After Medicare rule change, fewer facilities performed bariatric surgeries but outcomes improved

Following a rule expanding coverage of weight-loss surgery under Medicare, bariatric procedures in the Medicare population were centralized to a smaller number of certified centers, were more likely to be minimally invasive and were associated with improved outcomes, according to a report in the January issue of Archives of Surgery, one of the JAMA/Archives journals.

"The number of bariatric procedures performed in the United States increased from 12,775 in 1998 to 70,256 in 2001. The increase in bariatric surgery resulted in increasing scrutiny by third-party payers and the media with regard to the safety of bariatric surgery," according to background information in the article. Recent studies suggest that the 30-day mortality rate for patients undergoing gastric bypass is higher than previously reported (1.9 percent to 2 percent). "Although the beneficial effects of bariatric surgery have been well documented, the higher perioperative death rate from these recent reports is concerning, particularly for the population of patients with high-risk medical disability."

In February 2006, the Centers for Medicare and Medicaid Services issued a national coverage determination (NCD) for bariatric surgery. Under the NCD, Medicare began covering bariatric procedures for patients older than age 65 at institutions certified by the American College of Surgeons (ACS) or the American Society for Metabolic and Bariatric Surgery (ASMBS). These institutions must perform at least 125 operations per year and meet a number of other qualifications, including special equipment, trained surgeons and staff and a system for long-term follow-up.

Ninh T. Nguyen, M.D., of the University of California, Irvine Medical Center, Orange, and colleagues compared outcomes and volumes of bariatric surgical procedures performed on Medicare and Medicaid patients within the 18 months before and after NCD implementation in 102 academic medical centers and 150 of their affiliated hospitals from 2004 to 2007. Demographics, length of stay, illness, 30-day readmission, observed-to-expected death ratio and costs were noted.

During the study period, a total of 6,264 patients underwent bariatric surgery to treat morbid obesity. Of these, 3,196 had the surgery before NCD implementation and 3,068 had the surgery after NCD implementation.

"After the implementation of the NCD, the volume of gastric banding doubled and the proportion of laparoscopic gastric bypass increased from 60 percent to 77.2 percent. Patients who underwent bariatric surgery after the NCD benefited from a shorter length of stay (3.5 days vs. 3.1 days) and lower overall complication rates (12.2 percent vs. 10 percent), with no significant differences in the in-hospital mortality rates (0.28 percent vs. 0.2 percent)," the authors write.

Although the number of bariatric surgeries performed remained approximately the same, the number of facilities performing them decreased from 60 to 45, reflecting a shift to high-volume, certified centers. Patients tend to do better when their procedures are performed at high-volume centers or when they receive laparoscopic bariatric surgery, which can only be performed at facilities certified by the ACS or ASMBS, the authors note.

"Although we only examined the Medicare beneficiaries population in this analysis, we suspect that the improvement in outcomes will also be extrapolated to the population that is not eligible for Medicare," they conclude.