Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence

Justin B. Dimick, Lauren Nicholas, Andrew M. Ryan, Jyothi R. Thumma, John D. Birkmeyer

Research output: Contribution to journalArticle

Abstract

Importance: Starting in 2006, the Centers for Medicare & Medicaid Services (CMS) has restricted coverage of bariatric surgery to hospitals designated as centers of excellence (COE) by 2 major professional organizations. Objective: To evaluate whether the implementation of the COE component of the national coverage decision was associated with improved bariatric surgery outcomes in Medicare patients. Design, Setting, and Patients: Retrospective, longitudinal study using 2004-2009 hospital discharge data from 12 states (n=321 464 patients) of changes in outcomes in Medicare patients undergoing bariatric surgery (n=6723 before and n=15 854 after implementation of the policy). A difference-in-differences analytic approach was used to evaluate whether the national coverage decision was associated with improved outcomes in Medicare patients above and beyond existing time trends in non-Medicare patients (n=95 558 before and n=155 117 after implementation of the policy). Main Outcome Measures: Risk-adjusted rates of any complication, serious complications, and reoperation. Results: Bariatric surgery outcomes improved during the study period in both Medicare and non-Medicare patients; however, this change was already under way prior to the CMS coverage decision. After accounting for patient factors, changes in procedure type, and preexisting time trends toward improved outcomes, there were no statistically significant improvements in outcomes after (vs before) implementation of the CMS national coverage decision for any complication (8.0% after vs 7.0% before; relative risk [RR], 1.14 [95% CI, 0.95-1.33]), serious complications (3.3% vs 3.6%, respectively; RR, 0.92 [95% CI, 0.62-1.22]), and reoperation (1.0% vs 1.1%; RR, 0.90 [95% CI, 0.64-1.17]). In a direct assessment comparing outcomes at hospitals designated as COEs (n=179) vs hospitals without the COE designation (n=519), no significant differences were found for any complication (5.5% vs 6.0%, respectively; RR, 0.98 [95% CI, 0.90-1.06]), serious complications (2.2% vs 2.5%; RR, 0.92 [95% CI, 0.84-1.00]), and reoperation (0.83% vs 0.96%; RR, 1.00 [95% CI, 0.86-1.17]). Conclusions and Relevance: Among Medicare patients undergoing bariatric surgery, there was no significant difference in the rates of complications and reoperation before vs after the CMS policy of restricting coverage to COEs. Combined with prior studies showing no association of COE designation and outcomes, these results suggest that Medicare should reconsider this policy.

Original languageEnglish (US)
Pages (from-to)792-799
Number of pages8
JournalJournal of the American Medical Association
Volume309
Issue number8
DOIs
StatePublished - Feb 27 2013
Externally publishedYes

Fingerprint

Bariatric Surgery
Medicare
Reoperation
Outcome Assessment (Health Care)
Medicaid
Longitudinal Studies
Retrospective Studies

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence. / Dimick, Justin B.; Nicholas, Lauren; Ryan, Andrew M.; Thumma, Jyothi R.; Birkmeyer, John D.

In: Journal of the American Medical Association, Vol. 309, No. 8, 27.02.2013, p. 792-799.

Research output: Contribution to journalArticle

@article{6f1207c4e68744ba921e875a691b2aca,
title = "Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence",
abstract = "Importance: Starting in 2006, the Centers for Medicare & Medicaid Services (CMS) has restricted coverage of bariatric surgery to hospitals designated as centers of excellence (COE) by 2 major professional organizations. Objective: To evaluate whether the implementation of the COE component of the national coverage decision was associated with improved bariatric surgery outcomes in Medicare patients. Design, Setting, and Patients: Retrospective, longitudinal study using 2004-2009 hospital discharge data from 12 states (n=321 464 patients) of changes in outcomes in Medicare patients undergoing bariatric surgery (n=6723 before and n=15 854 after implementation of the policy). A difference-in-differences analytic approach was used to evaluate whether the national coverage decision was associated with improved outcomes in Medicare patients above and beyond existing time trends in non-Medicare patients (n=95 558 before and n=155 117 after implementation of the policy). Main Outcome Measures: Risk-adjusted rates of any complication, serious complications, and reoperation. Results: Bariatric surgery outcomes improved during the study period in both Medicare and non-Medicare patients; however, this change was already under way prior to the CMS coverage decision. After accounting for patient factors, changes in procedure type, and preexisting time trends toward improved outcomes, there were no statistically significant improvements in outcomes after (vs before) implementation of the CMS national coverage decision for any complication (8.0{\%} after vs 7.0{\%} before; relative risk [RR], 1.14 [95{\%} CI, 0.95-1.33]), serious complications (3.3{\%} vs 3.6{\%}, respectively; RR, 0.92 [95{\%} CI, 0.62-1.22]), and reoperation (1.0{\%} vs 1.1{\%}; RR, 0.90 [95{\%} CI, 0.64-1.17]). In a direct assessment comparing outcomes at hospitals designated as COEs (n=179) vs hospitals without the COE designation (n=519), no significant differences were found for any complication (5.5{\%} vs 6.0{\%}, respectively; RR, 0.98 [95{\%} CI, 0.90-1.06]), serious complications (2.2{\%} vs 2.5{\%}; RR, 0.92 [95{\%} CI, 0.84-1.00]), and reoperation (0.83{\%} vs 0.96{\%}; RR, 1.00 [95{\%} CI, 0.86-1.17]). Conclusions and Relevance: Among Medicare patients undergoing bariatric surgery, there was no significant difference in the rates of complications and reoperation before vs after the CMS policy of restricting coverage to COEs. Combined with prior studies showing no association of COE designation and outcomes, these results suggest that Medicare should reconsider this policy.",
author = "Dimick, {Justin B.} and Lauren Nicholas and Ryan, {Andrew M.} and Thumma, {Jyothi R.} and Birkmeyer, {John D.}",
year = "2013",
month = "2",
day = "27",
doi = "10.1001/jama.2013.755",
language = "English (US)",
volume = "309",
pages = "792--799",
journal = "JAMA - Journal of the American Medical Association",
issn = "0098-7484",
publisher = "American Medical Association",
number = "8",

}

TY - JOUR

T1 - Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence

AU - Dimick, Justin B.

AU - Nicholas, Lauren

AU - Ryan, Andrew M.

AU - Thumma, Jyothi R.

AU - Birkmeyer, John D.

PY - 2013/2/27

Y1 - 2013/2/27

N2 - Importance: Starting in 2006, the Centers for Medicare & Medicaid Services (CMS) has restricted coverage of bariatric surgery to hospitals designated as centers of excellence (COE) by 2 major professional organizations. Objective: To evaluate whether the implementation of the COE component of the national coverage decision was associated with improved bariatric surgery outcomes in Medicare patients. Design, Setting, and Patients: Retrospective, longitudinal study using 2004-2009 hospital discharge data from 12 states (n=321 464 patients) of changes in outcomes in Medicare patients undergoing bariatric surgery (n=6723 before and n=15 854 after implementation of the policy). A difference-in-differences analytic approach was used to evaluate whether the national coverage decision was associated with improved outcomes in Medicare patients above and beyond existing time trends in non-Medicare patients (n=95 558 before and n=155 117 after implementation of the policy). Main Outcome Measures: Risk-adjusted rates of any complication, serious complications, and reoperation. Results: Bariatric surgery outcomes improved during the study period in both Medicare and non-Medicare patients; however, this change was already under way prior to the CMS coverage decision. After accounting for patient factors, changes in procedure type, and preexisting time trends toward improved outcomes, there were no statistically significant improvements in outcomes after (vs before) implementation of the CMS national coverage decision for any complication (8.0% after vs 7.0% before; relative risk [RR], 1.14 [95% CI, 0.95-1.33]), serious complications (3.3% vs 3.6%, respectively; RR, 0.92 [95% CI, 0.62-1.22]), and reoperation (1.0% vs 1.1%; RR, 0.90 [95% CI, 0.64-1.17]). In a direct assessment comparing outcomes at hospitals designated as COEs (n=179) vs hospitals without the COE designation (n=519), no significant differences were found for any complication (5.5% vs 6.0%, respectively; RR, 0.98 [95% CI, 0.90-1.06]), serious complications (2.2% vs 2.5%; RR, 0.92 [95% CI, 0.84-1.00]), and reoperation (0.83% vs 0.96%; RR, 1.00 [95% CI, 0.86-1.17]). Conclusions and Relevance: Among Medicare patients undergoing bariatric surgery, there was no significant difference in the rates of complications and reoperation before vs after the CMS policy of restricting coverage to COEs. Combined with prior studies showing no association of COE designation and outcomes, these results suggest that Medicare should reconsider this policy.

AB - Importance: Starting in 2006, the Centers for Medicare & Medicaid Services (CMS) has restricted coverage of bariatric surgery to hospitals designated as centers of excellence (COE) by 2 major professional organizations. Objective: To evaluate whether the implementation of the COE component of the national coverage decision was associated with improved bariatric surgery outcomes in Medicare patients. Design, Setting, and Patients: Retrospective, longitudinal study using 2004-2009 hospital discharge data from 12 states (n=321 464 patients) of changes in outcomes in Medicare patients undergoing bariatric surgery (n=6723 before and n=15 854 after implementation of the policy). A difference-in-differences analytic approach was used to evaluate whether the national coverage decision was associated with improved outcomes in Medicare patients above and beyond existing time trends in non-Medicare patients (n=95 558 before and n=155 117 after implementation of the policy). Main Outcome Measures: Risk-adjusted rates of any complication, serious complications, and reoperation. Results: Bariatric surgery outcomes improved during the study period in both Medicare and non-Medicare patients; however, this change was already under way prior to the CMS coverage decision. After accounting for patient factors, changes in procedure type, and preexisting time trends toward improved outcomes, there were no statistically significant improvements in outcomes after (vs before) implementation of the CMS national coverage decision for any complication (8.0% after vs 7.0% before; relative risk [RR], 1.14 [95% CI, 0.95-1.33]), serious complications (3.3% vs 3.6%, respectively; RR, 0.92 [95% CI, 0.62-1.22]), and reoperation (1.0% vs 1.1%; RR, 0.90 [95% CI, 0.64-1.17]). In a direct assessment comparing outcomes at hospitals designated as COEs (n=179) vs hospitals without the COE designation (n=519), no significant differences were found for any complication (5.5% vs 6.0%, respectively; RR, 0.98 [95% CI, 0.90-1.06]), serious complications (2.2% vs 2.5%; RR, 0.92 [95% CI, 0.84-1.00]), and reoperation (0.83% vs 0.96%; RR, 1.00 [95% CI, 0.86-1.17]). Conclusions and Relevance: Among Medicare patients undergoing bariatric surgery, there was no significant difference in the rates of complications and reoperation before vs after the CMS policy of restricting coverage to COEs. Combined with prior studies showing no association of COE designation and outcomes, these results suggest that Medicare should reconsider this policy.

UR - http://www.scopus.com/inward/record.url?scp=84874384432&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84874384432&partnerID=8YFLogxK

U2 - 10.1001/jama.2013.755

DO - 10.1001/jama.2013.755

M3 - Article

C2 - 23443442

AN - SCOPUS:84874384432

VL - 309

SP - 792

EP - 799

JO - JAMA - Journal of the American Medical Association

JF - JAMA - Journal of the American Medical Association

SN - 0098-7484

IS - 8

ER -