Abstract
Purpose
Obesity has become a global health concern, associated with decreased quality of life and life expectancy. Although bariatric surgery has many benefits (e.g., substantial and durable weight loss, amelioration of comorbidities, and improvement in functionality), its patient attrition rate is relatively high. Therefore, we aim to assess the causes of withdrawal from our program.
Materials and Methods
We interviewed patients who dropped out of our bariatric surgery program between January 2016 and December 2021. A total of 1999 patients were eligible for bariatric surgery during this period, and 255 patients withdrew from the program. We interviewed patients over the phone to find out the reason for withdrawal. We divided participants into two groups: dropouts before and during the COVID-19 pandemic. Several options explaining the reason for leaving the program were presented to the patients to choose from.
Results
The number of patients who withdrew from the program before and during the COVID-19 pandemic was 135 (8.9%) and 120 (25.2%), respectively. Before the COVID-19 pandemic, most patients (49.1%) stated that the long waiting time was the cause of withdrawal. Even though during the COVID-19 pandemic, the main causes of attrition were the fear of contracting the disease and COVID-19 infection; the most common reason unrelated to COVID-19 was still the long preoperative preparation.
Conclusion
Long waiting time was the most common cause of patient attrition before bariatric surgery. To reduce the attrition rate, more studies should be conducted to find an optimized waiting time before bariatric surgery.
Graphical Abstract
Keywords: Bariatric surgery, Attrition, Obesity surgery
Introduction
Obesity has become a common health concern globally [1]. About 13% of the world’s population and 22.7% of people in Iran suffer from obesity [2, 3]. Obesity is associated with decreased quality of life and life expectancy. Patients with obesity have a higher risk of developing physical and mental disorders, including diabetes, hypertension, cardiovascular disease, depression, anxiety, and mood disorders. An estimated 5.02 million deaths worldwide were attributable to a high body mass index (BMI) in 2019 [1]. The most effective obesity treatment is bariatric surgery (BS) [4].
BS has many advantages, including substantial and durable weight loss, amelioration of comorbidities (e.g., diabetes, hypertension, dyslipidemia), and improvements in functionality, quality of life, and mental health [4, 5]. Also, there is a low rate of complications (10–17%) and a very low mortality rate (0.08–0.35%) associated with BS [5, 6]. Regardless of these advantages, the patient attrition rate is relatively high among candidates for BS [2].
Patient attrition is when a patient previously accepted for surgery withdraws from the program during preoperative preparation. Many factors contribute to patient attrition, including insurance denial or delay; failure to meet medical, psychological, and nutritional requirements for surgery; and change of mind [2]. Even when bariatric surgery costs are covered by insurance or the country's universal healthcare system (such as in Canada and New Zealand), the patient attrition rate is relatively high, ranging from 22 to 60% [2, 7–9].
There are very limited studies on patient attrition before bariatric surgery. Although a few studies have attempted to find predictors of patient attrition, none explored the cause of attrition from the patients’ point of view. We interviewed 201 patients who dropped out of our publicly funded bariatric surgery program before and during the COVID-19 pandemic (between January 2019 and March 2022). We hope that by better understanding patients’ concerns and problems, we will be able to remove barriers to care for those who need this life-altering and beneficial surgery.
Method and Materials
In this study, we surveyed patients who dropped out of our bariatric surgery program between January 2019 and December 2021. A total of 1999 patients were eligible for bariatric surgery during this period at the Rasoul-Akram obesity clinic affiliated with Iran University of Medical Sciences. Rasoul-Akram obesity clinic, with more than 28,000 patients in the database, is the first center of excellence (COE) accredited by the International Federation of Surgery for Obesity (IFSO) in Tehran, Iran. Our clinic is the most crowded center in Iran, with a waiting time of about 1 year. All eligible candidates received medical, psychological, and nutritional clearance and participated in the orientation sessions. All surgery and hospital costs were paid by universal healthcare insurance. Patients’ contact information and withdrawal status were extracted from our web-based national database [10].
During the study period, 255 patients withdrew from the program. We interviewed patients over the phone to find out the reason for withdrawal. The interview started with an open-ended question asking the patients about their withdrawal. Several options explaining the reason for leaving the program were presented to the patients to choose from. The options were added and completed during the interview course.
We divided participants into two groups: dropouts before the COVID-19 pandemic (pre-covid group, n = 135) and dropouts during the COVID-19 pandemic (covid group, n = 120). We assumed that the reasons for patients to leave the program would differ in these two intervals. For the pre-covid group, answers were put into nine categories, including (1) long waiting time, (2) preferring to receive surgery in other centers, (3) fear of postoperative complications, (4) problems with staff, (5) problems with the hospital, (6) medical problems, (7) personal problems, (8) successful weight loss, and (9) no specified reason, wishing to return to the program (Table 1). For the covid group, two options related to the COVID-19 disease were added: (1) fear of contracting the COVID-19 disease and (2) COVID-19 infection. The number of patients who refused to participate in our study or did not respond after two phone calls before and during the COVID-19 period was 29 and 21, respectively.
Table 1.
Options presented to patients as reasons for withdrawal
| Reason of withdrawal | Explanation |
|---|---|
| Long waiting time | Any reason related to the waiting time between confirmation of eligibility for surgery and receiving the surgery. This period includes multiple meetings with the surgeon, psychological counseling sessions, nutrition counseling sessions, medical counseling with other specialists (e.g., cardiologist, endocrinologist), orientation sessions, getting the insurance confirmation, waiting for the hospital bed to be empty, and waiting for the surgery |
| Preferring to receive surgery in other centers | If the patient withdrew from the program because they preferred to undergo surgery in another center due to the belief of receiving better care in general |
| Fear of postoperative complications | Any reason related to concerns or fears of postoperative complications that caused the patient not to receive the surgery |
| Problems with staff | Any problems with the clinic or hospital staff, including nurses, doctors, administrative staff, and consultants, caused the patient to withdraw from the program |
| Problems with the hospital | Any problems with the hospital, including distance, hospital hoteling, or previous bad experiences, caused the patient to withdraw from the program |
| Medical problems | Any new or exacerbated medical problem that makes the patient ineligible for the surgery or if the patient’s physician (outside of this facility’s program) has recommended against the surgery |
| Personal problems | Any personal problem that makes the patient unable to undergo surgery except for financial issues and concerns related to surgery |
| Successful weight loss | If the patient had successfully lost a substantial amount of weight with any non-surgical methods, including lifestyle changes, dietary changes, medical treatments, and exercise, and believed that they could continue to lose weight without surgery |
| No specified reason, wishing to return to the program | If the patient regrets leaving and prefers to return to the program and did not state a clear reason for withdrawal |
| Fear of contracting the COVID-19 disease | If the patient refused getting admitted to the hospital and receive surgery because of the fear of contracting COVID-19 disease (after issuing permission to perform bariatric surgeries by the Ministry of Health and national COVID-19 task force) |
| COVID-19 infection | Patients who could not undergo surgery because of active or recent COVID-19 infection or if they were suffering from complications of the disease |
This study was approved by the Institutional Review Board (IRB) of Iran University of Medical Sciences (IUMS).
Results
In this study, 1523 patients were candidates for bariatric surgery before the COVID-19 pandemic, and 476 were eligible for bariatric surgery during the COVID-19 pandemic period (Table 2). The number of patients who withdrew from the program before and during the COVID-19 pandemic was 135 (8.9%) and 120 (25.2%), respectively.
Table 2.
Total eligible patients and attrition rates before and during the COVID-19 pandemic
| Total eligible patients | Patients who dropped out of the program | Attrition rate | |
|---|---|---|---|
| Before COVID-19 pandemic | 1523 | 135 | 8.9% |
| During COVID-19 pandemic | 476 | 120 | 25.2% |
A total of 201 participants who withdrew from our bariatric surgery program were interviewed. Before the COVID-19 pandemic, most patients (n = 52, 49.1%) stated that the long waiting time was the cause of withdrawal (Fig. 1). Other causes of attrition were preferring to receive 1 (n = 17, 16%), successful weight loss (n = 11, 10.4%), problems with staff (n = 6, 5.7%), fear of postoperative complications (n = 6, 5.7%), medical problems (n = 5, 4.7%), problems with the hospital (n = 4, 3.8%), and personal problems (n = 3, 2.8%). Two patients (1.9%) died during the preoperative period (Table 3).
Fig. 1.
Distribution of attrition causes in the pre-covid group
Table 3.
The comparison of attrition reasons between pre-covid and covid groups
| Cause of attrition | Pre-covid group (n = 106) | Covid group (n = 95) |
|---|---|---|
| Fear of contracting COVID-19 | 0 | 29 (30.5%) |
| COVID-19 infection | 0 | 20 (21.1%) |
| Preferring to receive surgery in other centers | 17 (16.0%) | 0 |
| Long preoperative preparations | 52 (49.1%) | 18 (18.9%) |
| Problems with staff | 6 (4.7%) | 0 |
| Problems with the hospital | 4 (3.8%) | 0 |
| Medical problems | 5 (4.7%) | 4 (4.2%) |
| Successful weight loss | 11 (10.4%) | 6 (6.3%) |
| Fear of postoperative complications | 6 (4.7%) | 3 (3.2%) |
| Personal problems | 3 (2.8%) | 0 |
| Dead | 2 (1.9%) | 2 (2.1%) |
| No specified reason, wishing to return to the program | 0 | 13 (13.7%) |
| Total | 106 (100%) | 95 (100%) |
Even though during the COVID-19 pandemic, the main causes of attrition were the fear of contracting the disease (n = 29, 30.5%) and COVID-19 infection (n = 20, 21.1%); the most common reason unrelated to COVID-19 was still the long preoperative preparation (n = 18, 18.9%, see Fig. 2). Other causes of attrition were successful weight loss (n = 6, 6.3%), medical problems (n = 4, 4.2%), and fear of postoperative complications (n = 3, 3.2%). Two patients (2.1%) died during the preoperative period (Table 2). Also, 13 patients (13.7%) wanted to return to the program and regretted the withdrawal.
Fig. 2.
Distribution of attrition causes during the COVID-19 pandemic
Discussion
In this study, we interviewed patients who withdrew from our center’s bariatric surgery program to find the main causes of patient attrition. The main reason for withdrawal before the COVID-19 pandemic was the long waiting time and lengthy preoperative preparations. During the COVID-19 pandemic period, the main causes of patient attrition were fear of contracting the disease and COVID-19 infection. However, the most common cause unrelated to COVID-19 was the long waiting time. Nearly half of our patients (n = 89, 44%) left the program due to long waiting times, problems with the hospital, problems with the staff, and fear of postoperative complications. These issues are modifiable and can be solved by simple measures such as better staff training, better patient guidance, and improved hospital conditions.
The patient attrition rate in our center before and during the COVID-19 pandemic was 8.9% and 25.2%, respectively (an overall attrition rate of 12.7%). Previous studies reported much higher attrition rates, between 22 and 60% [2, 9, 11, 12]. One of the reasons for this low attrition rate is the full payment of medical expenses by the universal healthcare system. Also, there is no insurance-mandated weight loss before the surgery, which has been shown to be a reason for patient attrition [13]. We should also highlight that at the time of reporting this study, Rasoul-Akram obesity clinic is the only center of excellence (COE) accredited by the International Federation of Surgery for Obesity (IFSO) in Iran, which could also contribute to the low attrition rate.
Our center’s average waiting time is between 12 and 18 months. This long waiting time is partly due to being Iran’s only COE for bariatric surgery, hence a very busy schedule. The other reason for lengthy preoperative preparations is to ensure that the patient is committed to the treatment and what comes after the surgery during multiple sessions with bariatric surgeons, psychologists, nutritionists, and general physicians. Although ensuring commitment to dietary and lifestyle changes is important to minimize weight loss failure, nutritional complications, and the need for revisional surgery, waiting time prolongation may cause significant patient attrition [13, 14].
Two randomized clinical trials have shown that delayed surgery with the goal of preoperative weight loss is not beneficial for patients and will not affect surgical outcomes [13]. One study found 5% higher odds of attrition for each month longer in waiting times [2]. However, no study has recommended an optimal waiting time, and no evidence shows that the shorter the waiting time, the better. Randomized clinical trials or cohort studies comparing the effect of short and long waiting times on attrition, weight loss outcomes, postoperative complications, and other factors could help suggest an optimized wait time for bariatric surgeries.
Limitations
This study was limited by the small number of participants. Also, 49 (19.6%) patients refused to participate, despite receiving a proper explanation about the study. All interviews were conducted by a single person to eliminate the interview bias.
Conclusion
Understanding the causes of patient attrition from bariatric surgery programs is important to increase the number of patients receiving life-altering and beneficial surgery. In this study, long waiting time was the most common cause of patient attrition before bariatric surgery. To reduce the attrition rate, more studies should be conducted to find an optimized wait time before bariatric surgery.
Author Contribution
All authors have contributed equally to this work.
Declarations
Ethics Approval
For this type of study, formal consent is not required.
Consent for Participate
Informed consent does not apply.
Conflict of Interest
The authors declare no competing interests.
Footnotes
Key points
- Understanding the reasons for patient attrition before bariatric surgery is important to increase the number of patients receiving this life-altering and beneficial surgery.
- Long waiting time was the most common cause of patient attrition before bariatric surgery.
- Improving the modifiable causes of attrition (long waiting time, problems with the hospital, problems with the staff, and fear of postoperative complications) could reduce the attrition rate by nearly half.
- More studies should be conducted to find an optimized waiting time before bariatric surgery.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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