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Wealth and access to lap surgery

Taiwan: Wealth and access to laparoscopic bariatric surgery

Patients from the high SES had slightly lower length of hospital stay and hospital treatment cost than their counterparts after adjustment

Patients in Taiwan with high socioeconomic status (SES) have a higher chance of undergoing laparoscopic bariatric surgery, compared with those with medium and low SES, according to a paper, ‘A population-based analysis of use and outcomes of laparoscopic bariatric surgery across socioeconomic groups in Taiwan.’, published in the International Journal for Equity in Health. Overall, patients from the high SES had slightly lower length of hospital stay and hospital treatment cost than their counterparts after adjustment.

“The increased likelihood of undergoing laparoscopic bariatric surgery and lower length of hospital stay and hospital treatment cost were noted among morbidly obese patients with higher SES,” the authors write. “This finding suggests there is the need to improve clinical practice and reduce health disparities in the surgical treatment of morbidly obese patients.”

The study was carried out by researchers from the National Taiwan University, Taipei, Kaohsiung Medical University, Kaohsiung, Chang Gung University of Science and Technology, Chiayi, Chi Mei Medical Center, Liouying, and the Taiwan and the Southern Taiwan University of Science and Technology, Tainan, Taiwan.

The authors note that although the annual number of bariatric surgery cases and laparoscopic bariatric surgery has increased over the past few years laparoscopic bariatric surgery is only covered by Taiwan’s National Health Insurance (NHI) payment for surgical fee, ward fee, examination fee, treatment fee and medication fee, but not for some of special material fees of laparoscopic bariatric surgery.

The paper states that the average extra-expenses for laparoscopic bariatric surgery per patient are between NT$150,000-250,000 (approximately US$4,688–7,813). In addition, hospital treatment costs at different hospital levels are reimbursed under the national health insurance system, the highest of which were generally received by medical centres and the lowest of which were received by local hospitals.

The researchers add that although the use of bariatric surgery differs considerably across socioeconomic groups, it is not known whether the choice of laparoscopic bariatric surgery is influenced by SES. Therefore they carried out a population-based dataset to evaluate whether morbidly obese patients with high SES are more likely to undergo laparoscopic bariatric surgery and related outcomes under the national health insurance coverage system.

Study

The retrospective population-based cross-sectional study retrieved data from the Taiwan’s National Health Insurance Research Database between 2004 and 2011, including the inpatient expenditures by admissions, registry for contracted medical facilities, registry for medical personnel and registry for beneficiaries. A total of 3,713 patients with the principal diagnosis code for overweight or obesity and were eligible for bariatric surgery according to Taiwan’s NHIA reimbursement policy. Primary procedure code for bariatric operations, including open gastric bypass surgery (44.31 and 44.39), laparoscopic gastric bypass surgery (44.38), open gastroplasty (44.69), laparoscopic gastroplasty (including laparoscopic vertical banded gastroplasty, 44.68 and laparoscopic adjustable gastric band, 44.95) and sleeve gastrectomy (43.89) [6]. Thirty-five cases (0.9 %) had diagnosis codes for gastrointestinal tract neoplasm (150.0–159.9), inflammatory bowel disease (555.0–556.9) or non-infectious colitis (557.0–558.9) and those underwent emergent procedures were excluded. Therefore, the final sample included 3,678 patients who underwent conventional open or laparoscopic-assisted bariatric surgeries.

The primary outcome was whether or not a patient had laparoscopic bariatric surgery and secondary outcomes measures were the occurrence of surgical complications, length of the hospital stay and hospital treatment cost.

Taiwan’s National Health Insurance (NHI) scheme is financed by wage-based premiums for people with a clearly defined insurable monthly wage and by fixed premiums for people without a defined insurable monthly wage. Therefore, SES was divided into three categories: low (<NT$20,000), medium (NT$20,000–39,999) and high (≥ NT$40,000). Patients without a clearly defined insurable monthly wage were assigned to the same low socioeconomic status group as those people with insurable wage less than NT$20,000.

Outcomes

From the 3,678 patients included in the study who underwent bariatric procedure between 2004 and 2011 in Taiwan, 3,084 cases (83.9%) were received laparoscopic bariatric surgery. The outcome show that patients with high SES (88.1%) had the highest percentage of undergoing LBS than those with medium (84.6%) and low SES (80.2%, p< 0.001). In terms of hospital and surgeon characteristics, high SES patients who underwent bariatric surgery were more likely to be treated at regional hospitals and by high-volume surgeons compared with other SES groups.

In addition, a univariate analysis revealed that morbidly obese patients who had high and medium SES were more likely to undergo laparoscopic bariatric surgery than those with low SES. However, except for the age, gender, geographic location and CCI score of patients, the hospital accreditation and surgical volume were also significant predictors of undergoing LBS.

After adjusting for patient demographics, hospital and surgeon characteristics, the multivariate analysis revealed that the highest probability of undergoing laparoscopic bariatric surgery was noted in patients with high SES (OR = 1.48, 95 % CI 1.13–1.95, p=0.004), followed by those with medium SES (OR = 1.28, 95 % CI 1.04–1.58, p=0.022). The probability of undergoing LBS was significantly higher among patients who were living or working in the central and southern regions than those who were living or working in the northern region. In addition, after adjustment, patients who underwent laparoscopic bariatric surgery were more frequently treated at regional and district hospitals than at medical centres. Surgeons with high-volume practice had higher likelihood of performing laparoscopic bariatric surgery than those with low-volume practice.

In addition, medium SES patients were less likely to experience surgical related complications compared with those with low SES ((OR = 0.65, 95 % CI 0.47–0.89, p=0.007). High SES patients had significantly lower LOS (OR = 0.90, 95 % CI 0.82–0.99, p=0.046) and hospital treatment cost (OR = 0.93, 95 % CI 0.87–0.99, p=0.046) than their counterparts (Table 1).

Table 1: Distribution and multivariate analyses of in-hospital outcomes of bariatric surgery by socioeconomic status (SES) groups in Taiwan

“This study offers evidence that patient’s SES appeared to influence the use of LBS. However, patients’ clinical conditions and surgeons’ practice patterns may also explain the variation in the approaches to laparoscopic bariatric surgery,” the researchers conclude. “We did note that higher SES was associated with increased odds of undergoing laparoscopic bariatric surgery, which may suggest there is the need to improve clinical practice and reduce health disparities in the surgical treatment of morbidly obese patients.”

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