Preventing Hospital Readmissions in Bariatric Surgery Patients

Psychologist suggests red flags in Cleveland Clinic study

Bariatric surgery patients may present with red flags that could lead to readmissions after surgery, according to Leslie J. Heinberg, PhD, MA, Director of Behavioral Sciences at Cleveland Clinic’s Bariatric and Metabolic Institute. In a study she presented at Obesity Week 2016, a joint meeting of The Obesity Society and the American Society for Metabolic and Bariatric Surgery, in New Orleans Oct. 31 to Nov. 4, Dr. Heinberg found that one third of patients who were readmitted to the hospital within 30 days of bariatric surgery had vague, nonspecific complaints, such as nausea or pain.

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“We know that bariatric surgery patients are a psychiatrically vulnerable population,” she says. “They are more likely to have psychiatric difficulties than the population at large and even compared to patients with obesity who are not seeking surgery, and so these readmissions may be related to psychological issues.”

Study design

In the retrospective study, Dr. Heinberg and her colleagues compared 102 patients who were evaluated by Cleveland Clinic’s bariatric team and readmitted within 30 days after surgery from 2012 to 2015 to 204 gender- and age-matched nonreadmitted patients. Overall, they found that patients who were readmitted had less education, were less likely to be receiving outpatient psychiatric care, and were taking fewer psychiatric medications compared to nonreadmitted patients. Upon further analysis, those who were readmitted for vague, nonspecific reasons, such as complaints of pain or nausea, or reasons related to nonadherence, such as misuse of medications or dehydration, were significantly younger (average 43 years versus 49 years) and female than those who were readmitted for surgical complications, such as a leak, infection or deep vein thrombosis. There were no differences between the readmitted and nonreadmitted patients in terms of psychiatric diagnoses or binge eating.

A look at the findings

Contrary to the team’s hypothesis that readmitted patients would be healthier than nonreadmitted patients, they uncovered evidence that these patients may actually be less healthy psychologically. “We hypothesized that it was a healthy group because they weren’t getting treatment or on medications,” she says, “but it turned out there was a trend toward many of them having an inpatient psychiatric admission in their past. So perhaps they weren’t getting appropriate treatment, and then they underwent bariatric surgery, which is a major stressor.”

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The team also found significant differences in scores on the Uncommon Virtues subscale of the Minnesota Multiphasic Personality Inventory-Restructured Form (MMPI-2-RF), which is a measure of under-reporting at lower levels and “faking good” at higher ones. “Nonspecific readmissions were related to people who were really under-reporting their distress, saying ‘Nothing is wrong with me,’” Dr. Heinberg says. “And if they are under-reporting on psychological testing, then they are probably under-reporting to the bariatric team about medical and psychiatric issues. They have a style of denying everything, or saying they’re adherent — taking vitamins, using their CPAP — when they’re not, which makes it harder for the medical team to identify what’s happening with them.”

The key take-aways from the study, according to Dr. Heinberg, are that if “you see a younger woman or someone with a psychiatric history who says everything is great, consider that a red flag for readmission after bariatric surgery. These patients will need more discharge monitoring and follow-up phone calls.” If a surgical candidate is found to have a history of psychiatric hospitalization, it is also advisable for clinicians to order their inpatient records for further evaluation, and advise patients to create a strong mental health safety net before undergoing surgery.