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Somerset AE, Wood MH, Bonham AJ, Carlin AM, Finks J, Ghaferi AA, Varban OA. Association of program-specific variation in bariatric surgery volume for Medicaid patients and access to care: a tale of inequality? Surg Endosc 2023; 37:8570-8576. [PMID: 37872428 DOI: 10.1007/s00464-023-10411-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 07/30/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Although patients with lower socioeconomic status are at higher risk of obesity, bariatric surgery utilization among patients with Medicaid is low and may be due to program-specific variation in access. Our goal was to compare bariatric surgery programs by percentage of Medicaid cases and to determine if variation in distribution of patients with Medicaid could be linked to adverse outcomes. METHODS Using a state-wide bariatric-specific data registry that included 43 programs performing 97,207 cases between 2006 and 2020, we identified all patients with Medicaid insurance (n = 4780, 4.9%). Bariatric surgery programs were stratified into quartiles according to the percentage of Medicaid cases performed and we compared program-specific characteristics as well as baseline patient characteristics, risk-adjusted complication rates and wait times between top and bottom quartiles. RESULTS Program-specific distribution of Medicaid cases varied between 0.69 and 22.4%. Programs in the top quartile (n = 11) performed 18,885 cases in total, with a mean of 13% for Medicaid patients, while programs in the bottom quartile (n = 11) performed 32,447 cases in total, with a mean of 1%. Patients undergoing surgery at programs in the top quartile were more likely to be Black (20.2% vs 13.5%, p < 0.0001), have diabetes (35.1% vs 29.5%, p < 0.0001), hypertension (55.1% vs 49.6%, p < 0.0001) and hyperlipidemia (47.6% vs 45.2%, p < 0.0001). Top quartile programs also had higher complication rates (8.4% vs 6.6%, p < 0.0001), extended length of stay (5.6% vs 4.0%, p < 0.0001), Emergency Department visits (8.1% vs 6.5%, p < 0.0001) and readmissions (4.7% vs 3.9%, p < 0.0001). Median time from initial evaluation to surgery date was also significantly longer among top quartile programs (200 vs 122 days, p < 0.0001). CONCLUSIONS Bariatric surgery programs that perform a higher proportion of Medicaid cases tend to care for patients with greater disease severity who experience delays in care and also require more resource utilization. Improving bariatric surgery utilization among patients with lower socioeconomic status may benefit from insurance standardization and program-centered incentives to improve access and equitable distribution of care.
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Affiliation(s)
- Amy E Somerset
- Department of Surgery, Detroit Medical Center, Wayne State University, 3990 John R, Detroit, MI, 48201, USA.
| | - Michael H Wood
- Department of Surgery, Detroit Medical Center, Wayne State University, 3990 John R, Detroit, MI, 48201, USA
| | - Aaron J Bonham
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Arthur M Carlin
- Department of Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Jonathan Finks
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Amir A Ghaferi
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Oliver A Varban
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
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Howard R, Yang J, Thumma J, Ehlers A, O’Neill S, Arterburn D, Ryan A, Telem D, Dimick JB. Comparative Safety of Sleeve Gastrectomy and Gastric Bypass up to 5 Years After Surgery in Patients With Medicaid. Ann Surg 2023; 277:979-987. [PMID: 36036493 PMCID: PMC9971342 DOI: 10.1097/sla.0000000000005692] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Compare adverse outcomes up to 5 years after sleeve gastrectomy and gastric bypass in patients with Medicaid. BACKGROUND Sleeve gastrectomy is the most common bariatric operation among patients with Medicaid; however, its long-term safety in this population is unknown. METHODS Using Medicaid claims, we performed a retrospective cohort study of adult patients who underwent sleeve gastrectomy or gastric bypass from January 1, 2012, to December 31, 2018. Instrumental variables survival analysis was used to estimate the cumulative incidence and heterogeneity of outcomes up to 5 years after surgery. RESULTS Among 132,788 patients with Medicaid, 84,717 (63.8%) underwent sleeve gastrectomy and 48,071 (36.2%) underwent gastric bypass. A total of 69,225 (52.1%) patients were White, 33,833 (25.5%) were Black, and 29,730 (22.4%) were Hispanic. Compared with gastric bypass, sleeve gastrectomy was associated with a lower 5-year cumulative incidence of mortality (1.29% vs 2.15%), complications (11.5% vs 16.2%), hospitalization (43.7% vs 53.7%), emergency department (ED) use (61.6% vs 68.2%), and reoperation (18.5% vs 22.8%), but a higher cumulative incidence of revision (3.3% vs 2.0%). Compared with White patients, the magnitude of the difference between sleeve and bypass was smaller among Black patients for ED use [5-y adjusted hazard ratios: 1.01; 95% confidence interval (CI), 0.94-1.08 vs 0.94 (95% CI, 0.88-1.00), P <0.001] and Hispanic patients for reoperation [5-y adjusted hazard ratios: 0.95 (95% CI, 0.86-1.05) vs 0.76 (95% CI, 0.69-0.83), P <0.001]. CONCLUSIONS Among patients with Medicaid undergoing bariatric surgery, sleeve gastrectomy was associated with a lower risk of mortality, complications, hospitalization, ED use, and reoperations, but a higher risk of revision compared with gastric bypass. Although the difference between sleeve and bypass was generally similar among White, Black, and Hispanic patients, the magnitude of this difference was smaller among Black patients for ED use and Hispanic patients for reoperation.
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Affiliation(s)
- Ryan Howard
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Jie Yang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Jyothi Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Anne Ehlers
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Sean O’Neill
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - David Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Andrew Ryan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Center for Evaluating Health Reform, University of Michigan, Ann Arbor, Michigan
- School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Dana Telem
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Division of Minimally Invasive Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Justin B. Dimick
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Division of Minimally Invasive Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Melendez-araújo MS, Berber LCL, de Sousa KMQ, Figueiredo ACMG, Lamarca F, Dutra ES, de Carvalho KMB. New Insights on the Association Between Socioeconomic Status and Weight Loss After Bariatric Surgery: a Systematic Review and Meta-analysis. Obes Surg. [DOI: 10.1007/s11695-022-06269-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/01/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
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Zhang W, Fan M, Wang C, Mahawar K, Parmar C, Chen W, Yang W; Global Bariatric Research Collaborative. Hair Loss After Metabolic and Bariatric Surgery: a Systematic Review and Meta-analysis. Obes Surg 2021; 31:2649-59. [PMID: 33675022 DOI: 10.1007/s11695-021-05311-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Hair loss is a common complication after metabolic and bariatric surgery (MBS). There is a lack of published systematic review in the scientific literature on this topic. The aim of this study was to perform a systematic review and meta-analysis on hair loss after MBS in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. METHODS PubMed, CINAHL, EMBASE, Web of Science, SCOPUS, and four Chinese databases were searched. Data were pooled using Review Manager 5.3 and Stata 12.0, and subgroups were performed if necessary and feasible. RESULTS A total of 18 studies (n = 2538) were included. The pooled results showed that the incidence of hair loss after MBS was 57% (95% CI 42-71%). It decreased with longer follow-up times. Hair loss was significantly more common in younger (mean difference (MD), - 2.45; 95% CI, - 4.26 to - 0.64; p = 0.008) women (OR, 3.87; 95% CI, 0.59 to 17.59; p = 0.08). Serum zinc (standardized mean difference (SMD), - 1.13; 95% CI, - 2.27 to 0.01, p = 0.05), folic acid (SMD = - 0.88, 95% CI - 1.29 to - 0.46, p < 0.0001), and ferritin levels (SMD, - 0.22; 95% CI, - 0.38 to - 0.05; p = 0.01), but not serum iron and vitamin B12, were associated with hair loss following MBS. CONCLUSIONS Hair loss is common after MBS especially in younger women, and those with low serum levels of zinc, folic acid, and ferritin. Prospective studies on larger cohorts are needed.
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Martinez PL, McGarrity LA, Turner NA, Volckmann ET, Kohler RM, Morrow EH, Ibele AR. Self-Pay Payer Status Predicts Long-Term Loss to Follow-Up After Bariatric Surgery. Obes Surg 2021; 31:1590-1596. [PMID: 33515181 DOI: 10.1007/s11695-020-05161-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/05/2020] [Accepted: 12/07/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE In spite of widespread recommendations for lifelong patient follow-up with a bariatric provider after bariatric surgery, attrition to follow-up is common. Over the past two decades, many programs have sought to expand access to care for patients lacking insurance coverage for bariatric surgery by offering "self-pay" packages; however, the impact of this financing on long-term follow-up is unclear. We sought to determine whether payer status impacts loss to follow-up within 1 year after bariatric surgery. MATERIALS AND METHODS Records of 554 consecutive patients undergoing bariatric surgery who were eligible for 1-year post-surgical follow-up between 2014 and 2019 were retrospectively reviewed. Multiple logistic regression examined the relationship between demographics, psychological variables, payer status, and loss to follow-up. RESULTS Self-pay status more than tripled the odds of loss to follow-up (OR = 3.44, p < 0.01) at 1 year following surgery. Males had more than double the odds of attrition (OR = 2.43, p < 0.01), and members of racial and ethnic minority groups (OR = 2.51, p < 0.05) were more likely to experience loss. CONCLUSIONS Self-pay patients, males and members of racial and ethnic minority groups, may face additional barriers to long-term access to postoperative bariatric care. Further investigation is greatly needed to develop strategies to overcome barriers to and disparities in long-term post-surgical care for more frequently lost groups.
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Affiliation(s)
- Paige L Martinez
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - Larissa A McGarrity
- Division of Physical Medicine & Rehabilitation, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - Natalie A Turner
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - Eric T Volckmann
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - Rebecca M Kohler
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - Ellen H Morrow
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA
| | - Anna R Ibele
- Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132, USA.
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Takemoto E, Wolfe BM, Nagel CL, Boone-Heinonen J. Physical and Mental Health-Related Quality of Life Changes Among Insurer Subgroups Following Bariatric Surgery. Obesity (Silver Spring) 2020; 28:669-675. [PMID: 31984660 PMCID: PMC7042072 DOI: 10.1002/oby.22718] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 10/21/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVE This study sought to determine improvements in mental and physical health-related quality of life (HRQOL) following bariatric surgery in Medicaid and commercially insured patients. METHODS Using data from the Longitudinal Assessment of Bariatric Surgery, an observational cohort study of adults undergoing bariatric surgery (2006-2009), changes in Short Form 36 mental component summary (MCS) and physical component summary (PCS) scores were examined in 1,529 patients who underwent Roux-en-Y gastric bypass, laparoscopic adjustable band, or sleeve gastrectomy and were followed for 5 years. Piecewise linear mixed-effects models estimated MCS and PCS scores as a function of insurance group (Medicaid, N = 177; commercial, N = 1,352) from 0 to 1 year and from 1 to 5 years after surgery, with interactions between insurance group and surgery type. RESULTS Patients with Medicaid had lower PCS and MCS scores at baseline. At 1 year after surgery, patients with Medicaid and commercial insurance experienced similar improvement in PCS scores (commercial-Medicaid difference in PCS change [95% CI]: Roux-en-Y gastric bypass, 1.5 [-0.2, 3.3]; laparoscopic adjustable band, 1.9 [-2.2, 6.0]; sleeve gastrectomy, 6.4 [0.0, 12.8]). One-year MCS score improvement was minimal and similar between insurance groups. In years 1 to 5, PCS and MCS scores were stable in all groups. CONCLUSIONS Both insurance groups experienced improvements in physical HRQOL and minimal changes in mental HRQOL.
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Affiliation(s)
- Erin Takemoto
- OHSU-PSU School of Public Health, Portland, Oregon, USA
| | - Bruce M Wolfe
- Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Corey L Nagel
- College of Nursing, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Eguia E, Baker MS, Chand B, Sweigert PJ, Kuo PC. The impact of the affordable care act (ACA) Medicaid Expansion on access to minimally invasive surgical care. Am J Surg 2019; 219:15-20. [PMID: 31307661 DOI: 10.1016/j.amjsurg.2019.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 06/30/2019] [Accepted: 07/05/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION This study aims to evaluate the effect of the ACA Medicaid expansion on the utilization of minimally invasive (MIS) approaches to common general surgical procedures. METHODS We queried five Healthcare Cost and Utilization Project State Inpatient Databases to evaluate rates of utilization and costs of MIS and open approaches pre and post Medicaid expansion. RESULTS 117,241 patients met the inclusion criteria. Following the enactment of the ACA, use of both laparoscopic gastric bypass (IRR 1.08; 95% CI: [1.02, 1.15]) and Nissen fundoplication (IRR 1.17; 95% CI [1.09, 1.26]) increased in Medicaid patients treated in expansion states than in those treated in non-expansion states. Simultaneously, the costs reported for self-pay patients increased in expansion states more than in non-expansion states (+$1669; 95% CI [$655, $2682]). CONCLUSIONS Medicaid expansion was associated with increased rates of utilization of MIS approaches to several surgical procedures and a shifting of costs toward patients who were self-insured.
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Affiliation(s)
- Emanuel Eguia
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA.
| | - Marshall S Baker
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Bipan Chand
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Patrick J Sweigert
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Paul C Kuo
- Department of Surgery, University of South Florida, Tampa, FL, USA
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Takemoto E, Wolfe BM, Nagel CL, Boone-Heinonen J. Reduction in Comorbid Conditions Over 5 Years Following Bariatric Surgery in Medicaid and Commercially Insured Patients. Obesity (Silver Spring) 2018; 26:1807-1814. [PMID: 30358155 PMCID: PMC6817972 DOI: 10.1002/oby.22312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 08/21/2018] [Accepted: 08/21/2018] [Indexed: 01/30/2023]
Abstract
OBJECTIVE This study sought to determine changes in the prevalence of comorbid disease following bariatric surgery in Medicaid patients compared with commercially insured patients. METHODS Data were obtained from the Longitudinal Assessment of Bariatric Surgery, an observational cohort study of adults undergoing bariatric surgery at one of six geographically diverse centers in the United States. A total of 1,201 patients who underwent Roux-en-Y gastric bypass with 5 years of follow-up were identified. Poisson mixed models were used to estimate relative risks (RRs) and compare changes in common comorbidities between insurance groups within 0-1 and 1-5 years post surgery. Propensity scores were used to achieve balance in the baseline comorbidity burden between Medicaid and commercial patients. RESULTS In the first year, risk of all six comorbidities decreased substantially over time in both groups, ranging from a 32% to a 69% decrease from baseline. After 1 year post surgery, the risk of disease was stable in both groups (RRs ranged from 1.0 to 1.1). After propensity score weighting, the RRs in the first year were more similar in magnitude, while the RRs in the 1- to 5-year period were unchanged. CONCLUSIONS These results suggest that Medicaid patients experience a medium-term reduction in comorbid disease after bariatric surgery.
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Affiliation(s)
- Erin Takemoto
- Oregon Health & Science University—Portland State University School of Public Health 3181 SW Sam Jackson Park Rd., Mail Code CB669 Portland, OR 97239-3098
| | - Bruce M. Wolfe
- Oregon Health & Science University School of Medicine Department of Surgery, Portland, OR
| | - Corey L. Nagel
- University of Arkansas for Medical Sciences School of Nursing Little Rock, AR
| | - Janne Boone-Heinonen
- Oregon Health & Science University—Portland State University School of Public Health 3181 SW Sam Jackson Park Rd., Mail Code CB669 Portland, OR 97239-3098
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