Improved bariatric surgery outcomes not due to restricted Medicare coverage

Mar 6 2013

By Peter Sergo, medwireNews Reporter

Substantial improvements in perioperative outcomes of bariatric surgery over the past decade are not attributable to a restriction in Medicare coverage to patients receiving the weight loss operation at centers of excellence (COEs), report researchers.

Moreover, outcomes were not contingent on whether Medicare patients had undergone bariatric surgery before or after the Centers for Medicare and Medicaid (CMS) implemented a policy in 2006 that restricts coverage to COEs, they add.

"Combined with prior studies showing no association of COE designation and outcomes, these results suggest that Medicare should reconsider this policy," write Justin Dimick (University of Michigan, Ann Arbor, USA) and colleagues. "The absence of a COE effect could result from a lack of evidence-based COE criteria."

As reported in JAMA, Dimick at al conducted a retrospective, longitudinal study using 2004-2009 hospital discharge data from 12 states to compare outcomes of 6723 Medicare patients who underwent bariatric surgery before the policy was implemented with15,854 who did so afterwards. A difference-in-differences analysis compared these patients to pre- and post-policy non-Medicare patients.

Once patient factors, changes in procedure type, and pre-existing time trends toward improved outcomes were accounted for, the policy implementation was found to have played no significant role in the observed improvement in outcomes; complications (8.0% after and 7.0% before policy change), serious complications (3.3 and 3.6%), and reoperations (3.3 and 3.6%) were largely unaffected.

A direct comparison between COE designated hospitals to those without the accreditation also failed to find any significant difference in outcomes; complications (53.5 and 6.0%, respectively), serious complications (2.2 and 2.5%) and reoperation (0.83 and 0.96%).

"Rather than the CMS policy restricting bariatric surgery to COEs, we found that the improvement in outcomes over time could be explained in part by the evolution away from higher risk towards lower risk procedures," explain the authors.

The researchers note that a shift away from open to less invasive laparoscopic surgery as well as an increase in the use of laparoscopic gastric binding have made the procedure safer.

Dimick and team's study, along with others, has motivated the CMS to re-evaluate the need for bariatric surgery COEs, writes Caprice Greenberg (University of Wisconsin, Madison) in an accompanying editorial. "[T]here is an opportunity… to catapult surgical outcomes science forward… and to design a program that can not only identify high-quality hospitals, but also provide a sustained mechanism for quality improvement," she writes.

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