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US bariatric procedures

Study reports dramatic shift in US bariatric procedures 2011-2014

The proportion of all outpatient procedures decreased from 76.50% to 50.28% for gastric banding and increased from 7.99% to 40.27% for sleeve gastrectomy between 2011 and 2014

From 2011 to 2014 there was a dramatic change in the type of bariatric surgery procedures performed in the US - although disparities in the use of bariatric surgery regarding gender, race and insurance still exist - according to a review of 74,774 procedures from 436 hospitals for both inpatient and outpatient settings. The paper, ‘Changes in utilization and peri-operative outcomes of bariatric surgery in large U.S. hospital database, 2011-2014,’ by researchers from Greenville Health System, Greenville and Clemson University, Clemson, South Carolina, was published in PlosOne.

The researchers used data from Premier Perspective, one of the largest databases collecting standard hospital discharge files in the US, from all regions of the country from non-teaching hospitals of varying sizes. Patients’ demographic information, diagnosis codes, medication, charges, hospital characteristics, and physician information were included in the Premier Perspective dataset.

Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes were used to identify bariatric procedures and were grouped into 4 categories including: 1) gastric bypass 2) sleeve gastrectomy (3) gastric banding and 4) Other.

From 4,197,408 hospital visits by patients with BMI≥30 in the original dataset, a total of 74,774 bariatric procedures were identified. Gastric bypass was the most common surgery type in 2011 (44.76%) but decreased to the 2nd most common procedure in 2014 (31.28%; p< 0.0001). Gastric banding (100% performed laparoscopically) significantly decreased from 22.75% in 2011 to 5.22% in 2014 (p< 0.0001), but the proportion of sleeve gastrectomy (100% performed laparoscopically) dramatically increased from 13.68% in 2011 to 56.85% (p< 0.0001) and became the most commonly performed procedure in 2014.

The proportion of bariatric surgery procedures performed in outpatient settings decreased from 17.15% in 2011 to 8.11% in 2014 (p< 0.0001). Among all outpatient procedures, the proportion of each surgery type varied across years (Figure 1). For example, the proportion of sleeve gastrectomy increased from 7.99% to 40.72%; but gastric banding decreased from 76.50% to 50.28% between 2011 and 2014.

Figure 1: Proportion of outpatient procedures from 2011 to 2014

The mean age of patients undergoing bariatric surgery increased slightly from 44.77 years  in 2011 to 45.21 years  in 2014 (p=0.001). The percentage of older patients (≥65 years) increased from 5.39% in 2011 to 7.04% in 2014 (P for trend < 0.0001). Overall, the majority of patients were female (78.53%) and non-Hispanic white (65.57%). The percentage of female patients decreased slightly over time (from 78.83% to 77.69%; p=0.03) but the percentage of white patients increased (from 63.10% to 65.19%; p=0.02) from 2011 to 2014. More than half of patients (53.61%) were covered by managed care, but the proportion decreased from 56.14% to 50.31% (p<0.0001).

The proportion of procedures covered by Medicare and Medicaid increased from 15.82% to 19.20% (p<0.0001) and from 11.49% to 13.02% (p<0.0001), respectively. Overall, 31.24% patients had diabetes, 54.33% had hypertension, 37.95% had hyperlipidaemia, 10.21% had chronic liver disease, and 43.37% had sleep apnoea. The prevalence of the comorbidities among surgery patients remained stable over time except for sleep apnoea (42.92% in 2011 vs. 44.31% in 2014; p= 0.05).

The distribution of hospitals by volumes of bariatric procedures changed over time: low-volume hospitals (<50 procedures per year) decreased from 66.90% in 2011 to 54.91% in 2014 and high-volume hospitals (>125 procedures per year) increased from 13.88% to 29.09%. The other hospital characteristics remained consistent over time: teaching hospitals were 31.65%, hospitals with 500+ beds were 16.51%, and urban hospitals were 80.50%.

About half of the procedures were performed in teaching hospitals (decreasing from 52.14% in 2011 to 45.13% in 2014; p<0.0001) and a majority of the procedures were performed in urban hospitals (decreasing from 92.94% in 2011 to 90.68% in 2014; p<0.0001). In 2011, 53.55% of bariatric surgeries were performed in high-volume hospitals and 14.22% were performed in low-volume hospitals.

The gap became wider in 2014, with 79.89% of bariatric surgeries performed in high-volume hospitals and only 6.41% performed in low-volume hospitals. Approximately half (48.28%) of the surgeries were performed in middle-sized hospitals (200–499 beds). The proportion of procedures performed at large hospitals (500+ beds) was consistent over time (33.10% in 2011 and 31.79% in 2014; p=0.45).

The proportion of procedures performed in small hospitals (<200 beds) increased from 16.65% in 2011 to 21.52% in 2014 (p<0.0001) and the proportion of procedures performed in middle-sized hospitals decreased from 50.26% in 2011 to 46.68% in 2014 (p<0.0001).

The overall in-hospital mortality was 0.29% and the average length of hospital stay was 2.55 days. The percentage of systemic complications was 2.94% (pulmonary: 1.43%; cardiac: 0.40%; neurological: 0.04%; urinary tract: 1.51%; thromboembolic: 0.16%; post-operative shock: 0.10%) and did not change significantly over the four-year period. The percentage of haemorrhagic complication decreased from 2.66% in 2011 to 2.36% in 2014 (p0.03) but no significant difference was observed for wound complication (p=0.94).

“To our knowledge, our study is the first to investigate the proportion of outpatient bariatric surgery,” the authors write. “We found that the proportion of all outpatient surgeries decreased from 17.15% to 8.11% between 2011 and 2014. A potential explanation for this could be related to the predominant surgery type in this period. In an outpatient setting, gastric banding was the earliest and most widely accepted surgery type, while sleeve gastrectomy has been suggested to be safe as a new surgery type.”

Approximately, 78.20% of gastric banding surgeries and 5.81% of sleeve gastrectomy surgeries were performed as outpatient procedures in 2014 in the study (data were not shown in Fig 1ure). However, the proportion of all outpatient procedures decreased from 76.50% to 50.28% for gastric banding and increased from 7.99% to 40.27% for sleeve gastrectomy between 2011 and 2014, which reflects the transition of the popularity of bariatric surgery types.

The researchers noted that Medicaid patients are more likely to undergo gastric bypass than privately insured patients and their findings suggest that access to bariatric surgery, particularly for Medicare or Medicaid beneficiaries, did not decrease over the past few years.

“Except for a slight decrease in the proportion of haemorrhagic complication, we did not find changes in hospital mortality and other peri-operational complications. Most procedures are performed in high-volume hospitals,” the authors concluded. “Sex and racial disparities in bariatric surgery appear consistent. Findings from this study points to the direction that effort should be made to increase access to bariatric surgery with regarding to gender, race, and insurance type.”

To access this paper, please click here

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