Predictors of high cost after bariatric surgery: A single institution review

Cost Variation in Bariatric Surgery Across the United States

BACKGROUND

High costs have been cited as a barrier to utilization of bariatric surgery despite the increasing prevalence of obesity in the United States. The present work characterizes the center-level variation and risk factors for increased hospitalization costs following bariatric operations.

STUDY DESIGN

The 2016-2019 Nationwide Readmissions Database was queried to identify all adults undergoing elective laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). Random effects were estimated using Bayesian methodology and used to rank hospitals by increasing risk-adjusted center-level costs.

RESULTS

Of an estimated 687,866 patients at an annual 2435 hospitals, 69.9% underwent SG and 30.1% RYGB, with median costs of $10,900 (interquartile range: 8600-14,000) and $13,600 (10,300-18,000), respectively. Hospitals in the highest tertile of annual SG and RYGB volume were associated with a $1500 (95% CI - 2,100, -800) and $3400 reduction in costs (95% CI -4,200, -2600). Approximately 37.2% (95% CI 35.8-38.6) of variation in hospitalization costs was attributable to the hospital. Hospitals in the top decile of center-level costs were associated with increased odds of developing complications (AOR 1.22, 95% CI 1.05-1.40) but not mortality.

CONCLUSION

The present work identified significant interhospital variation in the costs of bariatric operations. Further efforts to standardize costs may enhance the value of bariatric surgical care in the US.

Outpatient physical therapy bundled payment models are feasible for total hip arthroplasty patients: an evaluation of utilization, cost and outcomes

BACKGROUND

Various episode-of-care bundled payment models for patients undergoing total joint arthroplasty have been implemented. However, participation in bundled payment programs has dropped given the challenges of meeting continually lower target prices. The purpose of our study is to investigate the cost of outpatient physical therapy (PT) and the potential for stand-alone outpatient PT bundled payments for patients undergoing total hip arthroplasty (THA).

METHODS

A retrospective review of 501 patients who underwent primary unilateral THA from November 2017 to February 2020 was performed. All patients included in this study received postoperative PT care at a single hospital-affiliated PT practice. Patients above the 75th percentile of therapy visits were then classified as high-PT utilizers and compared with the rest of the population using univariate statistics. Stepwise multivariate logistic regression was used to assess the predictors of high therapy utilization.

RESULTS

Patients averaged 65 ± 10 years of age and a BMI of 29 ± 5 kg/m². Overall, 80% of patients were white and 53% were female. The average patient had 11 ± 8 total therapy sessions in 42 days: one initial evaluation, one re-evaluation and 9 standard sessions. High-PT utilizers incurred estimated average costs of $1934 ± 431 per patient, compared to $783 ± 432 (P < 0.001) in the rest of the population. Further, no significant differences in 90-day outcomes including lower extremity functional scale scores, emergency department returns, readmissions, or returns to the operating room were observed between high utilizers and the rest of the population (all P > 0.08). In the multivariate analysis, women (OR = 1.68, P = 0.017) and those with sleep apnea (OR = 2.02, P = 0.012) were nearly twice as likely to be high utilizers, while white patients were 42% less likely to be high utilizers than patients of other races (OR = 0.58, P = 0.028).

CONCLUSIONS

Outpatient PT utilization is highly variable in patients undergoing THA. However, despite using more services and incurring increased cost, patients in the top quartile of utilization experienced similar outcomes to the rest of the population. If outpatient therapy bundles are to be developed, 16 visits appear to be a reasonable target for pricing, given this provides adequate coverage for 75% of THA patients.

Perioperative Cost Differences Between Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-en-Y Gastric Bypass: A Single Institutional Review

Background: Minimizing bariatric surgery care costs is important since more than 250,000 patients undergo bariatric surgery annually in the United States. The study objective was to compare perioperative costs for the two most common bariatric procedures: laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). In addition, we sought to identify predictors of high-cost perioperative care. Methods: Adult patients who underwent LSG or LRYGB from 2012 to 2017 were identified using our institutional bariatric surgery database. Perioperative costs, defined as costs incurred from the time of entering the preoperative unit until exiting the postanesthesia care unit, were obtained through billing data. Median perioperative cost components of LSG and LRYGB were compared using Mann-Whitney tests. Multivariable logistic regression was performed to investigate patient-level predictors of high-cost care, defined as the top tercile of perioperative costs. Results: We included 546 bariatric surgery patients with a mean age and body mass index (BMI) of 49.7 years and 45.9 kg/m², respectively. There were no significant differences in median perioperative costs between LSG and LRYGB ($14,942 versus $15,016; P = .80). Stapler use was the largest cost contributor for both procedures, accounting for 27.7% and 29.2% of costs for LSG and LRYGB, respectively. In multivariable analyses, preoperative patient characteristics, including BMI, were not associated with high-cost perioperative care. Conclusions: Perioperative costs for LSG and LRYGB were similar in our single institution study. Reducing costs outside of the operating room, including those related to ED visits and complications, may be more impactful than focusing on cost reduction directly related to perioperative care.

Characterization of urgent versus nonurgent early readmissions (<30 days) following primary bariatric surgery: a single-institution experience

BACKGROUND

Studies on early postoperative readmissions after bariatric surgery (BS) have examined readmissions as a single entity, regardless of urgency. Strategies to lower nonurgent readmissions would reduce unnecessary hospital utilization.

OBJECTIVES

To identify predictors of urgent readmissions (UR) versus nonurgent readmissions (NUR) at 30 days post-BS.

SETTING

Single academic institution.

METHODS

Patients undergoing primary BS over 2 years (n = 589) were retrospectively reviewed. Baseline demographic, medical, and hospitalization data were compared between readmitted patients, stratified by urgency, and nonreadmitted patients. Multivariate regression models of UR and NUR were created using variables with a P value ≤ .2 on univariate analyses. A P value ≤ .05 was considered statistically significant.

RESULTS

There were 39 documented instances of 30-day readmissions, of which 44% (n = 17) were NUR; NUR patients were more likely to be female (100% versus 78.2% male; P = .03) and trended toward being younger, experiencing ≥2 perioperative complications, and having a longer index hospital length of stay (LOS). Patients with URs had a higher baseline BMI (52.5 ± 11.4 kg/m² versus 48.7 ± 8.3 kg/m², respectively; P = .04), were more likely to have sleep apnea (77.3% versus 56.1%, respectively; P = .05), had a longer LOS (3 versus 2 d, respectively; P = .007), and were more likely to have ≥2 postoperative complications (46% versus 17.0%, respectively; P = .003) compared with those with an NUR. Independent predictors of NUR included public insurance (odds ratio [OR] = 3.7; 95% confidence interval [CI], 1.17-11.67; P = .03), younger age (OR = 1.05; 95% CI, 1-1.01; P = .04), and female sex, while URs were independently predicted by LOS (OR = 1.3; 95% CI, 1.04-1.5; P = .02).

CONCLUSIONS

Public insurance appears to be associated with NURs, while LOS predicts URs after BS. This suggests an important dichotomy within readmissions based on urgency, which has important implications for targeted quality initiatives.

Concurrent hiatal hernia repair and bariatric surgery: outcomes after sleeve gastrectomy and Roux-en-Y gastric bypass

BACKGROUND

Hiatal hernias are often repaired concurrently with bariatric surgery to reduce risk of gastroesophageal reflux disease-related complications.

OBJECTIVES

To examine the association between concurrent hiatal hernia repair (HHR) and bariatric outcomes.

SETTING

A 2010-2017 U.S. commercial insurance claims data set.

METHODS

We conducted a retrospective cohort study. We identified adults who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) alone or had bariatric surgery concurrently with HHR. We matched patients with and without HHR and followed patients up to 3 years for incident abdominal operative interventions, bariatric revisions/conversions, and endoscopy. Time to first event for each outcome was compared using multivariable Cox proportional hazards modeling.

RESULTS

We matched 1546 SG patients with HHR to 3170 SG patients without HHR, and we matched 457 RYGB patients with HHR to 1156 RYGB patients without HHR. A total of 73% had a full year of postoperative enrollment. Patients who underwent concurrent SG and HHR were more likely to have additional abdominal operations (adjusted hazard ratio [aHR], 2.1; 95% CI, 1.5-3.1) and endoscopies (aHR, 1.5; 95% CI, 1.2-1.8) but not bariatric revisions/conversions (aHR, 1.7; 95% CI, .6-4.6) by 1 year after surgery, a pattern maintained at 3 years of follow-up. Among RYGB patients, concurrent HHR was associated only with an increased risk of endoscopy (aHR, 1.4; 95% CI, 1.1-1.8)) at 1 year of follow-up, persisting at 3 years.

CONCLUSIONS

Concurrent SG/HHR was associated with increased risk of some subsequent operative and nonoperative interventions, a pattern that was not consistently observed for RYGB. Additional studies could examine whether changes to concurrent HHR technique could reduce risk.

Low Urologist Density Predicts High-Cost Surgical Treatment of Stone Disease

Introduction and Objectives: Lack of access to urologic specialists is approaching crisis levels as the number of urologists is decreasing, while the demand for urologic care is increasing. The financial implications of this have not been explored. The objective of this study is to examine the impact of access and other patient factors on cost to treat urolithiasis. We hypothesized that markers of poor access would associate with higher costs of surgical encounters for patients presenting with urolithiasis. Methods: A retrospective review of prospectively collected data from the Registry for Stones of the Kidney and Ureter (ReSKU) from September 2015 to July 2018 was conducted to investigate characteristics of surgical patients treated for urinary stone disease. Univariate analysis was performed using the Welch two-sample t-test. Multivariate analysis was performed using logistic regression. Statistical analysis was performed in R version 3.5. Results: When taking into account age, delayed presentation, procedure type, stone size >20 mm, American Society of Anesthesiologists (ASA) code, gender, race, income, distance, urologist density, body mass index, diabetes, infection, education, language, insurance, and stone complexity, patients undergoing percutaneous nephrolithotomy procedure (p < 0.001; odds ratio [OR] 12.9, confidence interval [CI] 4.05-48.5), urologist density in the bottom quartile (p = 0.014; OR 4.66, CI 1.40-16.9), diabetes (p = 0.018; OR 4.38, CI 1.32-15.6), and infection (p = 0.007; OR 4.51, CI 1.55-14.0) were the only variables statistically significant for association with top quartile of total cost. Conclusions: Surgical encounter costs are largely dictated by patient clinical factors, but low regional urologist density appears to independently predicted for high-cost stone surgery. Increasing patients' access to a urologist may prove to be financially beneficial in the longitudinal reduction in health care costs for stone disease.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Outcomes in conventional laparoscopic versus robotic-assisted revisional bariatric surgery: a retrospective, case-controlled study of the MBSAQIP database

Introduction

Revisional bariatric surgery is being increasingly performed and is associated with higher operative risks. Optimal techniques to minimize complications remain controversial. Here, we report a retrospective review of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant User Files (PUF) database, comparing outcomes between revision RBS and LBS.

Methods

The 2015 and 2016 MBSAQIP PUF database was retrospectively reviewed. Revision cases were identified using the Revision/Conversion Flag. Selected cases were further stratified by surgical approach. Subgroup analysis of sleeve gastrectomy and gastric bypass cases was performed. Case–controlled matching (1:1) was performed of the RBS and LBS cohorts, including gastric bypass and sleeve gastrectomy cohorts separately. Cases and controls were match by demographics, ASA classification, and preoperative comorbidities.

Results

26,404 revision cases were identified (93.3% LBS, 6.7% RBS). 85.6% were female and 67% white. Mean age and BMI were 48 years and 40.9 kg/m². 1144 matched RBS and LBS cases were identified. RBS was associated with longer operative duration (p < 0.0001), LOS (p = 0.0002) and a higher rate of ICU admissions (1.3% vs 0.5%, p = 0.05). Aggregate bleeding and leak rates were higher in the RBS cohort. In both gastric bypass and sleeve gastrectomy cohorts, the robotic-assisted surgery remain associated with longer operative duration (p < 0.0001). In gastric bypass, rates of aggregate leak and bleeding were higher with robotic surgery, while transfusion was higher with laparoscopy. For sleeve gastrectomy cases, reoperation, readmission, intervention, sepsis, organ space SSI, and transfusion were higher with robotic surgery.

Conclusion

In this matched cohort analysis of revision bariatric surgery, both approaches were overall safe. RBS was associated with longer operative duration and higher rates of some complications. Complications were higher in the robotic sleeve cohort. Robotic is likely less cost-effective with no clear patient safety benefit, particularly for sleeve gastrectomy cases.

Patient-reported quality of life after bariatric surgery: a single institution analysis

BACKGROUND

Bariatric surgery is an effective weight loss and comorbidity treatment among severely obese patients. However, there are limited data describing its impact on patient-reported quality of life (QoL). We examined patient-reported QoL after bariatric surgery and analyzed variables associated with higher postoperative QoL.

METHODS

Patient demographics, comorbidities, and weight loss data were obtained from our institutional database for patients who underwent bariatric surgery from January 2010 to December 2012. QoL scores were obtained during preoperative and postoperative visits (2, 6, 12, 24, 52, and 104 wk) from the Moorehead-Ardelt Quality of Life Questionnaire II. Multivariable logistic regression was performed to generate odds ratios for variables hypothesized a priori to be associated with higher postoperative QoL.

RESULTS

A total of 209 patients were included in the study. Patients lost an average of 59.1% (±19.0) of excess body weight 1 y after surgery. One-year postoperative QoL scores were available for 42% of patients. Mean QoL scores improved from 0.82 preoperatively to 1.66 1 y postoperatively (P = 0.004). Patients scored higher in all individual areas of Moorehead-Ardelt Quality of Life Questionnaire II: self-esteem (0.22 versus 0.36), physical activity (0.11 versus 0.31), social life (0.28 versus 0.36), work ability (0.07 versus 0.22), sexual functioning (0.04 versus 0.16), and approach to food (0.11 versus 0.26; all P values <0.05). On multivariable analysis, higher QoL was associated with private insurance/self-pay versus Medicare (odds ratio 4.20 [95% confidence interval 1.39-12.68]).

CONCLUSIONS

Bariatric surgery patients experienced significant improvement in QoL 1 y after surgery. Identifying modifiable predictors of high QoL after bariatric surgery requires additional investigation.