Equity in bariatric surgery use: a cohort study.

BACKGROUND: Metabolic and bariatric surgery (MBS) is the most effective and durable treatment for obesity; however, access to MBS is not equitable. OBJECTIVE: To determine the rate of MBS among eligible adults with obesity by demographics, health characteristics, and geography to better define populations that would benefit from resources to reduce barriers to access for this treatment. SETTING: Adults with obesity were identified in the US employer-based retrospective claims database (Merative™). METHODS: Rates of MBS were examined across demographics (age, sex, region, year, health plan type) health characteristics (obesity-related comorbidities, healthcare costs, inpatient admissions), and by state. Given differences in coverage requirements, rates are examined for 2 populations: Class 2 (BMI 35-39.9 kg/m2) and Class 3 (BMI 40+ kg/m2) obesity. RESULTS: Of the 777,565 eligible adults, 49,371 (6.4%) had MBS; 3.2% of those with Class 2 and 8.3% of those with Class 3 obesity had MBS. MBS rates varied substantially by demographic and health characteristics, ranging from 1% to 14%, and from 2% to 41% among those with Class 2 and Class 3 obesity, respectively. Geographically, rates ranged from 0% (Hawaii) to 7.4% (New Mexico) for those with Class 2 Obesity and from 4.2% (Hawaii) to 15.3% (Mississippi) among those with Class 3 Obesity. CONCLUSIONS: Use of MBS among eligible adults with obesity varies substantially across characteristics, indicating inequity in access to this treatment. To ensure greater access to the most effective treatment for obesity, policies should be implemented to reduce or eliminate barriers to care.

Trends in bariatric surgery training: bariatric operations performed by Fellowship Council trainees from 2012 to 2019.

BACKGROUND: The American Society for Metabolic and Bariatric Surgery (ASMBS) Fellowship Certificate was created to ensure satisfactory training and requires a minimum number of anastomotic cases. With laparoscopic sleeve gastrectomy becoming the most common bariatric procedure in the United States, this may present a challenge for fellows to obtain adequate numbers for ASMBS certification. OBJECTIVES: To investigate bariatric fellowship trends from 2012 to 2019, the types, numbers, and approaches of surgical procedures performed by fellows were examined. SETTING: Academic training centers in the United States. METHODS: Data were obtained from Fellowship Council records of all cases performed by fellows in ASMBS-accredited bariatric surgery training programs between 2012 and 2019. A retrospective analysis using standard descriptive statistical methods was performed to investigate trends in total case volume and cases per fellow for common bariatric procedures. RESULTS: From 2012 to 2019, sleeve gastrectomy cases performed by all Fellowship Council fellows nearly doubled from 6,514 to 12,398, compared with a slight increase for gastric bypass, from 8,486 to 9,204. Looking specifically at bariatric fellowships, the mean number of gastric bypass cases per fellow dropped over time, from 91.1 cases (SD = 46.8) in 2012-2013 to 52.6 (SD = 62.1) in 2018-2019. Mean sleeve gastrectomy cases per fellow increased from 54.7 (SD = 31.5) in 2012-2013 to a peak of 98.6 (SD = 64.3) in 2015-2016. Robotic gastric bypasses also increased from 4% of all cases performed in 2012-2013 to 13.3% in 2018-2019. CONCLUSIONS: Bariatric fellowship training has seen a decrease in gastric bypasses, an increase in sleeve gastrectomies, and an increase in robotic surgery completed by each fellow from 2012 to 2019.

Observational cohort investigating health outcomes and healthcare costs after metabolic and bariatric surgery: a study protocol.

INTRODUCTION: As the rate of obesity increases, so does the incidence of obesity-related comorbidities. Metabolic and bariatric surgery (MBS) is the most effective treatment for obesity, yet this treatment is severely underused. MBS can improve, resolve, and prevent the development of obesity-related comorbidities; this improvement in health also results in lower healthcare costs. The studies that have examined these outcomes are often limited by small sample sizes, reliance on outdated data, inconsistent definitions of outcomes, and the use of simulated data. Using recent real-world data, we will identify characteristics of individuals who qualify for MBS but have not had MBS and address the gaps in knowledge around the impact of MBS on health outcomes and healthcare costs. METHODS AND ANALYSIS: Using a large US employer-based retrospective claims database (Merative), we will identify all obese adults (21+) who have had a primary MBS from 2016 to 2021 and compare their characteristics and outcomes with obese adults who did not have an MBS from 2016 to 2021. Baseline demographics, health outcomes, and costs will be examined in the year before the index date, remission and new-onset comorbidities, and healthcare costs will be examined at 1 and 3 years after the index date. ETHICS AND DISSEMINATION: As this was an observational study of deidentified patients in the Merative database, Institutional Review Board approval and consent were exempt (in accordance with the Health Insurance Portability and Accountability Act Privacy Rule). An IRB exemption was approved by the wcg IRB (#13931684). Knowledge dissemination will include presenting results at national and international conferences, sharing findings with specialty societies, and publishing results in peer-reviewed journals. All data management and analytic code will be made available publicly to enable others to leverage our methods to verify and extend our findings.

ASMBS statement on metabolic and bariatric surgery for beneficiaries of Centers for Medicare and Medicaid Services with a review of the literature.

This position statement is issued by the American Society for Metabolic and Bariatric. Surgery in response to inquiries made to the Society by patients, physicians, Society members, hospitals, health insurance payors, the media, and others regarding the access and outcomes of metabolic and bariatric surgery for beneficiaries of Centers for Medicare and Medicaid Services. This position statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence available at this time. The statement is not intended to be and should not be construed as stating or establishing a local, regional, or national standard of care. This statement will be revised in the future as additional evidence becomes available.

Association of Women Surgeons' Comprehensive Initiative for Healthy Surgical Families During Residency and Fellowship Training.

Importance: The lack of family-friendly policies continues to contribute to the underrepresentation and attrition of surgical trainees. Women in surgery face unique challenges in balancing surgical education with personal and family needs. Observations: The Association of Women Surgeons is committed to supporting surgical families and developing equitable family-friendly guidelines. Herein we detail recommendations for adequate paid parental leave, access to childcare, breastfeeding support, and insurance coverage of fertility preservation and assisted reproductive technology. Conclusions and Relevance: The specific recommendations outlined in this document form the basis of a comprehensive initiative for supporting surgical families.

Gender disparities among leadership in academic surgical publishing over the past decade.

BACKGROUND: Women account for 19 % of practicing surgeons in the United States, with representation decreasing with higher academic rank. Less is known about the proportion of women in editorial leadership positions at surgical journals. The objective of this study was to examine gender representation among editorial leadership at high-impact surgical journals. METHODS: The five journals with the highest impact factors in general, cardiothoracic, plastics, otolaryngology, orthopedics, urology, vascular, and neurosurgery were identified. Data were abstracted on the proportion of women editors-in-chief (EIC) and editorial board members between 2010 and 2020 to determine how these demographics changed over time. RESULTS: Multiple fields had no women EIC over the past decade (orthopedics, urology, cardiothoracic, neurosurgery). In all other fields, women were a minority of EIC. In 2020, women made up 7.9 % of EIC and 11.1 % of editorial boards in surgical journals. CONCLUSIONS: Women remain under-represented among leadership at high-impact surgical journals, with varying improvement over the past decade among different subspecialties.

Development and Assessment of a Systematic Approach for Detecting Disparities in Surgical Access.

Importance: Although optimal access is accepted as the key to quality care, an accepted methodology to ascertain potential disparities in surgical access has not been defined. Objective: To develop a systematic approach to detect surgical access disparities. Design, Setting, and Participants: This cross-sectional study used publicly available data from the Health Cost and Utilization Project State Inpatient Database from 2016. Using the surgical rate observed in the 5 highest-ranked counties (HRCs), the expected surgical rate in the 5 lowest-ranked counties (LRCs) in North Carolina were calculated. Patients 18 years and older who underwent an inpatient general surgery procedure and patients who underwent emergency inpatient cholecystectomy, herniorrhaphy, or bariatric surgery in 2016 were included. Data were collected from January to December 2016, and data were analyzed from March to July 2020. Exposures: Health outcome county rank as defined by the Robert Wood Johnson Foundation. Main Outcomes and Measures: The primary outcome was the proportional surgical ratio (PSR), which was the disparity in surgical access defined as the observed number of surgical procedures in the 5 LRCs relative to the expected number of procedures using the 5 HRCs as the standardized reference population. Results: In 2016, approximately 1.9 million adults lived in the 5 HRCs, while approximately 246 854 lived in the 5 LRCs. A total of 28 924 inpatient general surgical procedures were performed, with 4521 being performed in those living in the 5 LRCs and 24 403 in those living in the 5 HRCs. The rate of general surgery in the 5 HRCs was 13.09 procedures per 1000 population. Using the 5 HRCs as the reference, the PSR for the 5 LRCs was 1.40 (95% CI, 1.35-1.44). For emergent/urgent cholecystectomy, the PSR for the 5 LRCs was 2.26 (95% CI, 2.02-2.51), and the PSR for emergent/urgent herniorrhaphy was 1.83 (95% CI, 1.33-2.45). Age-adjusted rate of obesity (body mass index [calculated as weight in kilograms divided by height in meters squared] greater than 30), on average, was 36.6% (SD, 3.4) in the 5 LRCs vs 25.4% (SD, 4.6) in the 5 HRCs (P = .002). The rate of bariatric surgery in the 5 HRCs was 33.07 per 10 000 population with obesity. For the 5 LRCs, the PSR was 0.60 (95% CI, 0.51-0.69). Conclusions and Relevance: The PSR is a systematic approach to define potential disparities in surgical access and should be useful for identifying, investigating, and monitoring interventions intended to mitigate disparities in surgical access that effects the health of vulnerable populations.

Evaluating readmissions following laparoscopic cholecystectomy in the state of New York.

INTRODUCTION: Hospital readmissions constitute an important component of associated costs of a disease and can contribute a significant burden to healthcare. The majority of studies evaluating readmissions following laparoscopic cholecystectomy (LC) comprise of single center studies and thus can underestimate the actual incidence of readmission. We sought to examine the rate and causes of readmissions following LC using a large longitudinal database. METHODS: The New York SPARCS database was used to identify all adult patients undergoing laparoscopic cholecystectomy for benign biliary disease between 2000 and 2016. Due to the presence of a unique identifier, patients with readmission to any New York hospital were evaluated. Planned versus unplanned readmission rates were compared. Following univariate analysis, multivariable logistic regression model was used to identify risk factors for unplanned readmissions after accounting for baseline characteristics, comorbidities and complications. RESULTS: There were 591,627 patients who underwent LC during the studied time period. Overall 30-day readmission rate was 4.94% (n = 29,245) and unplanned 30-days readmission rate was 4.58% (n = 27,084). Female patients were less likely to have 30-day unplanned readmissions. Patients with age older than 65 or younger than 29 were more likely to have 30-day unplanned readmissions compared to patients with age 30-44 or 45-64. Insurance status was also significant, as patients with Medicaid/Medicare were more likely to have unplanned readmissions compared to commercial insurance. In addition, variables such as Black race, presence of any comorbidity, postoperative complication, and prolonged initial hospital length of stay were associated with subsequent readmission. CONCLUSION: This data show that readmissions rates following LC are relatively low; however, majority of readmissions are unplanned. Most common reason for unplanned readmissions was associated with complications of the procedure or medical care. By identifying certain risk groups, unplanned readmissions may be prevented.

Patients insured by Medicare and Medicaid undergo lower rates of bariatric surgery.

BACKGROUND: Although the number of weight loss procedures is increasing, bariatric surgery is not used equitably in the United States. As obesity is more prevalent in minorities, higher priorities are placed toward improvement of access to care for these groups. OBJECTIVES: To evaluate whether patient insurance status has any effect on use of bariatric surgery for patients in New York State. SETTING: Administrative statewide database. METHODS: The Statewide Planning and Research Cooperative System administrative database was used to identify all patients undergoing primary bariatric procedures between 2005 and 2016. Revision procedures were excluded from analysis. Multivariable logistic regression models were used to compare outcomes among patients with different payor status after controlling for confounding factors. RESULTS: After the application of inclusion and exclusion criteria, there were 125,666 bariatric records from 2005 to 2016. Most patients had commercial insurance (n = 106,148, 84.5%), followed by Medicare (n = 9355, 7.4%), Medicaid (n = 7939, 6.3%), and other/unknown (n = 2224, 1.8%). The percentage of Medicaid was estimated to be increase by 12%/yr and the percentage of Medicare was estimated to be increase by 5%/yr during 2005 to 2016. Univariate analysis showed that patients with different insurance types were significantly different in terms of age, sex, race, region, subtype of surgeries, most co-morbidities, overall complication, 30-day readmission/emergency department visits, and length of stay (P values < .0001). After adjusting for other confounding factors, patients with Medicare insurance had significantly higher risk of having overall complications, 30-day readmissions/emergency department visits, and longer length of stay. CONCLUSIONS: The majority of patients undergoing bariatric surgery are insured by private insurance, whereas only 13.7% of bariatric surgeries are performed on patients with public insurance.

Incidence of Ventral Hernia Repair after Open Abdominal Aortic Aneurysm and Open Aortofemoral or Aortoiliac Bypass Surgery: An Analysis of 17,594 Patients in the State of New York.

The purpose of our study was to evaluate the rate of ventral hernia repair (VHR) after open abdominal aortic anneurysm in New York State compared with the rate of VHR after open abdominal aortic bypass procedures. The Statewide Planning and Research Cooperative System database was queried for all abdominal aortic aneurysm (AAA) and bypass procedures performed between 2000 and 2010. Social security death index was used to identify patients who died. The cause-specific Cox proportional hazard model was applied to compare the risk of having follow-up VHR between patients with AAA and bypass with death as a competing risk event. A multivariable model was used to explore independent relationship with the risk of having follow-up ventral hernia after adjusting for other factors. There were 9314 patients who underwent open AAA repair, 739 (7.93%) of which had subsequent VHR. Comparatively, 8280 patients underwent aortofemoral or aortoiliac bypass procedures, with 480 (5.8%) undergoing subsequent VHR. The observed one-year, five-year, and 10-year VHR rates for AAA versus bypass were 2.8 versus 1.8 per cent, 10.0 versus 8.0 per cent, 10.7 versus 9.38 per cent, respectively. After controlling for all other factors, patients undergoing AAA repair were more likely and elderly patients were less likely to undergo VHR (P < 0.0001). Patients with serious comorbid conditions such as valvular disease, diabetes mellitus, and neurologic disorders were less likely to undergo subsequent VHR controlling for other factors. VHR after AAA procedures is more common compared with bypass procedures for occlusive disease. Because this patient population has significant comorbidity, prophylactic mesh placement may play a role in preventing necessity for future procedures.

The Presence of an Advanced Gastrointestinal (GI)/Minimally Invasive Surgery (MIS) Fellowship Program Does Not Impact Short-Term Patient Outcomes Following Fundoplication or Esophagomyotomy.

INTRODUCTION: The current surgical landscape reflects a continual trend towards sub-specialization, evidenced by an increasing number of US surgeons who pursue fellowship training after residency. Despite this growing trend, however, the effect of advanced gastrointestinal (GI)/minimally invasive surgery (MIS) fellowship programs on patient outcomes following foregut/esophageal operations remains unclear. This study looks at two representative foregut surgeries (laparoscopic fundoplication and esophagomyotomy) performed in New York State (NYS), comparing hospitals which do and do not possess a GI/MIS fellowship program, to examine the effect of such a program on perioperative outcomes. We also aimed to identify any patient or hospital factors which might influence perioperative outcomes. METHODS: The SPARCS database was examined for all patients who underwent a foregut procedure (specifically, either an esophagomyotomy or a laparoscopic fundoplication) between 2012 and 2014. We compared the following outcomes between institutions with and without a GI/MIS fellowship program: 30-day readmission, hospital length of stay (LOS), and development of any major complication. RESULTS: There were 3175 foregut procedures recorded from 2012 to 2014. Just below one third (n = 1041; 32.8%) were performed in hospitals possessing a GI/MIS fellowship program. Among our entire included study population, 154 patients (4.85%) had a single 30-day readmission, with no observed difference in readmission between hospitals with and without a GI/MIS fellowship program, even after controlling for potential confounding factors (p = 0.6406 and p = 0.2511, respectively). Additionally, when controlling for potential confounders, the presence/absence of a GI/MIS fellowship program was found to have no association with risk of having a major complication (p = 0.1163) or LOS (p = 0.7562). Our study revealed that postoperative outcomes were significantly influenced by patient race and payment method. Asians and Medicare patients had the highest risk of suffering a severe complication (10.00 and 7.44%; p = 0.0311 and p = 0.0036, respectively)-with race retaining significance even after adjusting for potential confounders (p = 0.0276). Asians and uninsured patients demonstrated the highest readmission rates (15.00 and 12.50%; p = 0.0129 and p = 0.0012, respectively)-with both race and payment method retaining significance after adjustment (p = 0.0362 and p = 0.0257, respectively). Lastly, payment method was significantly associated with postoperative LOS (p < 0.0001), with Medicaid patients experiencing the longest LOS (mean 3.99 days) and those with commercial insurance experiencing the shortest (mean 1.66 days), a relationship which retained significance even after adjusting for potential confounders (p < 0.0001). CONCLUSION: The presence of a GI/MIS fellowship program does not impact short-term patient outcomes following laparoscopic fundoplication or esophagomyotomy (two representative foregut procedures). Presence of such a fellowship should not play a role in choosing a surgeon. Additionally, in these foregut procedures, patient race (particularly Asian race) and payment method were found to be independently associated with postoperative outcomes, including postoperative LOS.

Measuring Decision-Making During Thyroidectomy: Validity Evidence for a Web-Based Assessment Tool.

BACKGROUND: Errors in judgment during thyroidectomy can lead to recurrent laryngeal nerve injury and other complications. Despite the strong link between patient outcomes and intraoperative decision-making, methods to evaluate these complex skills are lacking. The purpose of this study was to develop objective metrics to evaluate advanced cognitive skills during thyroidectomy and to obtain validity evidence for them. METHODS: An interactive online learning platform was developed ( www.thinklikeasurgeon.com ). Trainees and surgeons from four institutions completed a 33-item assessment, developed based on a cognitive task analysis and expert Delphi consensus. Sixteen items required subjects to make annotations on still frames of thyroidectomy videos, and accuracy scores were calculated based on an algorithm derived from experts' responses ("visual concordance test," VCT). Seven items were short answer (SA), requiring users to type their answers, and scores were automatically calculated based on their similarity to a pre-populated repertoire of correct responses. Test-retest reliability, internal consistency, and correlation of scores with self-reported experience and training level (novice, intermediate, expert) were calculated. RESULTS: Twenty-eight subjects (10 endocrine surgeons and otolaryngologists, 18 trainees) participated. There was high test-retest reliability (intraclass correlation coefficient = 0.96; n = 10) and internal consistency (Cronbach's α = 0.93). The assessment demonstrated significant differences between novices, intermediates, and experts in total score (p < 0.01), VCT score (p < 0.01) and SA score (p < 0.01). There was high correlation between total case number and total score (ρ = 0.95, p < 0.01), between total case number and VCT score (ρ = 0.93, p < 0.01), and between total case number and SA score (ρ = 0.83, p < 0.01). CONCLUSION: This study describes the development of novel metrics and provides validity evidence for an interactive Web-based platform to objectively assess decision-making during thyroidectomy.

Presence of a fellowship improves perioperative outcomes following hepatopancreatobiliary procedures.

INTRODUCTION: There is an increase in subspecialization and in the number of surgeons seeking fellowship training in the USA. Little is known regarding the effect of hepatopancreatobiliary (HPB) fellowship programs' status of an institution on perioperative outcomes. This study aims to examine the effect of such status on perioperative outcomes across all institutions following complex surgeries involving HPB procedures in the State of New York (NYS). METHODS: The Statewide Planning and Research Cooperative System administrative database was used to identify several complex surgeries involving the pancreas, liver, and gallbladder by using ICD-9 codes for inpatient procedures between 2012 and 2014. Procedures were compared in terms of 30-day readmission, hospital length of stay (HLOS), and major complications between institutions with and without fellowship. Linear mixed model and generalized linear mixed models were used to compare the differences. RESULTS: There were 4156 procedures identified during 2012-2014 in NYS. Among these, 1685 (40.5%) were pancreatic surgeries only, 1031 (24.8%) were liver surgeries only, 1288 (31.0%) were gallbladder surgeries only, 11 (0.3%) were both pancreatic and liver surgeries, 124 (3.0%) were both liver and gallbladder, and 17 (0.4%) were both pancreatic and gallbladder. Elderly patients tended to go to the hospitals with HPB fellowship. Following multivariable regression and controlling for other factors, hospitals with fellowships remained significantly associated with less severe complications (OR 0.49, 95% CI 0.29-0.83, p = 0.0075). No significant differences were seen between hospitals with and without fellowship in terms of 30-day readmissions (p = 0.6) and HLOS (p = 0.4). CONCLUSION: Institutions offering HPB fellowship training were associated with significantly improved rate of complications, although there was no significant difference in terms of 30-day readmission rate or HLOS. This data highlight the importance of a presence of a fellowship in complex hepatopancreatobiliary procedures.

Effect of minimally invasive surgery fellowship on residents' operative experience.

INTRODUCTION: There is an increased need for surgical trainees to acquire advanced laparoscopic skills as laparoscopy becomes the standard of care in many areas of general surgery. Since the introduction of minimally invasive surgery (MIS) fellowships, there has been a continuing debate as to whether these fellowships adversely affect general surgery resident exposure to laparoscopic cases. The aim of our study was to examine whether the introduction of an MIS fellowship negatively impacts general surgery residents' experience at a single academic center. METHODS: We describe the changes following establishment of MIS fellowship at an academic center. Resident case log system from the Accreditation Council for Graduate Medical Education was queried to obtain all PGY 1-5 resident operative case logs. Two-year time period preceding and following the institution of an MIS fellowship at our institution in 2012 was compared. P values less than 0.05 were considered statistically significant. RESULTS: Following initiation of the MIS fellowship, an MIS service was established. The service comprised of a fellow, midlevel resident, and intern. Operative experience was examined. From 2010-2012 to 2012-2014, residents logged a total of 272 and 585 complex laparoscopic cases, respectively. There were 43 residents from 2010 to 2013 and 44 residents from 2013 to 2014. When the two time periods were compared, a trend of increased numbers for all procedures was noted, except laparoscopic GYN/genito-urinary procedures. Average percent increase in complex general surgery procedures was 249 ± 179.8 %. Following establishment of a MIS fellowship, reported cases by residents were higher or similar to those reported nationally for laparoscopic procedures. CONCLUSION: Institution of an MIS fellowship had a favorable effect on general surgery resident operative education at a single academic training center. Residents may benefit from the presence of a fellowship at an academic center because they are able to participate in an increased number of complex laparoscopic cases.

Long-term outcomes of patients with common bile duct injury following laparoscopic cholecystectomy.

INTRODUCTION: Common bile duct (CBD) injury is a serious and dreaded complication of cholecystectomy. A paucity of data assessing long-term outcomes exists. This study aimed to determine long-term mortality and liver transplantation rates following CBD injury requiring operative intervention. METHODS: Patients were identified via the New York State (NYS) Planning and Research Cooperative System longitudinal administrative database which captures patient-level data from every inpatient and outpatient hospital discharge in NYS. In total, 125 patients with CBD injuries were identified following 156,958 laparoscopic cholecystectomies for cholelithiasis performed in NYS from 2005 to 2010. Patients were then tracked by unique identifier to obtain rate of liver transplantation. Follow-up ranged from 4 to 9 years from surgery. RESULTS: There were 125 patients with CBD injuries detected. No mortalities occurred within 30 days. All-cause mortality was 20.8 % (n = 26) with mean time to death 1.64 ± 1.08 years. One patient who underwent hepaticoenterostomy required a liver transplant 4.3 years after surgery. Significant factors predictive of all-cause mortality included: age >61, Medicare insurance, male gender, White race, diabetes, hypertension and pulmonary complications following surgery. Overall 30-day morbidity, timing to and type of operative intervention did not influence mortality. CONCLUSION: Considerable long-term mortality, 20.8 %, is associated with common bile duct injury requiring operative intervention. This was an increase of 8.8 % above the cohort's expected age-adjusted rate of death. The mortality rate is appreciably higher than quoted previously. No difference was demonstrated by type of repair required. Liver transplant rate was 0.8 %. These data have significant implications for patient and family counseling both prior to cholecystectomy and following CBD injury.

Robotic-assisted outcomes are not tied to surgeon volume and experience.

INTRODUCTION: There are little data regarding whether hospital and surgeon factors affect outcomes following robotic-assisted surgery (RAS). The purpose of this study was to investigate whether any such factor was associated with hospital length of stay (HLOS) and complications following common RAS procedures in the State of New York. METHODS: Following IRB approval, The New York Statewide Planning and Research Cooperative System administrative dataset was used to identify eight common RAS procedures through ICD-9 codes: cholecystectomy, colectomy, Roux-en-Y gastric bypass, sleeve gastrectomy, esophageal fundoplication, pancreatectomy, splenectomy, and gastrectomy between 2008 and 2012. Physician factors evaluated included time since graduation, fellowship status, and number of procedures performed; hospital-level factors included urban versus rural setting, teaching status, hospital size, and the presence of a fellowship. All these factors were further evaluated in multivariable regression models to evaluate for effect on overall complication and HLOS after adjusting for covariates such as patients' characteristics and comorbidities. RESULTS: There were 1670 patients who underwent RAS with average HLOS of 4.433 days and overall complication rate of 18.8 %. Univariate analysis showed that patients of physicians having fellowship training tended to have higher rate of complication-22.82 versus 13.49 % (P = 0.0055), but these were also sicker patients. In addition, physicians with higher number of procedures had lower complications (P = 0.0138). However, these two factors were not significant after controlling for other covariates. Neither physician- nor hospital-related factors were significantly related to HLOS with or without adjusting for other covariates. CONCLUSIONS: Robotic assistance may eliminate the differences between hospitals and physicians.

Bariatric outcomes are significantly improved in hospitals with fellowship council-accredited bariatric fellowships.

BACKGROUND: With the increasing demand of bariatric surgery, there is a need to train more surgeons, while identifying institutional factors associated with improved outcomes. Little is known regarding the impact of a fellowship training program on institutional outcomes. This study examines the effect of bariatric fellowship program status on perioperative outcomes within New York state. METHODS: Using the New York statewide planning and research cooperative system, 47,342 adult patients in 91 hospitals were identified who underwent a laparoscopic bariatric surgery over a 6-year period. Hospitals with fellowships were identified from the Fellowship Council. Statistical comparison between patient demographics, payer source, comorbidities, bariatric procedure performed, and perioperative outcomes in hospitals with and without fellowship were performed. RESULTS: On univariate analysis, fellowship accreditation status was found to be associated with increased rates of cardiac complications and shock and decreased rates of pneumonia. Overall complication rate was not significantly different in fellowship versus non-fellowship institutions. However, when controlled for patient demographic, payer source, comorbidity, and operative procedure, there were significantly improved bariatric outcomes among institutions with fellowship programs. CONCLUSIONS: The presence of a fellowship program correlates with improved hospital outcomes, mitigating potential concerns about possible negative effects of trainees on hospitals and patients.