Choice of bariatric surgery procedure may depend on number of recent procedures
Adults undergoing bariatric surgery are more likely to choose sleeve gastrectomy over gastric bypass if more sleeve gastrectomies were performed in their state during the prior year, according to a study published in JAMA Network Open.
In an analysis of Medicare beneficiaries undergoing bariatric surgery from 2012 to 2017, researchers found the proportion of participants undergoing a sleeve gastrectomy increased from 6.2% in 2012, when Medicare first covered the procedure, to 72.2% in 2017, though utilization rates differed from state to state.
“A patient who just happens to live in a region with high sleeve gastrectomy utilization is more likely to get a sleeve gastrectomy, and a patient who just happens to live in a region with low sleeve gastrectomy utilization is less likely to get a sleeve gastrectomy,” Ryan Howard, MD, a resident in the department of surgery at the University of Michigan, and colleagues wrote.
Researchers conducted a cross-sectional study of 100% fee-for-service Medicare claims for adults undergoing sleeve gastrectomy or gastric bypass from 2012 to 2017. State-level sleeve gastrectomy utilization was used as the instrumental variable, and the strength of validity of the variable was assessed using the Kleibergen-Paap Wald F statistic. Data on mortality, complications, ED visits, hospitalization, reinterventions and revisions 1 year after operation were also collected and assessed.
A total of 76,077 adults underwent bariatric surgery during the study period, with 58.3% undergoing sleeve gastrectomy and 41.7% undergoing gastric bypass.
Among a representative sample of the 10 largest states, New Jersey had the largest increase in sleeve gastrectomy utilization from 7.9% in 2012 to 92.8% in 2017. The state with the smallest increase in sleeve gastrectomy utilization was Ohio, where utilization increased from 10.9% in 2012 to 63.2% in 2017. The prior year’s sleeve gastrectomy utilization was highly associated with adults choosing to have a sleeve gastrectomy in the current year (Kleibergen-Paap Wald F statistic = 910.3).
Adults who underwent sleeve gastrectomy had lower 1-year risks for mortality (0.9% vs. 1.7%), complications (11.6% vs. 14.1%), ED visits (48.3% vs. 53.6%), hospitalization (23.4% vs. 26.5%) and reintervention (8.7% vs. 12.2%) compared with those undergoing gastric bypass. No difference in surgery revision was observed.
“These results may have implications for health care policy,” the researchers wrote. “Although health care quality improvement requires rigorous evaluation of new policies, implementation of these policies often occurs without consideration of how they can be evaluated. In the current study, it just so happened that the Medicare coverage determination in 2012 resulted in a high degree of variation in utilization of sleeve gastrectomy. This allowed for pseudo randomization through the application of instrumental variables analysis, which strengthens the estimation of treatment effects.”
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