Out-of-pocket Costs for Commercially-insured Patients in the Years Following Bariatric Surgery: Sleeve Gastrectomy Versus Roux-en-Y Gastric Bypass.

OBJECTIVE: To compare out-of-pocket (OOP) costs for patients up to 3 years after bariatric surgery in a large, commercially-insured population. SUMMARY OF BACKGROUND DATA: More information on OOP costs following bariatric surgery may affect patients' procedure choice. METHODS: Retrospective study using the IBM MarketScan commercial claims database, representing patients nationally who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) January 1, 2011 to December 31, 2017. We compared total OOP costs after the surgical episode between the 2 procedures using difference-in-differences analysis adjusting for demographics, comorbidities, operative year, and insurance type. RESULTS: Of 63,674 patients, 64% underwent SG and 36% underwent RYGB. Adjusted OOP costs after SG were $1083, $1236, and $1266 postoperative years 1, 2, and 3. For RYGB, adjusted OOP costs were $1228, $1377, and $1369. In our primary analysis, SG OOP costs were $122 (95% confidence interval [CI]: -$155 to -$90) less than RYGB year 1. This difference remained consistent at -$119 (95%CI: -$158 to -$79) year 2 and -$80 (95%CI: -$127 to -$35) year 3. These amounts were equivalent to relative differences of -7%, -7%, and -5% years 1, 2, and 3. Plan features contributing the most to differences were co-insurance years 1, 2, and 3.The largest clinical contributors to differences were endoscopy and outpatient care year 1, outpatient care year 2, and emergency department use year 3. CONCLUSIONS: Our study is the first to examine the association between bariatric surgery procedure and OOP costs. Differences between procedures were approximately $100 per year which may be an important factor for some patients deciding whether to pursue SG or gastric bypass.

Births After Bariatric Surgery in the United States: Incidence, Obstetric Outcomes, and Reinterventions.

OBJECTIVE: To characterize incidence and outcomes for bariatric surgery patients who give birth. BACKGROUND: Patients of childbearing age comprise 65% of bariatric surgery patients in the United States, yet data on how often patients conceive and obstetric outcomes are limited. METHODS: Using the IBM MarketScan database, we performed a retrospective cohort study of female patients ages 18 to 52 undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass from 2011 to 2017. We determined the incidence of births in the first 2 years after bariatric surgery using Kaplan-Meier estimates. We then restricted the cohort to those with a full 2-year follow-up to examine obstetric outcomes and bariatric-related reinterventions. We reported event rates of adverse obstetric outcomes and delivery type. Adverse obstetric outcomes include pregnancy complications, severe maternal morbidity, and delivery complications. We performed multivariable logistic regression to examine associations between birth and risk of reinterventions. RESULTS: Of 69,503 patients who underwent bariatric surgery, 1464 gave birth. The incidence rate was 2.5 births per 100 patients in the 2 years after surgery. Overall, 85% of births occurred within 21 months after surgery. For 38,922 patients with full 2-year follow-up, adverse obstetric event rates were 4.5% for gestational diabetes and 14.2% for hypertensive disorders. In all, 48.5% were first-time cesarean deliveries. Almost all reinterventions during pregnancy were biliary. Multivariable logistic regression analysis showed no association between postbariatric birth and reintervention rate (odds ratio: 0.93, 95% confidence interval: 0.78-1.12). CONCLUSIONS: In this first national US cohort, we find giving birth was common in the first 2 years after bariatric surgery and was not associated with an increased risk of reinterventions. Clinicians should consider shifting the dialogue surrounding pregnancy after surgery to shared decision-making with maternal safety as one component.

Variation of ventral and incisional hernia repairs in kidney transplant recipients.

INTRODUCTION: As survivorship following kidney transplant continues to improve, so does the probability of intervening on common surgical conditions, such as ventral or incisional hernia, in this population. Ventral hernia management is known to vary across institutions and this variation has an impact on patient outcomes. We sought to evaluate hospital level variation of ventral or incisional hernia repair (VIHR) in the kidney transplant population. METHODS: We performed a retrospective review of 100% inpatient Medicare claims to identify patients who underwent kidney transplant between 2007 and 2018. The primary outcome was 1- and 3-year ventral or incisional risk- and reliability-adjusted VIHR rates. Patient and hospital characteristics were evaluated across risk- and reliability-adjusted VIHR rate tertiles. Models were adjusted for age, sex, race, and Elixhauser comorbidities. RESULTS: Overall, 139,741 patients underwent kidney transplant during the study period with a mean age (SD) of 51.6 (13.7) years. 84,717 (60.6%) were male, and 72,657 (52.0%) were white. Median follow up time was 5.4 years. 2098 (1.50%) patients underwent VIHR. the 1 year risk- and reliability-adjusted hernia repair rates were 0.49% (95% Conf idence Interval (CI) 0.48-0.51, range 0.31-0.59) in tertile 1, 0.63% (95% CI 0.62-0.63, range 0.59-0.68) in tertile 2, and 0.98 (95% CI 0.91-1.05, range 0.68-2.94) in tertile 3. Accordingly, compared to hospitals in tertile 1, the odds of post-transplant hernia repair tertile 2 hospitals were 1.78 (95% CI 1.37-2.31) and at tertile 3 hospitals 3.53 (95% CI 2.87-4.33). CONCLUSIONS: In a large cohort of Medicare patients undergoing kidney transplant, the overall cumulative incidence of hernia repair varied substantially across hospital tertiles. Patient and hospital characteristics varied across tertile, most notably in diabetes and obesity. Future research is needed to understand if program and surgeon level factors are contributing to the observed variation in treatment of this common disease.

Relationship Between Health Care Spending and Clinical Outcomes in Bariatric Surgery: Implications for Medicare Bundled Payments.

OBJECTIVE: To evaluate sources of 90-day episode spending variation in Medicare patients undergoing bariatric surgery and whether spending variation was related to quality of care. SUMMARY OF BACKGROUND DATA: Medicare's bundled payments for care improvement-advanced program includes the first large-scale episodic bundling program for bariatric surgery. This voluntary program will pay bariatric programs a bonus if 90-day spending after surgery falls below a predetermined target. It is unclear what share of bariatric episode spending may be due to unnecessary variation and thus modifiable through care improvement. METHODS: Retrospective analysis of fee-for-service Medicare claims data from 761 acute care hospitals providing inpatient bariatric surgery between January 1, 2011 and September 30, 2016. We measured associations between patient and hospital factors, clinical outcomes, and total Medicare spending for the 90-day bariatric surgery episode using multivariable regression models. RESULTS: Of 64,537 patients, 46% underwent sleeve gastrectomy, 22% revisited the emergency department (ED) within 90 days, and 12.5% were readmitted. Average 90-day episode payments were $14,124, ranging from $12,220 at the lowest-spending quintile of hospitals to $16,887 at the highest-spending quintile. After risk adjustment, 90-day episode spending was $11,447 at the lowest quintile versus $15,380 at the highest quintile (difference $3932, P < 0.001). The largest components of spending variation were readmissions (44% of variation, or $2043 per episode), post-acute care (19% or $871), and index professional fees (15% or $450). The lowest spending hospitals had the lowest complication, ED visit, post-acute utilization, and readmission rates (P < 0.001). CONCLUSIONS AND RELEVANCE: In this retrospective analysis of Medicare patients undergoing bariatric surgery, the largest components of 90-day episode spending variation are readmissions, inpatient professional fees, and post-acute care utilization. Hospitals with lower spending were associated with lower rates of complications, ED visits, post-acute utilization, and readmissions. Incentives for improving outcomes and reducing spending seem to be well-aligned in Medicare's bundled payment initiative for bariatric surgery.

Evaluating the Impact of Surgeon Self-awareness by Comparing Self Versus Peer Ratings of Surgical Skill and Outcomes for Bariatric Surgery.

OBJECTIVE: To evaluate variation in self versus peer-assessments of surgical skill using surgical videos and compare surgeon-specific outcomes with bariatric surgery. SUMMARY BACKGROUND DATA: Prior studies have demonstrated that surgeons with lower peer-reviewed ratings of surgical skill had higher complication rates after bariatric surgery. METHODS: This is a retrospective cohort study of 25 surgeons who voluntarily submitted a video of a typical laparoscopic sleeve gastrectomy (SG) between 2015 and 2016. Videos were self and peer-rated using a validated instrument based on a 5-point Likert scale (5= "master surgeon" and 1= "surgeon-in-training"). Risk adjusted 30-day complication rates were compared between surgeons who over-rated and under-rated their skill based on data from 24,186 SG cases and 12,888 gastric bypass (GBP) cases. RESULTS: individual overall self-rating of surgical skill varied between 2.5 and 5. Surgeons in the top quartile for self:peer ratings (n = 6, ratio 1.58) had lower overall mean peer-scores (2.98 vs 3.79, P = 0.0150) than surgeons in the lowest quartile (n = 6, ratio 0.94). Complication rates between top and bottom quartiles were similar after SG, however leak rates were higher with gastric bypass among surgeons who over-rated their skill with SG (0.65 vs 0.27, P = 0.0181). Surgeon experience was similar between comparison groups. CONCLUSIONS AND RELEVANCE: Self-perceptions of surgical skill varied widely. Surgeons who over-rated their skill had higher leak rates for more complex procedures. Video assessments can help identify surgeons with poor self-awareness who may benefit from a surgical coaching program.

Evaluation of Patient Reported Gastroesophageal Reflux Severity at Baseline and at 1-year After Bariatric Surgery.

OBJECTIVE: To assess patient-reported gastroesophageal reflux disease (GERD) severity before and after SG and Roux-en-Y gastric bypass (RYGB). SUMMARY OF BACKGROUND DATA: Development of new-onset or worsening GERD symptoms after bariatric surgery varies by procedure, but there is a lack of patient-reported data to help guide decision-making. Methods: Retrospective cohort study of patients undergoing bariatric surgery in a statewide quality collaborative between 2013 and 2017. We used a validated GERD survey with symptom scores ranging from 0 (no symptoms) to 5 (severe daily symptoms) and included patients who completed surveys both at baseline and 1-year after surgery (n = 10,451). We compared the rates of improved and worsened GERD symptoms after SG and RYGB. RESULTS: Within our study cohort, 8680 (83%) underwent SG and 1771 (17%) underwent RYGB. Mean baseline score for all patients was 0.94. Patients undergoing SG experienced similar improvement in GERD symptoms when compared to RYGB (30.4% vs 30.8%, P = 0.7015). However, SG patients also reported higher rates of worsening symptoms (17.8% vs 7.5%, P < 0.0001) even though they were more likely to undergo concurrent hiatal hernia repair (35.1% vs 20.0%, P<0.0001). More than half of patients (53.5%) did not report a change in their score. CONCLUSIONS: Although SG patients reported higher rates of worsening GERD symptoms when compared to RYGB, the majority of patients (>80%) in this study experienced improvement or no change in GERD regardless of procedure. Using clinically relevant patient-reported outcomes can help guide decisions about procedure choice in bariatric surgery for patients with GERD.

Bariatric Surgery in Medicare Patients: Examining Safety and Healthcare Utilization in the Disabled and Elderly.

OBJECTIVE: To compare safety and healthcare utilization after sleeve gastrectomy versus Roux-en-Y gastric bypass in a national Medicare cohort. SUMMARY BACKGROUND DATA: Though bariatric surgery is increasing among Medicare beneficiaries, no long-term, national studies examining comparative effectiveness between procedures exist. Bariatric outcomes are needed for shared decision-making and coverage policy concerns identified by the cMS Medicare Evidence Development and Coverage Advisory Committee. METHODS: Retrospective instrumental variable analysis of Medicare claims (2012-2017) for 30,105 bariatric surgery patients entitled due to disability or age. We examined clinical safety outcomes (mortality, complications, and reinterventions), healthcare utilization [Emergency Department (ED) visits, rehospitalizations, and expenditures], and heterogeneity of treatment effect. We compared all outcomes between sleeve and bypass for each entitlement group at 30 days, 1 year, and 3 years. RESULTS: Among the disabled (n = 21,595), sleeve was associated with lower 3-year mortality [2.1% vs 3.2%, absolute risk reduction (ARR) 95% confidence interval (CI): -2.2% to -0.03%], complications (22.2% vs 27.7%, ARR 95%CI: -8.5% to -2.6%), reinterventions (20.1% vs 27.7%, ARR 95%CI: -10.7% to -4.6%), ED utilization (71.6% vs 77.1%, ARR 95%CI: -8.5% to -2.4%), and rehospitalizations (47.4% vs 52.3%, ARR 95%Ci: -8.0% to -1.7%). Cumulative expenditures were $46,277 after sleeve and $48,211 after bypass (P = 0.22). Among the elderly (n = 8510), sleeve was associated with lower 3-year complications (20.1% vs 24.7%, ARR 95%CI: -7.6% to -1.7%), reinterventions (14.0% vs 21.9%, ARR 95%CI: -10.7% to -5.2%), ED utilization (51.7% vs 57.2%, ARR 95%CI: -9.1% to -1.9%), and rehospitalizations (41.8% vs 45.8%, ARR 95%Ci: -7.5% to -0.5%). Expenditures were $38,632 after sleeve and $39,270 after bypass (P = 0.60). Procedure treatment effect significantly differed by entitlement for mortality, revision, and paraesophageal hernia repair. CONCLUSIONS: Bariatric surgery is safe, and healthcare utilization benefits of sleeve over bypass are preserved across both Medicare elderly and disabled subpopulations.

Comparative Safety of Sleeve Gastrectomy and Gastric Bypass: An Instrumental Variables Approach.

OBJECTIVE: To compare the safety of sleeve gastrectomy and gastric bypass in a large cohort of commercially insured bariatric surgery patients from the IBM MarketScan claims database, while accounting for measurable and unmeasurable sources of selection bias in who is chosen for each operation. SUMMARY OF BACKGROUND DATA: Sleeve gastrectomy has rapidly become the most common bariatric operation performed in the United States, but its longer-term safety is poorly described, and the risk of worsening gastroesophageal reflux requiring revision may be higher than previously thought. Prior studies comparing sleeve gastrectomy to gastric bypass are limited by low sample size (in randomized trials) and selection bias (in observational studies). METHODS: Instrumental variables analysis of commercially insured patients in the IBM MarketScan claims database from 2011 to 2018. We studied patients undergoing bariatric surgery from 2012 to 2016. We identified re-interventions and complications at 30 days and 2 years from surgery using Comprehensive Procedural Terminology and International Classification of Disease (ICD)-9/10 codes. To overcome unmeasured confounding, we use the prior year's sleeve gastrectomy utilization within each state as an instrumental variable-exploiting variation in the timing of payers' decisions to cover sleeve gastrectomy as a natural experiment. RESULTS: Among 38,153 patients who underwent bariatric surgery between 2012 and 2016, the share of sleeve gastrectomy rose from 52.6% (2012) to 75% (2016). At 2 years from surgery, patients undergoing sleeve gastrectomy had fewer re-interventions (sleeve 9.9%, bypass 15.6%, P < 0.001) and complications (sleeve 6.6%, bypass 9.6%, P = 0.001), and lower overall healthcare spending ($47,891 vs $55,213, P = 0.003), than patients undergoing gastric bypass. However, at the 2-year mark, revisions were slightly more common in sleeve gastrectomy than in gastric bypass (sleeve 0.6%, bypass 0.4%, P = 0.009). CONCLUSIONS AND RELEVANCE: In a large cohort of commercially insured patients, sleeve gastrectomy had a superior safety profile to gastric bypass up to 2 years from surgery, even when accounting for selection bias. However, the higher risk of revisions in sleeve gastrectomy merits further exploration.

Comparative effectiveness of sleeve gastrectomy vs Roux-en-Y gastric bypass in patients giving birth after bariatric surgery: reinterventions and obstetric outcomes.

BACKGROUND: Women of childbearing age comprise approximately 65% of all patients who undergo bariatric surgery in the USA. Despite this, data on maternal reintervention and obstetric outcomes after surgery are limited especially with regard to comparative effectiveness between sleeve gastrectomy and Roux-en-Y gastric bypass, the most common procedures today. METHODS: Using IBM MarketScan claims data, we performed a retrospective cohort study of women ages 18-52 who gave birth after undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass with 2-year continuous follow-up. We balanced the cohort on observable characteristics using inverse probability weighting. We utilized multivariable logistic regression to examine the association between procedure selection and outcomes, including risk of reinterventions (revisions, enteral access, vascular access, reoperations, other) or adverse obstetric outcomes (pregnancy complications, severe maternal morbidity, and delivery complications). In all analyses, we controlled for age, U.S. state, and Elixhauser or Bateman comorbidities. RESULTS: From 2011 to 2016, 1,079 women gave birth within the first two years after undergoing bariatric surgery. Among these women, we found no significant difference in reintervention rates among those who had gastric bypass compared to sleeve gastrectomy (OR 1.41, 95% CI 0.91-2.21, P = 0.13). We then examined obstetric outcomes in the patients who gave birth after bariatric surgery. Compared to patients who underwent sleeve gastrectomy, those who had Roux-en-Y gastric bypass were not significantly more likely to experience any adverse obstetric outcomes. CONCLUSION: In this first national cohort of females giving birth following bariatric surgery, no significant difference was observed in persons who underwent Roux-en-Y gastric bypass versus sleeve gastrectomy with respect to either reinterventions or obstetric outcomes. This suggests possible equipoise between these two procedures with regards to safety within the first two years following a bariatric procedure among women who may become pregnant, but more research is needed to confirm these findings in larger samples.

Association of Historic Housing Policy, Modern Day Neighborhood Deprivation and Outcomes After Inpatient Hospitalization.

OBJECTIVE: To evaluate the association of historical racist housing policies and modern-day healthcare outcomes. SUMMARY OF BACKGROUND DATA: In 1933 the United States Government Home Owners Loan Corporation (HOLC) used racial composition of neighborhoods to determine creditworthiness and labeled them "Best", "Still Desirable", "Definitely Declining", and "Hazardous." Although efforts have been made to reverse these racist policies that structurally disadvantage those living in exposed neighborhoods, the lasting legacy on modern day healthcare outcomes is uncertain. METHODS: We performed a cross-sectional retrospective review of 212,179 Medicare beneficiaries' living in 171,930 unique neighborhoods historically labeled by the HOLC who underwent 1 of 5 of common surgical procedures - coronary artery bypass, appendectomy, colectomy, cholecystectomy, and hernia repair - between 2012 and 2018. We compared 30-day mortality, complications, and readmissions across HOLC grade and Area Deprivation Index (ADI) of each neighborhood. Outcomes were risk-adjusted using a multivariable logistical regression model accounting for patient factors (age, sex, Elixhauser comorbidities), admission type (elective, urgent, emergency), type of operation, and each neighborhoods ADI; a modern day measure of neighborhood disadvantage that includes education, employment, housing-quality, and poverty measures. RESULTS: Overall, 212,179 Medicare beneficiaries (mean age, 71.2 years; 54.2% women) resided in 171,930 unique neighborhoods historically graded by the HOLC. Outcomes worsened in a stepwise fashion across HOLC neighborhoods. Overall, 30-day postoperative mortality was 5.4% in "Best" neighborhoods, 5.8% in "Still Desirable", 6.1% in "Definitely Declining", and 6.4% in "Hazardous" (Best vs Hazardous Odds Ration: 1.23, 95% CI: 1.13-1.24, P < 0.001). The same stepwise pattern was seen from "Best" to "Hazardous" neighborhoods for complications (30.5% vs 32.2%; OR: 1.12 [95% CI: 1.07-1.17]; P < 0.001) and Readmissions (16.3% vs 17.1%; OR: 1.06 [95% CI: 1.01-1.11]; P = 0.023). After controlling for modern day deprivation using ADI, the patterns persisted with "Hazardous" neighborhoods having higher mortality (OR: 1.17 [95% CI: 1.08-1.27]; P < 0.001) and complications (OR: 1.07 [95% CI: 1.02-1.12]; P = 0.003), but not for readmissions (OR: 1.02 [95% CI: 0.97-1.07]; P = 0.546). CONCLUSIONS: Patients residing in neighborhoods previously "redlined" or labeled "Hazardous" were more likely to experience worse outcomes after inpatient hospitalization compared to those living in "Best" neighborhoods, even after taking into account modern day measures of neighborhood disadvantage.

Evaluating the Effect of Surgical Skill on Outcomes for Laparoscopic Sleeve Gastrectomy: A Video-based Study.

BACKGROUND: Prior studies have demonstrated a correlation between surgical skill and complication rates after laparoscopic Roux-en-Y gastric bypass. However, the impact of surgical skill on a similar but less technically challenging procedure such as sleeve gastrectomy (SG) is unknown. METHODS: Practicing bariatric surgeons (n = 25) participating in a statewide quality improvement collaborative submitted an unedited deidentified video of a representative laparoscopic SG. Videos were obtained between 2015 and 2016 and were rated by bariatric surgeons in a blinded fashion using a validated instrument that assesses surgical skill. Overall scores were based on a 5-point Likert scale with 5 representing a "master surgeon" and 1 representing a "surgeon-in-training." Risk-adjusted 30-day complication rates, 1-year weight loss among cases performed during the study period, and operative technique were compared between surgeons rated in the top and bottom quartiles according to skill. RESULTS: Surgeon ratings for skill varied between 2.73 and 4.60. Ratings for skill did not correlate with overall 30-day risk-adjusted complication rates (Pearson correlation coefficient, 0.213, P = 0.303). However, surgeons with higher skill ratings had lower rates of specific surgical complications, including postoperative obstruction (0.13% vs 0.3%, P = 0.017), hemorrhage (0.85% vs 1.27%, P = 0.005), and reoperation (0.24% vs 0.92%, P < 0.0001). Surgeons ranked in the top quartile for skill had faster operating times for SG (59.0 vs 82.1 min, P < 0.0001) and higher annual case volumes for both SG and any bariatric procedure (224.3 cases/yr vs 73.4 cases/yr, P = 0.009 and 244.9 cases/yr and 93.9 cases/yr, P = 0.009) when compared with surgeons in the bottom quartile. When comparing operative technique, top rated surgeons were noted to have a higher likelihood of using buttressing (83.3% vs 0%, P = 0.0041) and intraoperative endoscopy (83.3% vs 0%, P = 0.0041). CONCLUSIONS: Peer ratings for surgical skill varied for laparoscopic sleeve gastrectomy but did not have a significant impact on overall complication rates. Top rated surgeons had lower rates of obstruction, hemorrhage, and reoperation; however, severe morbidity remained extremely low among all surgeons.

Association of a Statewide Surgical Coaching Program With Clinical Outcomes and Surgeon Perceptions.

OBJECTIVE: To assess risk-adjusted outcomes and participant perceptions following a statewide coaching program for bariatric surgeons. SUMMARY OF BACKGROUND DATA: Coaching has emerged as a new approach for improving individual surgeon performance, but lacks evidence linking to clinical outcomes. METHODS: This program took place between October 2015 and February 2018 in the Michigan Bariatric Surgery Collaborative. Surgeons were categorized as coach, participant, or nonparticipant for an interrupted time series analysis. Multilevel logistic regression models included patient characteristics, time trends, and number of sessions. Risk-adjusted overall and surgical complication rates are reported, as are within-group relative risk ratios and 95% confidence intervals. We also compared operative times and report risk differences and 95% confidence intervals. Iterative thematic analysis of semi-structured interviews examined participant and coach perceptions of the program. RESULTS: The coaching program was viewed favorably by most surgeons and many participants described numerous technical and nontechnical practice changes. The program was not associated with significant change in risk-adjusted complications with relative risks for coaches, participants, and nonparticipants of 0.99 (0.62-1.37), 0.91 (0.64-1.17), and 1.15 (0.83-1.47), respectively. Operative times did improve for participants, but not coaches or nonparticipants, with risk differences of -14.0 (-22.3, -5.7), -1.0 (-4.5, 2.4), and -2.6 (-6.9, 1.7). Future coaching programmatic design should consider dose-complexity matching, hierarchical leveling, and optimizing video review. CONCLUSIONS: This statewide surgical coaching program was perceived as valuable and surgeons reported numerous practice changes. Operative times improved, but there was no significant improvement in risk-adjusted outcomes.

In the eye of the beholder: surgeon variation in intra-operative perceptions of hiatal hernia and reflux outcomes after sleeve gastrectomy.

BACKGROUND: Hiatal hernia repair performed at the time of laparoscopic sleeve gastrectomy (LSG) may reduce post-operative reflux symptoms. It is unclear whether intra-operative diagnosis of hiatal hernia varies among surgeons or if it affects outcomes. STUDY DESIGN: Surgeons (n = 38) participating in a statewide bariatric surgery quality improvement collaborative reviewed 33 videos of LSG in which no hiatal hernia repair was performed. Reviewers were blinded to patient information and were asked whether they perceived a hiatal hernia. Surgeon characteristics and surgeon-specific patient outcomes for LSG were compared between surgeons who identified at least one hiatal hernia during video review and those who did not. RESULTS: Ten surgeons (26%) identified at least one hiatal hernia after reviewing the videos. There were no significant differences in operative experience or practice type between surgeons who did and did not identify hiatal hernias. Surgeons who identified a hiatal hernia more often performed concurrent hiatal hernia repair in their practice when compared to those who did not (43.0% versus 36.5%, p < 0.001). Although complication rates were similar between surgeon groups, there were higher rates of de novo reflux symptoms (13.6% versus 11.1%, p = 0.032) and lower rates of antacid discontinuation at one-year (71.0% versus 77.2%, p = 0.043) among surgeons who identified hiatal hernias. CONCLUSION: Surgeons who identified hiatal hernias during video review had a higher rate of concurrent hiatal hernia repairs in their practice. This was not associated with improved patient-reported reflux symptoms after LSG. Standardizing identification and management of hiatal hernias during bariatric surgery may help improve reflux outcomes post-operatively.

Medicare's Hospital Acquired Condition Reduction Program Disproportionately Affects Minority-serving Hospitals: Variation by Race, Socioeconomic Status, and Disproportionate Share Hospital Payment Receipt.

OBJECTIVE: To assess whether a hospital's percentage of Black patients associates with variations in FY2017 overall/domain-specific Hospital Acquired-Condition Reduction Program (HACRP) scores and penalty receipt. Differences in socioeconomic status and receipt of disproportionate share hospital payments (a marker of safety-net status) were also assessed. SUMMARY OF BACKGROUND DATA: In FY2015, Medicare began reducing payments to hospitals with high adverse event rates. Concern has been expressed that HACRP penalties could adversely affect minority-serving hospitals, leading to reductions in resources and exasperation of disparities among hospitals with the greatest need. METHODS: 100% Medicare FFS claims from 2013 to 2014 identified older adult inpatients, aged ≥65 years, presenting for 8 common surgical conditions. Multilevel mixed-effects regression determined differences in FY2017 HACRP scores/penalties among hospitals managing the highest decile of minority patients. RESULTS: A total of 695,775 patients from 2923 hospitals were included. As a hospital's percentage of Black patients increased, climbing from 0.6% to 32.5% (lowest vs highest decile), average HACRP scores also increased, rising from 5.33 to 6.36 (higher values indicate worse scores). Increases in HACRP penalties did not follow the same stepwise increase, instead exhibiting a marked jump within the highest decile of racial minority-serving extent (45.7% vs 36.7%; OR [95% CI]: 1.45[1.42-1.47]). Similar patterns were observed for high disproportionate share hospital (OR [95% CI]: 1.44 [1.42-1.47]; absolute difference: +7.4 percentage-points) and low socioeconomic status-serving (1.38[1.35-1.40]; +7.3% percentage-points) hospitals. Restricted analyses accounting for the influence of teaching status and severity of patient case-mix both accentuated disparities in HACRP penalties when limiting hospitals to those at the highest known penalty-risk (more residents-to-beds, more severe), absolute differences +13.9, +20.5 percentage-points. Restriction to high operative volume, in contrast, reduced the penalty difference, +6.6 percentage-points. CONCLUSIONS: Minority-serving hospitals are being disproportionately penalized by the HACRP. As the program continues to develop, efforts are needed to identify and protect patients in vulnerable institutions to ensure that disparities do not increase.

Surgeon variation in severity of reflux symptoms after sleeve gastrectomy.

BACKGROUND: Prior studies have demonstrated an increase in gastroesophageal reflux after laparoscopic sleeve gastrectomy (LSG). However, it is unknown whether symptom severity varies or if outcomes are surgeon-specific. METHODS: A validated reflux symptom survey was obtained at baseline and at 1 year after primary LSG on 7358 patients participating in a state-wide quality improvement collaborative between 2013 and 2018. Patients with worsening symptoms after surgery were divided into terciles based on the degree of increase in survey score (0 = no symptoms, 50 = max symptoms). Surgeon-level data was obtained on 52 bariatric surgeons performing at least 25 LSG cases/year during the study period. Surgeon characteristics, operative experience, and risk-adjusted 30-day complication rates were compared between surgeons in the highest tercile for moderate worsening of symptoms vs those in the lowest. RESULTS: A total of 2294 (31.2%) patients had worsening symptoms of reflux after sleeve gastrectomy. Overall mean increase in severity score was 6.11 (range 1 to 48) and patients with minimal, mild, and moderate symptoms had a mean increase of 1.4, 4.2, and 13.8, respectively. There were no significant differences in surgeon-specific characteristics when comparing surgeons in the highest tercile for moderate worsening of symptoms (44.7% of patients) vs those in the lowest tercile (18.7% of patients). In addition, there were no significant differences in risk-adjusted rates of overall complications (3.70% vs. 4.33%, p = 0.686), endoscopic dilations (2.83% vs. 1.91%, p = 0.417), or concurrent hiatal hernia repair (34.3% vs. 27.0%, p = 0.415) between surgeons in the highest and lowest terciles. CONCLUSIONS: We found that 1/3 of patients had worsening symptoms of reflux after LSG and that severity of symptoms varied. Surgeons with the highest rates of worsening reflux had similar operative experience and complication rates than those with the lowest. Further assessment of operative technique and skill may be informative.

Early Impact of Medicare Accountable Care Organizations on Inpatient Surgical Spending.

OBJECTIVE: To evaluate whether hospital participation in accountable care organizations (ACOs) is associated with reduced Medicare spending for inpatient surgery. BACKGROUND: ACOs have proliferated rapidly and now cover more than 32 million Americans. Medicare Shared Savings Program (MSSP) ACOs have shown modest success in reducing medical spending. Whether they have reduced surgical spending remains unknown. METHODS: We used 100% Medicare claims from 2010 to 2014 for patients aged 65 to 99 years undergoing 6 common elective surgical procedures [abdominal aortic aneurysm (AAA) repair, colectomy, coronary artery bypass grafting (CABG), hip or knee replacement, or lung resection]. We compared total Medicare payments for 30-day surgical episodes, payments for individual components of care (index hospitalization, readmissions, physician services, and postacute care), and clinical outcomes for patients treated at MSSP ACO hospitals versus matched controls at non-ACO hospitals. We accounted for preexisting trends independent of ACO participation using a difference-in-differences approach. RESULTS: Among 341,675 patients at 427 ACO hospitals and 1,024,090 matched controls at 1531 non-ACO hospitals, patient and hospital characteristics were well-balanced. Average baseline payments were similar at ACO versus non-ACO hospitals. ACO participation was not associated with reductions in total Medicare payments [difference-in-differences estimate=-$72, confidence interval (CI95%): -$228 to +$84] or individual components of payments. ACO participation was also not associated with clinical outcomes. Duration of ACO participation did not affect our estimates. CONCLUSION: Although Medicare ACOs have had success reducing spending for medical care, they have not had similar success with surgical spending. Given that surgical care accounts for 30% of total health care costs, ACOs and policymakers must pay greater attention to reducing surgical expenditures.

Hot Spotting as a Strategy to Identify High-Cost Surgical Populations.

OBJECTIVE: The aim of this study was to determine the feasibility of "hot spotting" in elective surgical populations. BACKGROUND: Prospective identification of high-cost patients, known as "hot spotting," is well developed in medical populations, but has not been performed in surgical populations. Population-based management of surgical expenditures requires identification of high-cost surgical patients to allow for effective implementation of cost-saving strategies. METHODS: Using 100% Medicare claims data for 2010 to 2013, we identified patients aged 65 to 99 years undergoing elective surgical procedures. We calculated price-standardized Medicare payments for the surgical episode from the index admission through 30 days after discharge. Patient-level factors associated with payments were analyzed by multivariable linear regression. RESULTS: Medicare patients in the highest decile of spending accounted for a disproportionate share of aggregate costs: 30% in Colectomy (COL), 22% in coronary artery bypass grafting (CABG), 19% in Total Hip Arthroplasty, and 18% in Total Knee Arthroplasty. Medicare expenditure differences between the highest and lowest deciles were because of a 5-fold difference for COL and 3-fold difference for CABG in index hospitalization cost. In contrast, for orthopedic procedures, there were 47- to 80-fold post-acute care expenditures between highest and lowest deciles. In multivariable analyses, patients with ≥3 comorbidities had significantly higher costs than healthier patients. CONCLUSION: We found that a subset of multimorbid patients was responsible for a disproportionate share of total Medicare spending, but the individual components of spending vary by procedure. These findings suggest that targeting high-cost Medicare patients (ie, hot spotting) for cost containment efforts would be a potentially effective strategy to reduce costs in surgical populations.

Assessing variation in technique for sleeve gastrectomy based on outcomes of surgeons ranked by safety and efficacy: a video-based study.

BACKGROUND: Considerable technical variation exists when performing laparoscopic sleeve gastrectomy (LSG). However, little is known about which techniques are associated with optimal outcomes. OBJECTIVE: To compare technical variation among surgeons with the lowest complication rates and whose patients achieved the most weight loss. METHODS: Practicing bariatric surgeons (n = 30) voluntarily submitted a video of a typical LSG performed between 2015 and 2016. Technique-specific data captured from videos and a questionnaire included bougie size, stapler vendor, number of staple loads, use of staple line reinforcement, fibrin sealant, intraoperative leak test, endoscopy, and drain placement. Surgeon-specific outcomes were obtained from cases performed by surgeons during the study period (n = 7023) using a state-wide bariatric-specific data registry. Surgeons were ranked based on 30-day risk-adjusted surgical complication rates ("safety") and excess body weight loss (EBWL) % ("efficacy") at 1 year after surgery. Technique-specific variables were compared between surgeons ranked in the top and bottom quartile for both safety and efficacy. RESULTS: Surgical complication rates ranged from 0 to 4.32% while EBWL varied from 45.3 to 65.3%. There was no correlation between surgeon rankings for safety and efficacy (Pearson's r = 0.063, p = 0.741). Surgeons ranked in the top quartile for safety and efficacy had significantly shorter mean operative times than surgeons ranked in the bottom quartile (65 min vs. 69 min, p < 0.0001). Surgeons with the highest leak rates were more likely to use buttressing (85.7% vs 40.0%, p = 0.032), otherwise operative techniques varied considerably. CONCLUSIONS: Technical variation appears to have minimal effect on the safety or efficacy of sleeve gastrectomy among surgeons participating in a state-wide quality improvement collaborative. Top ranked surgeons did have faster mean operative times indicating that there may be other metrics of technical quality that correlate to optimal outcomes.

Hospital quality, patient risk, and Medicare expenditures for cancer surgery.

BACKGROUND: Surgical resection is a cornerstone of curative-intent therapy for patients with solid organ malignancies. With increasing attention paid to the costs of surgical care, there is a new focus on variations in the costs of cancer surgery. This study evaluated the potential interactive effect of hospital quality and patient risk on expenditures for cancer resections. METHODS: With 100% Medicare claim data for 2010-2013, patients aged 65 to 99 years who had undergone cancer resection were identified. Medicare payments were calculated for the surgical episode from the index admission through 30 days after discharge. Risk- and reliability-adjusted hospital rates of serious complications and mortality within 30 days of the index operation were assessed to categorize high- and low-quality hospitals. RESULTS: There was no difference in patient characteristics between the highest and lowest quality hospitals. There were substantial increases in expenditures for procedures performed at the lowest quality hospitals for each procedure. Increased expenditures at the lowest quality hospitals were found for all patients, but they were highest for the highest risk patients. At low-quality hospitals, low-risk patients undergoing pancreatectomy had payments of $29,080, whereas high-risk patients had average payments of $62,687; this was a difference of $33,607 per patient episode. CONCLUSIONS: Total episode expenditures for cancer resections were lower when care was delivered at low-complication, high-quality hospitals. Expenditure differences were particularly large for high-risk patients, and this suggests that the selective referral of high-risk patients to high-quality centers may be an effective strategy for optimizing value in cancer surgery. Cancer 2018;124:826-32. © 2017 American Cancer Society.

Strategies for Reducing Population Surgical Costs in Medicare: Local Referrals to Low-cost Hospitals.

OBJECTIVE: We sought to assess hospital cost variation for elective inpatient surgical procedures within small geographic areas. SUMMARY BACKGROUND DATA: Previous studies have documented cost variation for inpatient surgical procedures on a national basis, suggesting opportunities for savings. Cost variation within small geographic areas is more relevant to policymakers, providers, and patients, but it has not been studied. METHODS: Using Medicare payment data, we identified elderly patients undergoing 1 of 7 elective inpatient surgical procedures during 2010-2012. We calculated 30-day surgical episode costs including payments for the index hospitalization, readmission, physician services, and post-acute care. Using hierarchical regression models, we identified hospitals with significantly higher average costs than the least expensive hospitals in their metropolitan statistical areas. RESULTS: The proportion of patients undergoing surgery at the lowest-cost hospitals in their metropolitan statistical areas ranged from 10% for hip replacement to 25% for coronary artery bypass grafting. In contrast, the proportion of patients undergoing surgery at significantly higher-cost hospitals ranged from 5.0% for bariatric surgery to 64% for hip replacement. These high-cost hospitals had higher complication and readmission rates than their lowest-cost peers. Surgery at high-cost hospitals resulted in Medicare expenditures that were $4427 to $10,417 higher than those at the lowest-cost hospitals, increasing episode costs by 25% to 47% per case. CONCLUSIONS: Significant excess expenditures are incurred due to care at hospitals with substantially higher average costs than their nearby peers. This finding highlights the potential for substantial savings without the need to refer patients over long distances. Some of the procedures studied may represent appropriate targets for future Medicare bundled payment initiatives.