Introduction

Despite bariatric surgery being the only effective method for sustainable weight loss, it remains underutilized at less than 1% of eligible persons [1]. Even more concerning is that of those who initiate the bariatric surgery process; globally, nearly 50% will drop out prior to completing surgery [2,3,4,5,6,7]. Required time intensive workup and number of visits are two of the important factors associated with increased dropout [2, 8].

Telehealth allows patients to access care from their chosen location which can help incorporate health into the lives of patients, especially those who have other household and work responsibilities or who for other reasons have difficulty attending in-person visits. Thus, mechanisms of healthcare delivery like telehealth, which can potentially reduce the burden of visits, may improve follow-through.

The COVID-19 pandemic provided a natural experiment to assess telehealth’s impact on pre-operative bariatric visits. First, best practices limited in-person visits, leading to a large increase in the number of telehealth visits completed globally [9, 10]. This allowed clinicians and patients to become familiar with telehealth as a care delivery modality. Second, countries [10,11,12] and large insurers [13] instituted policies covering telehealth to continue to provide care access without risk of exposure to COVID-19. In this context, we sought to understand telehealth’s impact on pre-operative bariatric visit utilization and provider telehealth experience using a US healthcare system as a case study.

Methods

This study was performed at a large healthcare system caring for a diverse patient population. Using convergent mixed methods design to understand telehealth use (video visits and phone visits) from a healthcare system standpoint, we simultaneously collected data on visit type and provider perspectives [14]. The University of Michigan Institutional Review Board deemed this study exempt given the use of de-identified data.

We quantitatively examined pre-operative workup visits, which are completed in this system by advanced practice providers (APPs) and dieticians. APPs include physician assistants and nurse practitioners who are able to ensure patients are medically, psychologically, and socially optimized for surgery. APPs complete the full initial surgical evaluation; conduct physical exams; order and evaluate testing; refer to specialists such as cardiologists, pulmonologists, psychologists, and social workers when appropriate; and prescribe medications. Dieticians provide longitudinal dietary counseling for patients during the pre-operative process. Visits were classified as an office visit (in-person), phone visit, video visit, or no show. We used Epic Clarity, a reporting database extracted from electronic medical records and validated against manual data pulls, to collect data on visits. We assess contemporary no-show rates versus historical controls (March/April 2020 vs March/April 2019) using chi-square analysis.

For qualitative analysis, all APPs, dieticians, and surgeons were first invited to participate in a focus group to develop an interview guide (Appendix). They were then invited to individual interviews. Interviews were transcribed and then iteratively coded and analyzed using MaxQDA20 (VERBI Software). An inductive method was used to develop themes. All data were collected May-July 2020.

Results

There were 413 APPs and 383 dietician pre-operative visits scheduled in March/April 2020. Figure 1 shows the number and proportion of patient visit types that occurred in March/April 2019 and 2020. No-show rates for all pre-operative visits were 17.2% (2019) and 10.7% (2020), representing a -37.8% difference. Chi-square analysis showed that telehealth implementation in 2020 was significantly associated with decreased no-show rates when compared with 2019 rates (χ2, 10.3; P = .001).

Fig. 1
figure 1

Telehealth use in pre-operative bariatric surgery visits

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Interviews with APPs (n = 3), a dietician (n = 1), and surgeons (n = 4) revealed the following themes. (1) Providers felt that telehealth allowed adequate patient-provider communication. (2) Regarding policy, providers expressed concern that insurance providers would deny authorization for surgery because of the telehealth modality despite unchanged visit content. (3) Providers identified resource limitations for weight measurements. Table 1 demonstrates representative quotes.

Table 1 Provider interview themes and participant quotes
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Discussion

This study found that telehealth implementation was associated with decreased no-show rates compared with prior year data and identifies positive provider experiences in appropriateness and feasibility of telehealth use. Combined, these findings support continued telehealth use which may mitigate patient dropout from the bariatric surgery process, a global phenomenon.

Possible implementation barriers identified by providers were that patient-reported weights may not be reliable and insurance providers would reject data not obtained in-person. However, prior research has found self-reported weights reliable within 1.3 kg (2.7 lbs) among bariatric patients [15]. Thus, our study demonstrates the importance of alternatives like patient-reported weights to maximize telehealth’s potential.

There are several limitations. First, patients participating in telehealth may have been more willing to use telehealth and show than those who chose in-office or delayed care. Second, this study focused on providers. Future analyses are needed of patient perspectives after pandemic precautions resolve. Patient broadband and equipment limitations are also important to consider to ensure equitable access [16]. However, barriers like childcare, work hours, and long travel distances will remain, so telehealth will continue to be an important option for patient care.

Telehealth has the important potential to increase follow-through to surgery by lowering barriers to bariatric care for patients around the globe. The decrease in no-show rate also holds positive implications for healthcare system efficiency in resource utilization. Thus, continued coverage for telehealth is needed. How telehealth impacts insurance authorization for surgery, a major component of feasibility of telehealth use in bariatric surgery, remains unknown. Insurance providers and bariatric accreditation bodies globally should consider accepting telehealth visits and self-reported weights when determining coverage decisions to ensure access for patients.