All Publications

  • Comparison of Outpatient Satisfaction Survey Scores for Asian Physicians and Non-Hispanic White Physicians. JAMA network open Garcia, L. C., Chung, S., Liao, L., Altamirano, J., Fassiotto, M., Maldonado, B., Heidenreich, P., Palaniappan, L. 2019; 2 (2): e190027


    Patient satisfaction scores are used to inform decisions about physician compensation, and there remains a lack of consensus regarding the need to adjust scores for patient race/ethnicity. Previous research suggests that patients prefer physicians of the same race/ethnicity as themselves and that Asian patients provide lower satisfaction scores than non-Hispanic white patients.To examine whether Asian physicians receive less favorable patient satisfaction scores relative to non-Hispanic white physicians.This population-based survey study used data from Press Ganey Outpatient Medical Practice Surveys collected from December 1, 2010, to November 30, 2014, which included 149?775 patient survey responses for 962 physicians. Every month, 5 patients per physician were randomly selected to complete a satisfaction survey after an outpatient visit. Hierarchical multivariable logistic regression was used to examine the association between Asian race/ethnicity of the physician and racial/ethnic concordance of the patient with the probability of receiving the highest score on the survey item rating the likelihood to recommend the physician. Statistical analysis was performed from April 2 to August 27, 2018.Physician characteristics included race/ethnicity, sex, years in practice, and proportion of Asian patient responders. Patient characteristics included race/ethnicity, sex, age, and language spoken.The highest score (a score of 5 on a 1-5 Likert scale, where 1 indicates very poor and 5 indicates very good) on the survey item rating the likelihood to recommend the physician on the Press Ganey Outpatient Medical Practice Survey.Of the 962 physicians in this study, 515 (53.5%) were women; physicians had a mean (SD) of 19.9 (9.1) years of experience since graduating medical school; 573 (59.6%) were white, and 350 (36.4%) were Asian. In unadjusted analyses, the odds of receiving the highest score on the survey item rating the likelihood to recommend the physician were lower for Asian physicians compared with non-Hispanic white physicians (odds ratio, 0.78; 95% CI, 0.72-0.84; P?

    View details for PubMedID 30794297

  • The association between Asian patient race/ethnicity and lower satisfaction scores. BMC health services research Liao, L., Chung, S., Altamirano, J., Garcia, L., Fassiotto, M., Maldonado, B., Heidenreich, P., Palaniappan, L. 2020; 20 (1): 678


    BACKGROUND: Patient satisfaction is increasingly being used to assess, and financially reward, provider performance. Previous studies suggest that race/ethnicity (R/E) may impact satisfaction, yet few practices adjust for patient R/E. The objective of this study is to examine R/E differences in patient satisfaction ratings and how these differences impact provider rankings.METHODS: Patient satisfaction survey data linked to electronic health records from two large outpatient centers in northern California - a non-profit organization of community-based clinics (Site A) and an academic medical center (Site B) - was collected and analyzed. Participants consisted of adult patients who received outpatient care at Site A from December 2010 to November 2014 and Site B from March 2013 to August 2014, and completed Press-Ganey Medical Practice Survey questionnaires (N=216,392 (Site A) and 30,690 (Site B)). Self-reported non-Hispanic white (NHW), Black, Latino, and Asian patients were studied. For six questions each representing a survey subdomain, favorable ratings were defined as top-box ("very good") compared to all other categories ("very poor," "poor," "fair," and "good"). Using multivariable logistic regression with provider random effects, we assessed whether the likelihood of giving favorable ratings differed by patient R/E, adjusting for patient age and sex.RESULTS: Asian, younger and female patients provided less favorable ratings than other R/E, older and male patients. After adjustment, Asian patients were less likely than NHW patients to provide top-box ratings to the overall assessment question "likelihood of recommending this practice to others" (Site A: Asian predicted probability (PP) 0.680, 95% confidence interval (CI): 0.675-0.685 compared to NHW PP 0.820, 95% CI: 0.818-0.822; Site B: Asian PP 0.734, 95% CI: 0.733-0.736 compared to NHW PP 0.859, 95% CI: 0.859-0.859). The effect sizes for Asian R/E were greater than the effect sizes for older age and female sex. An absolute 3% decrease in mean composite score between providers serving different percentages of Asian patients translated to an absolute 40% drop in national ranking.CONCLUSIONS: Patient satisfaction scores may need to be adjusted for patient R/E, particularly for providers caring for high panel percentages of Asian patients.

    View details for DOI 10.1186/s12913-020-05534-6

    View details for PubMedID 32698825

  • Preoperative weight loss: is waiting longer before bariatric surgerymore effective? Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery Eng, V., Garcia, L., Khoury, H., Morton, J., Azagury, D. 2019


    BACKGROUND: Many insurance companies require patients to undergo supervised weight loss programs lasting several months. However, the association between time to surgery (TTS)-the wait time between the initial consultation visit and the immediate preoperative visit-and weight loss is not well documented.OBJECTIVES: To investigate whether TTS affects pre- or postoperative weight loss or complication rates.SETTING: University hospital, United States.METHODS: Data from 415 patients undergoing laparoscopic Roux-en-Y gastric bypass (n = 263) or sleeve gastrectomy (n = 152) at a single academic institution between 2014 and 2015 were retrospectively reviewed. TTS was compared with the percentage of total weight lost, change in body mass index, and adverse surgical events.RESULTS: Participants had an average body mass index of 47.42 kg/m2 at the consultation visit and TTS ranged from 7 to 1813 days with an average wait of 209.23 days. There was a statistically significant negative correlation between TTS and preoperative percentage of total weight lost among gastric bypass patients (b = -.005; P = .0492 2-tailed). A similar inverse relationship was identified among sleeve gastrectomy patients. Extended TTS provided no significant long-term benefits in weight loss by 24 months. No significant difference in rates of complications or readmissions was identified.CONCLUSIONS: Longer preoperative wait times do not result in improved weight loss or reducedadverse events. Determination of patient eligibility for bariatric surgery should rest with the health team and delay of treatment should be minimized.

    View details for DOI 10.1016/j.soard.2019.03.012

    View details for PubMedID 31104959

  • The Impact of Ethnicity on Metabolic Outcomes after Bariatric Surgery. The Journal of surgical research Valencia, A., Garcia, L. C., Morton, J. 2019; 236: 345?51


    BACKGROUND: Previous studies have demonstrated that ethnic minority patients experience significant metabolic improvements after bariatric surgery but less so than non-Hispanic whites. Previous research has primarily investigated differences between non-Hispanic white and black patients. Thus, there remains a need to assess differences in diabetic outcomes among other ethnic groups, including Hispanic and Asian patient populations.MATERIALS AND METHODS: A retrospective analysis including 650 patients with type II diabetes mellitus (T2DM), who underwent either laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy (LSG) procedures, was conducted to understand ethnic disparities in diabetic metabolic outcomes, including weight loss, serum concentrations of glucose, fasting insulin, and hemoglobin A1c (HbA1c). Data were from a single academic institution in northern California. Ethnicity data were self reported. T2DM was defined as having one or more of the following criteria: a fasting glucose concentration >125mg/dL, HbA1c >6.5%, or taking one or more diabetic oral medications. Diabetes resolution was defined as having a fasting glucose <125mg/dL, a HbA1c <6.5%, and discontinuation of diabetic oral medications.RESULTS: Within-group comparisons in all ethnic groups showed significant reductions in body mass index, body weight, fasting insulin, fasting glucose, and HbA1c by 6mo, but Asian patients did not experience further improvement in body mass index or diabetic outcomes at the 12-mo visit. Black patients did not experience additional reductions in fasting insulin or glucose between the 6- and 12-mo visit and their HbA1c significantly increased. Nevertheless, the majority of patients had diabetes remission by the 12-mo postoperative visit (98%, 97%, 98%, and 92% in Non-Hispanic, Hispanic, black, and Asian, respectively).CONCLUSIONS: The results of this study demonstrate that bariatric surgery serves as an effective treatment for normalizing glucose metabolism among patients with T2DM. However, this study suggests that additional interventions that support black and Asian patients with achieving similar metabolic outcomes as non-Hispanic white and Hispanic patients warrant further consideration.

    View details for DOI 10.1016/j.jss.2018.09.061

    View details for PubMedID 30694776

  • The Comparative Effect of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy on 10-Year and Lifetime Atherosclerotic Cardiovascular Disease Risk. Obesity surgery Raygor, V., Garcia, L., Maron, D. J., Morton, J. M. 2019


    Bariatric surgery reduces atherosclerotic cardiovascular disease (ASCVD) risk. However, the comparative effect of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) on 10-year and lifetime ASCVD risk, as defined by the American College of Cardiology/American Heart Association (ACC/AHA), remains unknown.Using the ACC/AHA ASCVD risk estimator, 10-year and lifetime ASCVD risks were calculated before and 1 year after bariatric surgery for patients aged 40-78 who underwent RYGB or SG at an academic medical center in California between 2003 and 2015. Change in risk was calculated by taking the difference between 1-year and baseline risk. Statistical analyses included the Wilcoxon signed rank test, Mann-Whitney U test, Quade's test, and multiple logistic regression.There were 536 patients (mean age 52?±?10 years, 20% male), of whom 438 underwent RYGB and 98 underwent SG. Patients undergoing RYGB were predominately female (82% vs 71%, p?=?0.021) and had higher baseline BMIs (44.4?±?8.4 vs 41.9?±?8.0, p?

    View details for DOI 10.1007/s11695-019-03948-8

    View details for PubMedID 31115847

  • Heterogeneity of weight loss after gastric bypass, sleeve gastrectomy, and adjustable gastric banding. Surgery Azagury, D., Mokhtari, T. E., Garcia, L., Rosas, U. S., Garg, T., Rivas, H., Morton, J. 2018


    BACKGROUND: Laparoscopic Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic adjustable gastric banding all lead to substantial weight loss in obese patients. Long-term weight loss can be highly variable beyond 1-year postsurgery. This study examines and compares the frequency distribution of weight loss and lack of treatment effect rates after laparoscopic Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic adjustable gastric banding.METHODS: A total of 1,331 consecutive patients at a single academic institution were reviewed from a prospectively collected database. Preoperative data collected included demographics, body mass index, and percent excess weight loss. Postoperative BMI and %EWL were collected at 12, 24, and 36 months. Percent excess weight loss was analyzed by the percentiles of excess weight lost, and the distribution of percent excess weight loss was evaluated in 10% increments. Lack of a successful treatment effect was defined as <25% excess weight loss.RESULTS: Of the 1,331 patients, 72.4% (963) underwent laparoscopic Roux-en-Y gastric bypass, 18.3% (243) laparoscopic sleeve gastrectomy, and 9.4%(125) laparoscopic adjustable gastric banding. Mean percent excess weight loss was greatest for laparoscopic Roux-en-Y gastric bypass, followed by laparoscopic sleeve gastrectomy, and then by laparoscopic adjustable gastric banding at every time point: at 2 years mean percent excess weight loss was 77.9± 24.4 for laparoscopic Roux-en-Y gastric bypass, 50.8 ± 25.8 for laparoscopic sleeve gastrectomy, and 40.8± 25.9 for laparoscopic adjustable gastric banding (P < .0001). The rates of a successful treatment effect s for laparoscopic Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic adjustable gastric banding were 0.9%, 5.2%, and 24.3% at 1 year; 0.3%, 11.1%, and 26.0% at 2 years; and 1.0%, 25.3%, and 30.2% at 3 years. At 1 year, the odds ratio of lack of a successful treatment effect of laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass was 6.305 (2.125-19.08; P?=?.0004), the odds ratio for laparoscopic adjustable gastric banding versus laparoscopic Roux-en-Y gastric bypass was 36.552 (15.64-95.71; P < .0001), and the odds ratio for laparoscopic adjustable gastric banding versus laparoscopic sleeve gastrectomy was 5.791 (2.519-14.599; P < .0001). At 2 years, the odds ratio for laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass increased to 70.7 (9.4-531.7; P < .0001), the odds ratio for laparoscopic adjustable gastric banding versus laparoscopic Roux-en-Y gastric bypass increased to 128.1 (16.8-974.3; P < .0001), and the odds ratio for laparoscopic adjustable gastric banding versus laparoscopic sleeve gastrectomy decreased to 1.8 (0.9-3.6; P?=?.09).CONCLUSION: This study emphasizes the existing variability in weight loss across bariatric procedures as well as in the lack of a treatment effect for each procedure. Although laparoscopic adjustable gastric banding has the greatest rate of a lack of a successful treatment effect, the rate remained stable over 3 years postoperatively. Laparoscopic sleeve gastrectomy showed a doubling in the rate of a lack of a successful treatment effect every year reaching 25% at year 3. The rates for lack of a successful treatment effect for laparoscopic Roux-en-Y gastric bypass remained stable at about 1% for the first 3 years postoperatively.

    View details for PubMedID 30316577

  • Surgical Outcomes after Laparoscopic Sleeve Gastrectomy and Gastric Bypass: Findings from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Garcia, L. C., Azagury, D. E., Rivas, H., Morton, J. M. ELSEVIER SCIENCE INC. 2018: S28
  • Does Urinary Bisphenol-A Change after Bariatric Surgery? Journal of the American College of Surgeons Dambkowski, C. L., Garcia, L., Leva, N., Morton, J. M. 2018


    BACKGROUND: One of the world's highest volume chemicals is bisphenol-A (BPA), an organic compound with a high solubility in fat. An emerging body of literature has suggested a link between BPA, obesity, and insulin resistance. The study aim was to determine if surgical weight loss is associated with changes in BPA levels.STUDY DESIGN: Demographic, preoperative, and 3-, 6-, and 12-month postoperative urine and laboratory data were prospectively collected on 22 bariatric surgery patients at a single academic institution. Laboratory values included hemoglobin A1C, fasting insulin, and fasting glucose. Demographic, preoperative and postoperative data, and urinary BPA levels were compared using Student's t-tests and simple regression analyses using GraphPad Prisim6 software.RESULTS: Patients were predominantly privately insured (86%), female (83%), and white (68%). Urinary BPA excretion was negatively correlated with weight at 6 months (r= -0.47, p=0.029) and 12 months (r= -0.65, p= 0.006). The average weight before surgery was 274 pounds. Average preoperative BPA excretion was 2.4 ng/mL (SD= 1.0 ng/mL) in patients lighter than average weight and 1.3 ng/mL (SD= 0.7 ng/mL) in patients heavier than average weight (p= 0.006). Average BPA excretion at 12 months was 2.5 ng/mL (SD=2.2 ng/mL) among lighter patients and 0.58 ng/mL (SD= 0.4 ng/mL) among heavier patients (p= 0.05). Follow-up included 18 patients at 3 months, 22 patients at 6 months, and 16 patients at 12 months. Higher urinary excretion of BPA preoperatively correlated with lower 6-month patient weight (r= -0.557, p= 0.025). Higher preoperative fasting insulincorrelated significantly with reduced BPA excretion at 6 months postoperatively (r=-0.5366, p= 0.032).CONCLUSIONS: Excretion of BPA increases as bariatric surgery patients lose weight. Heavier patients with insulin resistance may store more BPA in adipose tissue and therefore excrete less BPA.

    View details for PubMedID 29753982

  • Changes in Cerebral Cortical Thickness Related to Weight Loss Following Bariatric Surgery. Obesity surgery Bohon, C., Garcia, L. C., Morton, J. M. 2018


    Cerebral cortical thickness is associated with memory and intelligence test scores and serves as a measure for changes in cortical gray matter. Previous studies suggest reduced cortical thickness in patients with obesity. This study aimed to investigate changes in cortical thickness following bariatric surgery. Magnetic resonance imaging (MRI) data of five patients were analyzed preoperatively and 6 months postoperatively to assess changes in global measures of cortical thickness. No patients were lost to follow-up. This study provides preliminary evidence of brain change following surgery, suggests increases in cerebral cortical thickness in patients with greater excess weight loss, and indicates the need for further investigation using larger samples and correlation with neurocognitive measures, such as memory recall.

    View details for PubMedID 29876838

  • Comorbidity Remission Following Intragastric Dual Balloon Placement. Obesity surgery Garcia, L., Vajanaphanich, S., Morton, J. M. 2018


    The intragastric dual balloon was FDA approved in 2015 for the treatment of obesity. The objective of this study was to report the weight loss, comorbidity remission, and biochemical improvements experienced by 28 patients following intragastric dual balloon placement at a single institution between September 2015 and June 2017. Demographic data were collected preoperatively. Anthropometric, clinical, and biochemical data were collected preoperatively and 3 and 6 months postoperatively. Two patients were lost to data follow-up. Participants experienced significant improvements in blood pressure and lipid profiles, in addition to substantial weight loss 6 months after balloon insertion. The results of this study underscore the promise of the intragastric dual balloon as an efficacious intervention for weight loss and comorbidity remission in patients with early-stage obesity.

    View details for PubMedID 30382461

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