Medicare’s Coverage of Bariatric Surgery at
Certified Facilities Improved Results
Patients benefited from shorter length of stay,
lower complication rates, no significant change in hospital mortality
rates.
>> Second study finds morbidly obese live longer with
gastric bypass (see below first story)
Jan. 18, 2010 – When Medicare decided to approve
coverage for bariatric weight-loss surgery, the agency also established
a requirement that senior citizens could only be treated at certified
institutions. The results have been better results and more minimally
invasive procedures, according to a report in the January issue of
Archives of Surgery, one of the JAMA/Archives journals.
About 26% of seniors 65 and older in U.S. are
obese, nearly 40% are overweight, putting them at a higher risk for Type
2 diabetes, high blood pressure and heart disease
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.
Second Study
Computer Model Says Morbidly Obese Live Longer with
Gastric Bypass
Jan. 18, 2010 - A computerized model suggests that
most morbidly obese individuals would likely live longer if they had
gastric bypass surgery, according to a report in the January issue of
Archives of Surgery, one of the JAMA/Archives
journals. However, the best decision for individual patients varies
based on factors such as age, increasing body mass index and the
effectiveness of surgery.
An estimated 5.1 percent of the U.S. population is
morbidly obese, often defined as having a body mass index (BMI) of 40 or
higher, according to background information in the article. Previous
evidence suggests that dietary, behavioral and pharmacologic treatments
frequently do not result in meaningful weight loss for individuals in
this group. Bariatric surgery appears to be the only effective therapy
for promoting clinically significant weight loss and improving
obesity-related health conditions for the morbidly obese.
However, the procedure is not without risk,
including in-hospital death.
Daniel P. Schauer, M.D., M.Sc., of the University
of Cincinnati Academic Health Center, and colleagues used two nationally
representative surveys and a recent large observational trial to
construct a model estimating the benefits and risks of gastric bypass
surgery for individuals with morbid obesity. The model included data
from almost 400,000 individuals nationwide to estimate the risk of death
from obesity and its complications; data from 23,281 patients undergoing
bariatric surgery to calculate in-hospital death rates following the
procedures; and outcomes from participants in a seven-year study to
determine the effects of surgery on survival and to calibrate and
validate the model.
According to the resulting model, an average
42-year-old woman with a BMI of 45 would gain an estimated additional
three years of life expectancy as a result of undergoing bariatric
surgery; a 44-year-old man with the same BMI would gain an estimated 2.6
additional years.
Additional analyses revealed that younger women
with higher BMIs are projected to gain the most life expectancy from
surgery. Younger men with higher BMIs might also gain more life
expectancy after surgery, but the gain would be less for men than for
women in each subgroup. "Younger patients have lower surgical risk and
more time over which to realize the benefits of surgery," the authors
write. "For older patients, the gain is smaller, and for some, gastric
bypass surgery will decrease life expectancy."
"The decision analysis presented here is a step
forward in understanding optimal patient selection but also highlights
some of the areas for which better data are needed," they continue. For
instance, the risk-benefit balance changes based on how effective
bariatric surgery is likely to be. More information is needed about how
individual patient characteristics—for example, having diabetes—affect
the efficacy of the procedure.
"In conclusion, while not all patients are
guaranteed a good outcome, our model indicates that gastric bypass
increases life expectancy for most patient subgroups; however, for those
at high surgical risk or in whom efficacy of surgery is likely to be
low, benefit will be minimal," the authors write. "We believe results of
this analysis can be used to better inform both patients' and
physicians' decisions regarding gastric bypass surgery."
Editor's Note: This study was funded by a
grant from the National Institute of Diabetes and Digestive and Kidney
Diseases.
Keep up with the latest news for senior citizens, baby
boomers
Jan. 18, 2010 – When Medicare decided to approve
coverage for bariatric weight-loss surgery, the agency also established
a requirement that senior citizens could only be treated at certified
institutions. The results have been better results and more minimally
invasive procedures, according to a report in the January issue of
Archives of Surgery, one of the JAMA/Archives journals.