Part 1: A Proposal: Why We Need a New Aftercare Plan

by Eric J. DeMaria, MD

Dr. DeMaria is from New Hope Wellness Center, Raleigh, North Carolina.

In the first installment of this column, I discussed long-term care after bariatric surgery. This month is a bit of a sequel, and I actually have some good news: I have heard from many of our colleagues in the bariatric surery community who agree that our system of care needs improvement.  Many agree that surgeons cannot possibly provide the level of aftercare support that our patients need and deserve, unless of course they stop performing surgery on the millions of people who might benefit from it.
It reassured me to learn that many of us agree that we need a better system and that we recognize the impossibility of delivering the care we would like to provide our patients. I guess it should go without saying that surgeons are bred and trained to focus on the surgery itself. It is after all a pretty intense technical feat to perform such complex procedures day after day and be able to report the extremely low mortality rates that one can easily find in today’s scientific literature.

In the early days of surgery, our surgeon predecessors performed surgery primarily for extirpation of disease. Then, a dramatic evolution changed surgery forever. Surgical interventions were undertaken to improve organ function (e.g., sphincter augmentation for the treatment of gastroesophageal reflux disease [GERD] and organ transplantation). Bariatric surgery, however, represents a further advance in the application of surgical intervention as it represents an anatomic intervention designed to alter patient behavior. All bariatric operations commonly performed today produce some degree of restriction, designed to modify eating behavior, as part of the procedure. Even the duodenal switch (DS), commonly described as a malabsorptive procedure, includes a gastric sleeve resection, which has ultimately been demonstrated to serve some patients quite well as a stand-alone procedure by virtue of its ability to reduce oral intake.

Although we modify the anatomy through surgery, we achieve varying degrees of success via these different techniques. I learned long ago that most phenomena in biology can be described as conforming to a bell-shaped curve, and I believe that the behavior changes we induce via surgery fit this description. We see some high responders and some low responders, but most patients fall into the widest range of average responders.

Why do we perform an anatomic alteration and ultimately see a wide range of responsiveness to that identical intervention? I believe a big part of the answer lies in the variations of human behavior. There are likely other factors at play here, such as genetics and metabolic variances, but of course we have limited ability at the present time to manipulate these variables. So, we are left with behavior as a likely major determinant of ultimate outcome on which we can focus our efforts on improving long-term success.

Unfortunately, our biggest problem in bariatric surgery care today is the issue of follow up, which is important for promoting successful long-term behavior modification. Perhaps even more important from a patient-safety standpoint, follow-up care is critical in providing surveillance for complications and to prevent the various nutritional issues that can arise long term. In addition, we need to collect long-term data, the lack of which has hampered acceptance by payors and medical doctors alike. Now I estimate that we are operating on 200,000 people or more per year, each of whom need long-term care, including at least one routine annual visit.

Let’s do the math. Over a five-year period in the United States, using a conservative estimate of our current annual case volume, one could estimate that we “create” one million postoperative patients, each of whom requires at least one annual follow-up exam. Thus, after five years at this case volume rate, bariatric surgeons in the United States are responsible for delivering one million follow-up visits, assuming that each patient follows current guidelines. In addition, in order to perform 200,000 operations, we must see patients preoperatively to get them ready for surgery. Let’s say this takes two preoperative visits per procedure. That is 400,000 more visits for patients in the properative period over the course of one year. Then, let’s postulate that postoperative patients from last year are not seen once, but rather four times over their first year postoperatively. This increases our burden of postoperative visits from one million to 1.6 million encounters, as the most recent year visits increase from 200,000 to 800,000. Overall, in the past five years in the United States, one could estimate that we bariatric surgeons would be responsible for two million office visits, which is about 10 times the number of annual surgeries. And this model does not include the probability that some patients will require more than the minimum number of encounters.

So, if there are 2,500 bariatric surgeons in the United States (this number is higher than most estimates), we would each potentially need to have 800 visits each year (16 visits per week) in order to keep up with our patients’ during the last five years. Now, increase the number of people needing care to reflect a 10-year period of high-volume bariatric surgery in the United States and you will find our 2,500 bariatric surgeons need to provide three million patient encounters per year (15 times the number of surgeries), or 24 visits per week just to keep up with the aftercare needs of patients. And this model does not reflect the estimate of 250,000 procedures per year, which some believe to be more accurate. Bariatric surgery, although it has grown in recent years, has been around for decades, so these numbers are very conservative in estimating the amount of care bariatric surgeons really would need to provide to patients long term if they followed our guidelines for annual follow-up care. The number of potential follow-up visits could easily approach five million per year (2,000 routine encounters per surgeon per year) or more if each patient returned as our guidelines recommend for their annual follow-up care. This number will continue to grow and outpace our available resources as bariatric surgeons.

Is it any wonder that surgeons might be considered ambivalent about patients not coming back for follow-up care? Could we realistically fit this many patients into our clinic schedules? We probably would not be able to be surgeons with this exponentially increasing burden of providing long-term care if patients actually came back as they are supposed to do.

I conclude that the bariatric surgeon workforce cannot support the follow-up care of all bariatric surgery patients long term. It is an impossible burden to place on this specialty and we must seek new answers to this problem. In my first column of “Total Bariatric Care,” I asked, “Aftercare—are we providing value to our patients?” and answered it with a resounding “no.”  Although some viewed this as a criticism of colleagues and the specialty as a whole, I do not agree.  I have found that most of our colleagues are genuinely concerned about their patients, butI believe we are fighting a losing battle in this numbers game. I think our only failure is that we have not been able to figure out a better system of care to make certain our patients’ needs are met long term.

In Part 2 of this installment, I will delve into what I believe to be a relatively simple and rapidly attainable strategy to improve our flawed long-term system of care. I believe a reasonable answer lies in equipping our primary care providers with the education and skills they need to provide high-quality care to our patients long term, and in publically identifying providers who have acquired this knowledge and skill so that the public can seek out their care. It would be my hope that we surgeons might—even briefly—take our focus off the surgical procedures themselves long enough to debate and ultimately introduce some solutions to the issue of providing quality long-term care to our patients.
I believe it is past time to solve this problem. Our patients’ long-term success and safety depend on it.

Category: Past Articles, Total Bariatric Care