Comparative analysis of short-term outcomes after bariatric surgery between two disparate populations.
ABSTRACT Risk adjustment is a critically important aspect of outcomes research. Racial, geographic, cultural, and socioeconomic differences are nonclinical parameters that can affect clinical outcomes measurement after gastric bypass surgery.
A single surgeon's experience with 217 consecutive laparoscopic gastric bypass patients in private practice in Southern California was compared with the same surgeon's experience with 124 consecutive patients in an academic institution in Philadelphia.
Of the Southern California and Philadelphia groups, 89%, 1%, 9%, and 1% and 55%, 38%, 6%, and 0% were white, black, Hispanic, and Asian, respectively. The average number of co-morbidities was 7.8 in the Southern California group versus 14.4 in the Philadelphia group (P <.001). The 60-day readmission to the hospital rate and emergency room admission rate was 1.4% versus 10.4% and 1.4% versus 18.5%. The insurer mix of private pay, private insurer, and federally funded insurer was 20%, 80%, and 0% in the Southern California group and 0.8%, 71%, and 28% in the Philadelphia group, respectively. Multivariate logistic regression analysis found Medicaid status and practice location independently predicted for the 60-day readmission rate (odds ratio [OR] 3.7, P = .04 and OR 5.6, P = .04, respectively) and a return to the emergency room (OR 3.2, P = .03 and OR 16.3, P <.001). Race, income, and the presence of diabetes were not independent predictors. Variables with nonsignificant differences between the Southern California and Philadelphia cohorts included average age, average body mass index, and major complications (return to surgery and intensive care unit admissions).
The results of this study have shown that in comparing and predicting the outcomes after bariatric surgery, adjustment for demographic and insurance variables might be necessary to improve accuracy.
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ABSTRACT: Case series demonstrate that bariatric surgery can be performed with a low rate of perioperative mortality (0.5%), but the rate among high-risk patients and the community at large is unknown. To evaluate the risk of early mortality among Medicare beneficiaries and to determine the relative risk of death among older patients. Retrospective cohort study. All fee-for-service Medicare beneficiaries, 1997-2002. Thirty-day, 90-day, and 1-year postsurgical all-cause mortality among patients undergoing bariatric procedures. A total of 16 155 patients underwent bariatric procedures (mean age, 47.7 years [SD, 11.3 years]; 75.8% women). The rates of 30-day, 90-day, and 1-year mortality were 2.0%, 2.8%, and 4.6%, respectively. Men had higher rates of early death than women (3.7% vs 1.5%, 4.8% vs 2.1%, and 7.5% vs 3.7% at 30 days, 90 days, and 1 year, respectively; P<.001). Mortality rates were greater for those aged 65 years or older compared with younger patients (4.8% vs 1.7% at 30 days, 6.9% vs 2.3% at 90 days, and 11.1% vs 3.9% at 1 year; P<.001). After adjustment for sex and comorbidity index, the odds of death within 90 days were 5-fold greater for older Medicare beneficiaries (aged > or =75 years; n = 136) than for those aged 65 to 74 years (n = 1381; odds ratio, 5.0; 95% confidence interval, 3.1-8.0). The odds of death at 90 days were 1.6 times higher (95% confidence interval, 1.3-2.0) for patients of surgeons with less than the median surgical volume of bariatric procedures (among Medicare beneficiaries during the study period) after adjusting for age, sex, and comorbidity index. Among Medicare beneficiaries, the risk of early death after bariatric surgery is considerably higher than previously suggested and associated with advancing age, male sex, and lower surgeon volume of bariatric procedures. Patients aged 65 years or older had a substantially higher risk of death within the early postoperative period than younger patients.JAMA The Journal of the American Medical Association 10/2005; 294(15):1903-8. · 29.98 Impact Factor
- Surgery for Obesity and Related Diseases 01/2007; 3(1):91-3. · 4.12 Impact Factor
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ABSTRACT: To evaluate pre- and postoperative clinical parameters associated with improvement of diabetes up to 4 years after laparoscopic Roux-en-Y gastric bypass (LRYGBP) in patients with type 2 diabetes mellitus (T2DM). The surgical treatment of morbid obesity leads to dramatic improvement in the comorbidity status of most patients with T2DM. However, little is known concerning what preoperative clinical factors are associated with postoperative long-term improvement in diabetes in the morbidly obese patient with diabetes. METHODS We evaluated pre- and postoperative data, including demographics, duration of diabetes, metabolic parameters, and clinical outcomes, in all patients with impaired fasting glucose (IFG) and type T2DM undergoing LRYGBP from July 1997 to May 2002. During this 5-year period, 1160 patients underwent LRYGBP and 240 (21%) had IFG or T2DM. Follow up was possible in 191 of 240 patients (80%). There were 144 females (75%) with a mean preoperative age of 48 years (range, 26-67 years). After surgery, weight and body mass index decreased from 308 lbs and 50.1 kg/m2 to 211 lbs and 34 kg/m2 for a mean weight loss of 97 lbs and mean excess weight loss of 60%. Fasting plasma glucose and glycosylated hemoglobin concentrations returned to normal levels (83%) or markedly improved (17%) in all patients. A significant reduction in use of oral antidiabetic agents (80%) and insulin (79%) followed surgical treatment. Patients with the shortest duration (<5 years), the mildest form of T2DM (diet controlled), and the greatest weight loss after surgery were most likely to achieve complete resolution of T2DM. LRYGBP resulted in significant weight loss (60% percent of excess body weight loss) and resolution (83%) of T2DM. Patients with the shortest duration and mildest form of T2DM had a higher rate of T2DM resolution after surgery, suggesting that early surgical intervention is warranted to increase the likelihood of rendering patients euglycemic.Annals of Surgery 10/2003; 238(4):467-84; discussion 84-5. · 6.33 Impact Factor