Sleeve gastrectomy selection soared nearly 2000% following Medicare coverage change
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The 2012 Medicare change to cover sleeve gastrectomy, in addition to Roux-en-Y gastric bypass, for bariatric surgery boosted its selection exponentially, with significant regional and temporal variation between states.
In data published in JAMA Network Open, researchers also noted that the selection of sleeve gastrectomy over gastric bypass depended on how widely used that procedure was used in that state during the prior year.
“This study sought to understand whether geographic variation in the use of sleeve gastrectomy following implementation of insurance coverage could be used as an instrumental variable in analysis of observational data,” Ryan Howard, MD, a general surgery resident at Michigan Medicine, and colleagues wrote.
In a National Medicare claims database, the researchers identified 76,077 patients who had bariatric surgery from 2012 to 2017 — 44,367 by sleeve gastrectomy (mean age, 56.9; 73.4% women) and 31,710 by laparoscopic Roux-en-Y gastric bypass (mean age, 55.9; 74.9% women).
Looking at a sample of the 10 largest states, the researchers found that New Jersey had the largest increase in sleeve gastrectomy (7.9% in 2012 to 92.8% in 2017) and Ohio had the smallest increase (10.9% in 2012 to 63.2% in 2017).
“Utilization of sleeve gastrectomy increased during the study period from 515 procedures
performed in 2012 to 9955 procedures performed in 2017,” Howard and colleagues wrote. “This represented an increase in the annual proportion of sleeve gastrectomy from 6.2% in 2012 to 72.2% in 2017.”
In assessing the efficacy between the two procedures, sleeve gastrectomy had a lower risk for mortality (0.9%; 95% CI, 0.8-1.1 vs. 1.7%; 95%CI 1.3-2), complications (11.6%; 95% CI, 10.9-12.3 vs. 14.1%; 95% CI, 13-15.3), emergency department visits (48.3%; 95% CI, 46.9-49.8 vs. 53.6%; 95% CI, 52.3-55), hospitalization (23.4%; 95%CI, 22.4-24.4 vs. 26.5%; 95% CI, 25.1-28) and reinterventions (8.75; 95% CI, 8-9.4 vs. 12.2%; 95% CI, 11.2-13.3).
“There was substantial geographic and temporal variation in utilization of sleeve gastrectomy following insurance coverage implementation, which served as a strong and valid instrument in comparing the effectiveness of alternative bariatric surgical procedures,” Howard and colleagues wrote.
The researchers noted that these variations are likely “not unique to bariatric surgery,” and that similar analyses could be applied to other areas of health services research to “generate rich clinical results that serve as an important complement to clinical trials.”
“I think the biggest implications of this study are for researchers, since it demonstrates how we can use changes in health insurance coverage and procedure utilization to minimize bias in observational studies,” Howard told Healio.
In addition to the study demonstrating the ability to better assess differences across many medical disciplines, Howard told Healio he saw the potential for more opportunities to help patients seeking bariatric surgery. “I think future studies could use similar methodology to examine comparative outcomes in bariatric surgery by leveraging geographic variation in procedure adoption,” he said.
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