title: Analysis of patient attrition in a publicly funded bariatric surgery program.
abstract: BACKGROUND
  Obesity is a global epidemic, and several surgical programs have been created to combat this public health issue. Although demand for bariatric surgery has grown, so too has the attrition rate. In this study we identify patient characteristics and operational interventions that have contributed to high attrition in a multistage, multidisciplinary bariatric surgery program.
  
  
  METHODS
  A retrospective study was conducted of 1,682 patients referred for bariatric surgery at the University Health Network in Toronto, Canada, from June 2008 to July 2011. Demographic information, presurgical assessment dates, and records describing operational changes were collected. Several penalized likelihood and mixed effects multivariable logistic regression models were used to determine whether patient characteristics, operational changes, and previous experience affected program completion and intermediate transitions between assessments.
  
  
  RESULTS
  Although the majority of attrition appears to be the result of patient self-removal, males (odds ratio [OR] 0.511, 95% CI 0.392 to 0.663, p < 0.001), and individuals with active substance use (OR 0.223, 95% CI 0.096 to 0.471, p < 0.001) were less likely to undergo surgery. Operational practices had a detrimental effect on program completion (OR 0.590, 95% CI 0.456 to 0.762, p < 0.001). Conversely, patients with a BMI > 40 kg/m(2) (OR 1.756, 95% CI 1.233 to 2.515, p = 0.002) and those who lived within 25 to 300 km of the center (OR > 1.633, p < 0.001) were more likely to undergo surgery.
  
  
  CONCLUSIONS
  Certain subgroups in the referral population were found to be at a higher risk of noncompletion. Specialized care pathways must be implemented to address this issue. Furthermore, careful consideration must be given to operational decisions because they may negatively affect access to care, as we have shown.
authors.affiliation: Rotman School of Management, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Adam
authors.initials: A
authors.lastname: Diamant
authors.affiliation: Rotman School of Management, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Joseph
authors.initials: J
authors.lastname: Milner
authors.affiliation: Division of General Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Michelle
authors.initials: M
authors.lastname: Cleghorn
authors.affiliation: Department of Psychiatry, University Health Network, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Sanjeev
authors.initials: S
authors.lastname: Sockalingam
authors.affiliation: Division of General Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Allan
authors.initials: A
authors.lastname: Okrainec
authors.affiliation: Division of General Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Timothy D
authors.initials: TD
authors.lastname: Jackson
authors.affiliation: Division of General Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada. Electronic address: fayez.quereshy@uhn.ca.
authors.forename: Fayez A
authors.initials: FA
authors.lastname: Quereshy
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D050110:Bariatric Surgery / Q000191:economics / Q000706:statistics & numerical data*; D015331:Cohort Studies; D005260:Female; D005380:Financing, Government; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009313:National Health Programs; D009765:Obesity / Q000601:surgery*; D009767:Obesity, Morbid / Q000601:surgery; D009864:Ontario; D010352:Patient Dropouts / Q000706:statistics & numerical data*; D012017:Referral and Consultation; D012189:Retrospective Studies; D016312:Treatment Refusal / Q000706:statistics & numerical data*