Degree project, 30 ECTS Aug 12, 2020
Hospital Admission and
Emergency Department Visit
After Bariatric Surgery, a
2-Year Follow Up
Version 2
Author: Viktor Sharan, MB, School of Medical Sciences, Örebro
University, Örebro, Sweden.
Supervisor: Johan Ottosson MD PhD Department of Surgery,
Örebro University Hospital, SE-70185 Örebro, Sweden
Word count: Abstract: [250] Manuscript: [2725]
Abstract
Introduction
Previous study investigating Emergency Department (ED) visits rate and admission rates in bariatric patients’ post-surgery shows a 2-year admission rate of 26%.
Aim
The primary aim of this study was to assess the number of ED visits and admissions as well as examine if there is a correlation with comorbidities, education level, quality of life, and image method used. The secondary aim was to compare the ED and admission rate between the cohort and the general population.
Methods
This retrospective study included a total of 190 patients. They were followed for 2 years. All the patients were operated on during 2017 in Region Örebro. The cohort and data were obtained from the Scandinavian Obesity Surgery Registry and data concerning ED visit and admittance rate was collected by reviewing medical records.
Results
The ED visit rate was 116 (61%) and the admittance rate was 76 (40%). Poor mental health, low education level and smoking were correlated to a higher degree of admittance and ED visit rate. There were more imagining used in the group that visited the ED or got admitted. The most common diagnoses were symptoms related to the digestive system and abdomen. The study population had a higher degree of admittance and ED visit rate than the general population.
Conclusions
Rate of admittance seem to be correlated to factors related to socioeconomic status. More research is needed to investigate what intervention would help this subgroup most, so they don’t have to seek medical care to the same degree.
Keywords
1
Abbreviations
BMI – Body Mass Index CT – Computer Tomography ED – Emergency Department
MRI – Magnetic Resonance Imaging RYGB – Roux-en-Y gastric Bypass SG – Sleeve Gastrectomy
SOReg – Scandinavian Obesity Surgery Registry USG – Ultrasonography
Introduction
Obesity is defined by the World Health Organization as an ”abnormal or excessive fat accumulation that presents a risk to health” [1]. Adults with a BMI of 25 kg/m2 or greater are
classified as being overweight. The definition for obesity class I, II and III are defined as a BMI of 30 kg/m2 to 34 kg/m2, 35 kg/m2 to 39 kg/m2, and 40 kg/m2 or greater, respectively [2].
In Sweden, more than 50% of adults have self-reported that they are suffering from obesity or are overweight [3]. Obesity is correlated with a wide range of diseases such as diabetes type II, obstructive sleep apnea, hypertension, dyslipidemia, infertility, non-alcoholic fatty liver disease and several types of cancer. These diseases are in turn associated with a large decrease in life expectancy [1,4].
The treatment of obesity can be divided into non-surgical interventions, such as diet, exercise, drugs, cognitive behavioral therapy, and surgical interventions. Current studies have so far shown that non-surgical interventions only lead to a moderate weight loss [5,6]. If non-surgical alternatives have been unsuccessful, only surgery remains. The effects on weight loss after surgery is superior to non-surgical interventions [7]. The two main surgeries performed in Sweden are Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). Both lead to significant weight loss and an increased remission in comorbidities such as diabetes, dyslipidemia, hypertension and sleep apnea [8]. In Sweden, the number of bariatric surgeries performed in 2017 was 5400. In Region Örebro the number of bariatric surgeries performed in 2017 was 191 with 67.5% using RYGB and 30.9% using SG [9]. It is still uncertain whether RYGB or SG is best from a weight loss perspective or a complications perspective [10].
The criteria for being offered bariatric surgery in Sweden is: [11] • BMI >35 with comorbidities or BMI >40 without comorbidity. • Age >18 years.
• Earlier serious dieting attempts. • Stable psychosocial situation. • Acceptable operational risk.
Obesity surgery, like all surgery, is associated with complications that can affect quality of life. Long term complications after obesity surgery involve: nutritional deficiencies, hypoglycemia, abdominal pain, neurological complications and psychological impacts [12].
After surgery, patients require lifelong supplementation with multivitamin, Vitamin B12 and calcium/vitamin D tablets. There may also be an increase in post-operative eating disorders, binge eating and an increased suicide risk post-bariatric-surgery [13].
Recent findings regarding readmission rate after obesity surgery studies showed that the 30-days readmission rate was between 6.1% to 17.5% [14–18]. Furthermore, a study by Bruze et al. shows that the 1-year admission rate was 21.4% and the 6-year admission rate was 65.9% [18]. Several studies showed that the most common reason for hospital readmission were abdominal pain, nausea, vomiting, wound infections, and dehydration [19–21]. However, short-term studies may underestimate true hospital utilization and misses long-term complication rate. Many of the previous studies do not include emergency visits without admission, nor the use of image method used when diagnosing and treating the patients.
Aim
The primary aim was to assess the number of ED visits and admissions in patients as well as examine if there was a correlation to comorbidities, education level, quality of life and diagnostic measures. The secondary aim was to compare the use of ED and admission rate between the cohort and the general population.
Material and Methods
The inclusions criteria for this study were: Undergone either a RYGB or a SG surgery in region Örebro during 2017. Exclusion criteria was to have locked their medical record.
A cohort consisting of 191 patients fit the inclusions criteria. One patient had locked their medical record and was therefore excluded from the study. Participants’ ages ranged between 19 and 70 years. Data about the general population ED visit rate and admission rate was acquired from the Swedish Health and Welfare statistical database.
An ED visit was defined as having visited the ED and meeting a doctor. Regardless of the result of the visit was to get admitted to the hospital or not. An admittance to the hospital was defined as being connected to a bed in a department in the hospital.
The patients were obtained from the Scandinavian Obesity Surgery Registry (SOReg). Preoperative data were also extracted from SOReg and consisted of the patients’ status at operation. This includes birthdate, gender, operation method, length of education, prior bariatric surgery, other concomitantsurgery, sleep apnea, diabetes, hypertension, dyslipidemia, dyspepsia, diarrhea, smoking, depression, BMI, and quality of life data from questionnaire RAND -36. Data from the 2 year follow up was also extracted from the registry. Data for 99 patients were available from the follow up. The data collected from the follow up were sleep apnea, diabetes, hypertension, dyslipidemia, dyspepsia, diarrhea, smoking, depression, and BMI. The remaining data was collected by reviewing medical records. This included: Number of endoscopies, CT, MRI, other x-rays and ultrasound, date of ED visit and the diagnosis, number of times admitted, and diagnosis for admittance were collected. The journal review was performed February 2020, approximately 2 years after operation.
The patient cohort was classified into two groups according to if they visited the ED (n=116) or not (n=74). The cohort were classified again according to if they had undergone an RYGB (n=130) or a SG (n=60). They were then compared for different characteristics.
Day-surgeries was not calculated for the admittance group as every day-surgery is counted as an admittance to the hospital. The factor Visited ED within 30 days postoperative was not calculated for the ED group because if the patients belong in the not visited ED group, then it is given that they have not visited the ED in the 30 days postoperative.
Statistical analysis
The data that was analyzed using the following statistical analysis. chi 2 squares were used when analyzing for significance of a variables with nominal scale. Fisher's Exact test were used when chi 2 was applicable but a cell count was below 5. T-test were used with variables of interval scale and the sample was normally distributed. Mann-Whitney u-test were used when the variable was of ordinal scale or if it was an interval scale but was not normally distributed. Normal distribution of a variable was checked by plotting it in front of a normal distributed histogram. Significant numbers were defined as p<0.05.
Ethical considerations
This project is a project-based quality control. The assessment was made that there is no need for permission from the ethical board as this will only involve patients treated in Region Örebro. The value of this study comes from the fact that this is a tool to help doctors choose the most adequate treatment for each unique patient, which in turn leads to a better patient outcome.
Results
Of the 190 patients, 116 (61%) had visited the ED at least one time and 76 (40%) had been admitted to the hospital at least one time during the 2-year follow-up. There was no statistical difference between the group that visited the ED and the group that were admitted to the hospital regarding a majority of the characteristics, shown in table 1 and table 2. Additional characteristics of the population are shown in appendix 1 and appendix 2.
The ED visit rate during the two-year observation period was higher in patients that visited the ED in the first 30 days n=7 (6.0%) compared to patients that did not visit the ED in the first 30 days n=0 (0.0%; p=0.031). The admittance rate was also higher in patients that visited the ED in the first 30 days n=7 (9.2%) compared to patients that did not visit the ED in the first 30 days n=0 (0.0%; p <0.001).
The rates of the hospital readmission were higher in patients with education less than or equal to 9 years (p=0.010), dyslipidemia (p=0.047), low levels of p-LDL (median 3 mmol/l in admitted and 3.2 mmol/l in not admitted, p=0.025) and worse mental health scores (median 70 in admitted and 80 in not admitted, p=0.017).
Abbreviations: RYGB – Roux-en-Y gastric bypass SG – Sleeve gastrectomy. p-value calculated with
Chi-2 squares or Fisher's Exact test if a cell size is <5.
Table 2 shows the characteristics analyzed using Mann-Whitney u test. Smoking, education, and mental health score on rand -36 were shown to be significant for being admitted to the hospital. The subtotal mental health was shown to being significant for ED visits.
Table 1. Description of population.
All (n=190)
Did not visit ED (n=74) Visited ED (n=116) Not admitted (n=114) Admitted to the hospital (n=76) n % n % n % p n % n % p Gender Women 147 77.4% 55 74.3% 92 79.3% 0.423 55 48.2% 52 68.4% 0.671 Men 43 22.6% 19 25.7% 20.7% 19 16.7% 24 31.6% Sleep apnea 19 10.0% 6 8.1% 13 11.2% 0.488 10 8.8% 9 11.8% 0.490 Diabetes 20 10.5% 10 13.5% 10 8.6% 0.284 10 8.8% 10 13.2% 0.335 Hypertension 36 19.0% 13 17.6% 23 19.8% 0.698 22 19.3% 14 18.4% 0.880 Dyslipidemia 10 5.3% 3 4.1% 7 6.0% 0.724 3 2.6% 7 9.2% 0.092
Prior bariatric surgery 3 1.6% 2 2.7% 1 0.9% 0.561 2 1.8% 1 1.3% 1
Other simultaneous operation 13 6.8% 2 2.7% 11 9.5% 0.282 6 5.3% 7 9.2% 0.291 Dyspepsia 8 4.2% 3 4.1% 5 4.3% 1 5 4.4% 3 3.9% 1 Diarrhea 2 1.1% 0 0.0% 2 1.7% 0.521 0 0.0% 2 2.6% 0.158 Depression 13 6.8% 3 13.5% 10 8.6% 0.256 6 5.3% 7 9.2% 0.381 Method RYGB 130 68.4% 48 64.9% 82 70.7% 0.400 77 67.5% 53 69.7% 0.750 SG 60 31.6% 26 35.1% 34 29.3% 37 32.5% 23 30.3% Visited ED within 30 days postoperative 0 0.0% 7 9.2% 0.001 Day-surgery performed 32 16.8% 6 8.1% 26 22.4% 0.010
Table 2. Description of population
All (n=190)
Did not visit ED (n=74) Visited ED (n=116) p Not admitted (n=114) Admitted to the hospital (n=76) p Smoking Yes 25 13.2% 7 9.5% 18 15.5% 0.772 11 9.6% 14 18.4% 0.026 No 96 50.5% 43 58.1% 53 45.7% 56 49.1% 40 52.6% Unknown 8 4.2% 2 2.7% 6 5.2% 7 6.1% 1 1.3% Quit 61 32.1% 22 29.7% 39 33.6% 40 35.1% 21 27.6% Education ≤9 Year 8 4.3% 0 0.0% 8 6.9% 0.051 1 0.9% 7 9.2% 0.010 9–12 Year 138 74.6% 55 74.3% 83 71.6% 89 78.1% 49 64.5% > 12 Year 39 21.1% 18 24.3% 21 18.1% 21 18.4% 18 23.7%
Mental health score on RAND -36 Median (q1, q3) 76 (62, 88) 80 (65, 92) 76 (57, 87) 0.051 80 (64, 90) 70 (56, 84) 0.028
Subtotal mental health score on RAND -36 Median (q1, q3) 51.6 (42.7, 56.7) 54.1 (44.5, 57.6) 49.3 (42.5, 54.9) 0.028 51.9 (44.7, 57.1) 49.25 (38.1, 56.4) 0.116 p-value calculated with Mann-Whitney u test.
Table 3. Description of population
All (n=190)
Did not visit ED (n=74) Visited ED (n=116) p Not admitted (n=114) Admitted to the hospital (n=76) p
Operation time, min Median (q1, q3) 68.0 (58.25, 78.0) 69.5 (57.0, 79.8) 67.5 (59.0, 76.3) 0.955 66 (56, 78) 69 (61.8, 77.3) 0.095
Age at operation, years
Average (SD) 40.4 (11.4) 41.4 (11.3) 39.9 (11.5) 0.394 41.1 (10.9) 39.4 (12.2) 0.315
BMI at operation date Median (q1, q3) 40.5 (37.5, 44.0) 41.5 (37.1, 43.6) 43 (37.9, 44.1) 0.729 40.45 (37.53, 44.33) 40.75 (37.6, 43.9) 0.352 BMI reduction after 2 year Median (q1, q3) -14.0 (-16,9, -9,2) -15.0 (-17.2, -8.6) -13.3 (-16.7, -10.2) 0.271 -14.53 (-16.59, -9.99) -12.69 (-17.6, -8,2) 0.280 P-LDL, mmol/L Median (q1, q3) 3.1 (2.5, 3.7) 3.10 (2.5, 3.6) 3.05 (2.5, 3.7) 0.829 3.20 (2.5, 3.8) 3.00 (2.3, 3.5) 0.025
The groups were also analyzed regarding if there was any correlation between their visits to the ED or admittance and if they had a comorbidity 2-year after the operation. The only significance difference seen was regarding dyspepsia related to ED visit.
Table 4. Comorbidities after 2 years.
p-value calculated with Chi-2 squares or Fisher's Exact test if a cell size is <5. p-value of smoking calculated with Mann Whitney u-test.
All (n=99) Didn’t visit ED (n=37) Visited ED (n=62) Not admitted (n=57) Admitted (n=42) n % n % n % p n % n % p
Sleep apnea 2 year 6 6.1% 2 5.4% 4 6.5% 1 2 3.5% 4 9.5% 0.397
Diabetes 2 year 5 5.1% 1 2.7% 4 6.5% 0.648 3 5.3% 2 4.8% 1 Hypertension 2 year 16 16.2% 6 16.2% 10 16.1% 0.991 10 17.5% 6 14.3% 0.663 Dyslipidemia 2 year 5 5.1% 0 0.0% 5 8.1% 0.157 1 1.8% 4 9.5% 0.160 Dyspepsia 2 year 5 5.1% 2 5.4% 3 4.8% 0.004 1 1.8% 4 9.5% 0.160 Diarrhea 2 year 1 1.0% 1 2.7% 0 0.0% 0.374 1 1.8% 0 0.0% 1 Depression 2 year 14 14.1% 2 5.4% 12 19.4% 0.073 6 10.5% 8 19.0% 0.256 Smoking 2 year Yes 18 18.2% 7 18.9% 11 17.7% 0.211 12 21.1% 6 14.3% 0.185 No 43 43.4% 17 45.9% 26 41.9% 24 42.1% 19 45.2% Unknown 13 13.1% 7 18.9% 6 9.7% 9 15.8% 4 9.5% Quit 25 25.3% 6 16.2% 19 30.7% 12 21.1% 13 31.0%
Table 5 shows the number of imaging procedures done in the groups. This is divided into the number of endoscopies, CT scans, MRI, and other x-rays and ultrasonography (USG). CT, MRI, and x-ray + USG were more prevalent in the groups that visited the ED or were admitted. The number of endoscopies was correlated with a visit to the ED but not to being admitted.
Table 5. The number of imaging procedures done.
All
(n=190) Did not visit ED (n=74) Visited ED (n=116)
Not admitted (n=114) Admitted to the hospital (n=76) Endoscopy n % n % n % p n % n % p 0 176 92.6% 72 97.3% 104 89.7% 0.048 108 94.7% 68 89.5% 0.172 1 11 5.8% 2 2.7% 9 7.8% 5 4.4% 6 7.9% 2 3 1.6% 0 0.0% 3 2.6% 1 0.9% 2 2.6% CT 0 117 61.6% 70 94.6% 47 40.5% <0.001 90 78.9% 27 35.5% <0.001 1 41 21.6% 1 1.4% 40 34.5% 15 13.2% 26 34.2% 2 14 7.4% 3 4.1% 11 9.5% 6 5.3% 8 10.5% 3+ 18 9.5% 0 0.0% 18 15.5% 3 2.6% 15 19.7% MRI 0 156 82.1% 67 90.5% 89 76.7% 0.016 100 87.7% 56 73.7% 0.018 1 23 12.1% 5 6.8% 18 15.5% 8 7.0% 15 19.7% 2 7 3.7% 1 1.4% 6 5.2% 4 3.5% 3 3.9% 3+ 4 2.1% 1 1.4% 3 2.6% 2 1.8% 2 2.6% X-RAY+USG 0 116 61.1% 58 78.4% 58 50.0% <0.001 82 71.9% 34 44.7% <0.001 1 33 17.4% 10 13.5% 23 19.8% 15 13.2% 18 23.7% 2 20 10.5% 4 5.4% 16 13.8% 9 7.9% 11 14.5% 3+ 21 11.1% 2 2.7% 19 16.4% 8 7.0% 13 17.1%
Abbreviations: MRI – Magnetic resonance imaging, USG – Ultrasonography. p-value calculated with
Figure 1 shows the distribution of the diagnosis for the 261 visits done by the study population.
Fig 1. Top 6 reasons for ED visits (n = 261).
The most common diagnosis that was set for ED visits were diagnoses involving symptoms from the digestive system and abdomen (R1 group, 56.7%). The second most common diagnosis group was diseases of intestines like IBS, Crohn’s, and ulcerative colitis (K5 group, 10.5%).
Figure 2 shows the number of admittance to the hospital and ED visits/100,000 in Örebro during 2017 and compares it to the study population. The study population was admitted and visited the ED to a higher degree than the general population. The total number of admissions for the study population was 137. The total number of ED visits for the study population was 261.
Fig 2. Number of admittances to the hospital and ED visits /100,000 for the study population and general population
0% 10% 20% 30% 40% 50% 60% R1, Symptoms involving the digestive system and abdomen K5, IBD and other diseases of intestines R0, Symptoms from circulatory and respiratory systems M7, Other soft tissue diseases R5, General symptoms and signs of illness S0, Injuries to the head
Reasons For ED Visits
10 000 20 000 30 000 40 000 50 000 60 000 70 000 80 000
Admitted to the hospital ED visit
Admissions and ED/100,000
Figure 3 shows that the most common diagnosis for admittance to the hospital was diagnoses involving symptoms from the digestive system and abdomen (R1 group). The second most common was diagnoses in the O8 group that involves giving birth. The admission rate for the study population was calculated on the total number of admittances in the study population which was 137.
Fig 3. Comparison between the general population and study population regarding admittance to the hospital. 1 000 2 000 3 000 4 000 5 000 6 000 R1, Symptoms from digestive system and abdomen O8 Encounter for delivery K8, Gallbladder, biliary tract and pancreas
K4 Hernia I4 Other forms
of heart disease I8 Veins, lymphatic vessels and lymph nodes N9 Female genital tract
Diagnosis for admittance, 2017
Discussion
Bariatric surgery is today a common surgical procedure for the treatment of morbid obesity and considered as the main treatment option when non-surgical interventions have failed. Postoperative admission rates and ED rates after bariatric surgery are important to monitor since they place a burden on the health care system as well as stress on the patients. Few previous studies measure the number of ED visits without admittance or the usage of diagnostic measures. Furthermore, several studies on hospital admission after bariatric procedures often focus on complications within 30-days. This catches many of the early complications but misses potential later complications. This study on the other hand focus on late term complication with a 2 year follow up time and measures both ED visits and admissions to the hospital.
Before the study participants underwent the operation, they answered the questionnaire RAND-36 and answered other preoperative questions regarding health, education, and other aspects of their lives. A significant difference was shown regarding education and smoking. Lower education and higher smoking rates tend to lead to a higher degree of admittance to the hospital. This agrees with Bruze et al. [19] findings but the reason why is unknown. It was also observed that the group that was admitted to the hospital and the group that visited the ED scored lower on the mental health modality and mental health-subgroup, respectively, as measured in RAND-36. This indicate that these patients may have a vulnerable mental health that becomes disrupted from the dietary and lifestyle changes after surgery. The patients may feel overwhelmed resulting in an ED visit or an admission to the hospital. These finding also agrees with the study by Bruze et al. [19]. Another possibility is that these findings are connected to the general poorer health of people with a low degree of socioeconomic status [22]. People with a low degree of socioeconomics usually have a lower degree of education, more mental health problems and tend to smoke to a higher degree compared to people from higher socioekonomical backgrounds [23–25]. One possible way to assist this supgroup is to offer more extensive preoperative education and more intense postoperative follow-up protocols to catch arising problems before they lead to an emergency visit or an admittance to the hospital.
The 2 -year admission rate in this study was 40%. Previous studies have shown a readmission rate between 16.7% for a 1-year readmission rate [26], 26% for a 2-year admission rate [27] and 65% for a 6-year readmission rate [18]. The readmission rates observed in the present study
population were greater than what was expected. Many of the studies that report lower admission rates counted all-cause admission, but it is unclear whether they counted elective day surgeries. Previous studies may also only include admissions related to the surgical procedure. This is supported by the high rate of childbirth observed in this study but not shown in other studies. Another possibility may be that several of these studies are performed in USA where you have to pay for the medical care yourself which can affect how willing the patients is to being admitted.
There was no significant increase in ED visit rate or admittance rate for the majority of the comorbidities, as shown in both table 1 which shown comorbidities before operation and table 3 which shows comorbidities at the 2-year follow-up. The reason for this may be attributed to that many of the comorbidities have been shown to enter remission or improve with a normalization in body weight, most notably diabetes but also hypertension and dyslipidemia [29–32]. This suggests the notion that patients are not drawn to the ED or admitted because of their comorbidities. Instead the reason for their elevated ED rate and admission rate may be connected more to the patients having undergone a major surgery or may have other comorbidities that was out of scope for this study.
Higher LDL levels were found to be positively associated with admittance to the hospital, but on the other hand, dyslipidemia was found to be negatively associated with admittance to the hospital. This may be because of the differences between the definition of dyslipidemia and high LDL. Ahmed et al. [33] shows in his study that dyslipidemia is a contributing factor for admittance to the hospital.
A large proportion of patients were admitted with hernia as diagnosis. It is impossible to say if these numbers represent people who got a hernia from the operation or suffered from a hernia before the operation that was asymptomatic and manifested sometime after they lost some weight. A large number of admittances for gallstones was seen and can be explained by the increased incidence of gallstones seen after bariatric surgery [34].
The patients that were diagnosed with diagnoses related to symptoms from the digestive track or general symptoms or signs of illness, received symptomatic diagnoses. This may indicate that the attending physician was not able to set a specific diagnosis and pinpoint the cause for
the patients’ distress. The attending physician instead opted for the diagnosis for the symptom which the patient presented with. There may be a possibility to avoid these ED visits or admittances by letting the patients have easy access to telephone consultations with a health staff familiar to bariatric surgery. They may be able to give good advice over the phone or reschedule the patient for a fast appointment thus avoiding visits to the ED.
A weakness when comparing between the operated group and the general population is that the differences may lead to an uneven comparison. The groups are not matched according to age, gender, comorbidities, or any other factor and the general population have not undergone major surgery, have lower average BMI and have a lower degree of comorbidities. This may skew the proportions of ED visits and admittances and makes it difficult to draw significant conclusions. Another weakness is the 52% follow up rate for the 2-year comorbidities. The high drop-of rate is attributed to a failure to document the follow-up and the failure of patients to come to their follow-up appointments. This leads to a difficulty in drawing conclusions from this data set.
In summary, this study aimed to investigate which risk factors lead to a worsened outcome after bariatric surgery which points towards a lower socioeconomical status may be a contributing factor. Next step is to find ways to better assist this subgroup that could potentially result in lower ED visit rates and lower admission rates. Further studies are needed on how best to identify patients and how to best help these patients.
Conclusion
Rate of admittance seem to be correlated to factors related to socioeconomic status. More research is needed to investigate what intervention would help this subgroup most, so they do not have to seek medical care to the same degree.
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Appendix 1 All (190) Didn’t visit ED (74) Visited ED (116) p Not admitted (114) Admitted to the hospital (76) p Hb Median (q1, q3) 139 (131.3, 147) 141.5 (132.5, 148.8) 138.5 (130.75, 146) 0.546 140.5 (132.3, 148.8) 138 (129.8, 146) 0.526 fP-Glukos Median (q1, q3) 5.7 (5.3, 6.3) 5.7 (5.4, 6.4) 5.7 (5.2, 6.2) 0.816 5.7 (5.3, 6.2) 5.65 (5.3, 6.3) 0.515 B-HbA1c Median (q1, q3) 36 (34, 40) 36 (33.3, 41.8) 36 (34, 39.3) 0.835 36 (34, 40) 36.5 (33.75, 40) 0.645 fP-TG Median (q1, q3) 1.5 (1.1, 2) 1.6 (1.2, 2) 1.45 (1.1, 1.9) 0.986 1.6 (1.125, 2.1) 1.4 (1.1, 1.8) 0.088 P-HDL Median (q1, q3) 1 (0.9, 1.2) 1 (0.9, 1.2) 1 (0.9, 1.1) 0.984 1 (0.9, 1.2) 1 (0.8, 1.1) 0.474 P-Creatinine Median (q1, q3) 67 (61, 77) 69.5 (64, 79.8) 65 (58.8, 74.3) 0.679 68 (63, 77) 63.5 (58.8, 76) 0.237 PTH (parathyroid hormone) Median (q1, q3) 5.3 (4.3, 6.6) 5.25 (4.3, 6.5) 5.25 (4.2, 7.3) 0.270 5.2 (4.3, 6.9) 5.3 (4.4, 6.3) 0.718 Vitamin D Median (q1, q3) 57 (43, 73) 58 (47.3, 75.3) 57 (41, 72.8) 0.416 58 (44.3, 8) 55 (41, 71.3) 0.407 fS-insulin Median (q1, q3) 23 (15.6, 33) 24 (17.1, 36) 23 (14.8, 31.3) 0.224 24 (15.3, 32) 23 (16.4, 33.8) 0.696 Physical function Median (q1, q3) 60 (41.9, 80) 65 (45, 80) 60 (40, 78.8) 0.371 60 (41.9, 80) 60 (43.75, 80) 0.673 Weight at surgery Median (q1, q3) 106 (96, 119.5) 109 (95, 126.3) 104 (96, 116.3) 0.165 104.5 (96.3, 117.8) 107.5 (95.8, 120.3) 0.513
Appendix 2 All (190) Didn’t visit ED (74) Visited ED (116) p Not admitted (114) Admitted to the hospital (76) p Physical role Median (q1, q3) 50 (12.5, 100) 50 (25, 100) 50 (0, 100) 0.768 50 (25, 100) 50 (0, 100) 0.823 Bodily pain Median (q1, q3) 42 (31, 62) 51 (32, 62) 41 (31, 62) 0.201 51 (32, 62) 41 (31, 62) 0.206 General health Median (q1, q3) 57 (41, 75) 57 (42, 72) 57 (40, 75) 0.892 60 (42, 73.5) 55 (40, 75.5) 0.641 Vitality Median (q1, q3) 50 (35, 65) 50 (35, 65) 45 (30, 63.8) 0.270 50 (35, 65) 45 (30, 65) 0.571 Social function Median (q1, q3) 75 (56.3, 100) 75 (62.5, 100) 75 (50, 100) 0.210 75 (62.5, 100) 75 (50, 100) 0.189 Emotional role Median (q1, q3) 100 (66.7, 100) 100 (66.7, 100) 100 (66.7, 100) 0.560 100 (66.7, 100) 100 (66.7, 100) 0.177 Subtotal physical health Median (q1, q3) 35.6 (27.8, 43.5) 36.9 (29, 43.7) 35 (26.7, 42.9) 0.460 37 (28.1, 42.8) 33.6 (27.5, 43.8) 0.930
Appendix 3 Etisk reflektion
Alla studier omfattar etiska övervägande och denna uppsats är inget undantag. De etiska frågeställningar jag har valt att fokusera på i denna reflektion är om nyttan med en kvalitetsgranskning överstiger patientens potentiella lidande.
Autonomiprincipen säger att patienten har en självbestämmande rätt vad gäller sin vård och angående sin journal. Patienten måste vara informerad och har en rätt att avstå från erbjuden behandling eller att medverka i studier.
Göra gott principen talar för att man som läkare ska göra det som anses ge mest gott. Detta kan innebära rent praktiskt att man försummar en person självbestämmande rätt, inom rimliga gränser, för att detta gynnar samhället.
I detta fall så bryts autonomiprincipen då patienten inte tillfrågas ifall vi får tillstånd att gå in i patientens journaler. Bedömningen har gjorts att den potentiella vinningen av att utföra denna kvalitetsgranskning överväger den potentiella skadan en patient utsätts för vid läsning av journal. Den potentiella vinningen i detta fall skulle vara ifall man lyckas identifiera en grupp patienter som söker sjukvården signifikant mer i jämförelse med andra patientgrupper. Man kan sedan genomföra vidare studier för att identifiera vad de söker för och vilka riskfaktorer som ökar risken för att drabbas av detta. Detta kommer i sin tur skapa möjlighet att ge profylaktisk behandling för att minska risken, öka det samlade kunskapsläget samt möjligen ge patienterna en personligare bild av vad riskerna med att genomgå en sådan operation skulle innebära för just denna patient med sin unika riskfaktorprofil.
Appendix 4
From: Viktor Sharan Date: 2020/04/21
To,
Editor-in-Chief: Professor J. W. Y. Lau, International Journal of Surgery
Dear Editor,
I, Viktor Sharan, on behalf of my co‐authors submit the following manuscript titled Hospital
Admission and Emergency Department Visit After Bariatric Surgery, a 2-Year Follow Up for
publication consideration. The primary aim was to assess the number of ED visits and admissions as well as examine if there is a correlation to comorbidities, education level, quality of life and imaging method used. We found that out of the 190 study participants,
• 116 (61%) had visited the ED at least one time and 76 (40%) had been admitted at least one time.
• The most common diagnosis group for visiting the ED and being admitted was symptoms from digestive system and abdomen.
• Poor mental health, low education level and smoking are positively correlated for admittance to the hospital.
The secondary aim was to compare the use of ED and admission rate between the cohort and the general population. In this regard we found that a large proportion of the study population has visited the ED or been admitted compared to the general population. But it was not the patient’s comorbidities that drove them to the ED.
I understand the objectives of the journal and have formatted the manuscript to fit the style and needs of the journal. I confirm that the manuscript has been prepared for and sent only to the International Journal of Surgery for publication consideration and not submitted to any other journal or any other type of publication either by me or any of my co‐authors.
Thanking you, Yours’ sincerely,
Viktor Sharan BA, Department of General Surgery, Faculty of Medicine and Health Örebro University, Örebro, Sweden
Appendix 5
Populärvetenskaplig sammanfattning
Vilken övervikts operation är bäst?
Obesitas är ett växande problem i dagens samhälle och ett ökat antal personer genomgår obesitasoperationer. Tidigare forskning har visat att många av dessa patienter söker akuten eller blir inlagda efter kirurgin. Denna studie undersöker lite närmare varför patienterna söker akuten och vilka diagnoser som det är vanligast att dessa patienter blir inlagda för. Studien har även analyserat diverse faktorer för att utreda ifall det finns någon sjukdom eller tillstånd som ökar risken att söka till akuten eller att bli inlagd på sjukhuset.
Tabell 1. Några olika faktorer som var med i analysen. * Innebär statiskt signifikant (p <0,05).
Slutsatsen var att den vanligaste anledningen till att söka akuten eller att bli inlagd är generell buksmärta. Man kunde se ett samband mellan lägre utbildningsnivå, rökning och sämre mental hälsa i relation till att bli inlagd på sjukhuset. Vad gäller akut besök så kunde man inte visa att det var patienternas andra sjukdomar som var orsaken till att söka
akuten eller ledde till att de blev inlagda. Detta signalerar att den huvudsakliga orsaken till akutbesöken var att de har undergått en stor bukkirurgi. En annan möjlighet är andra bidragande faktorer som inte är kända än.
Framtida studier behövs för att utreda andra riskfaktorer och då möjligtvis se vad som driver patienter till att söka akuten. I framtiden kan detta leda till nya behandlings-rekommendationer som har potentialen att förbättra framtida vård för patienter som opereras med obesitasoperationer.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
sömnapne Diabetes Hypertoni Dyslipidemi Annan
samtidig operation
Dyspepsi Depression ≤9 år 9–12 År > 12 År Ja Män
Utbildning Rökning
Enkla Karakteristiska
Inte inlagd Inlagd
*
