., 2022	• Most common barriers to referral: time constraints, did not consider BSY • One-third unsure of referral process and risks/benefits		• Descriptive statistics
Ouni et al., 2022	• Comfortable referring patients: 70% PCPs comfortable, 6.9% PCPs unfamiliar with referral process for weight management		• Descriptive statistics
Zawadzka et al., 2022	• Frequency of referral: diabetologists more frequently refer patients to BSY consultations compared with non-diabetologists (p = 0.034) • Self-estimated knowledge of provider significantly associated with greater frequency of recommending BSY to eligible patients (p = 0.0016)	• Have knowledge about recommended plan for outpatient postoperative follow-up: 68.8% of all physicians, 73.5% of diabetologists, 63.3% of non-diabetologists	• Chi-squared test

Abbreviations: BARI bariatric medicine, BMI Body Mass Index, BS bariatric surgeon, BSY bariatric surgery, CARD cardiologists, EBT endoscopic bariatric procedure, ENDO endocrinologists, LAGB laparoscopic adjustable gastric banding, PCP primary care physician, RD registered dietician