Early Mortality Among Medicare Beneficiaries
Undergoing Bariatric Surgical Procedures
David R. Flum, MD, MPH
Leon Salem, MD
Jo Ann Broeckel Elrod, PhD
E. Patchen Dellinger, MD
Allen Cheadle, PhD
Leighton Chan, MD, MPH
procedures are the only interven-
tions2that consistently help patients
loss and improvements in comorbid
has been dramatic growth in bariatric
surgery over the last decade, with in-
based on associated medical condi-
tions and the growing population of
risks of perioperative death and short-
term adverse outcomes. These risks
have been poorly defined in the com-
largely derived from case series.4Sev-
eral high-profile reports of death after
estimates and have triggered a critical
reappraisal of bariatric surgical safety.
Medicare, the United States’ largest
health care insurer, currently reim-
gional basis and is the primary payer
for approximately 20% of all proce-
dures performed in at least 1 state.7
However, Medicare policy in this area
is at a crossroads: there is no national
N THEUNITEDSTATES, MOST ADULTS
sity is soon to become the leading
cause of death. Bariatric surgical
garding the efficacy and safety of bar-
medical decision making. A second-
verse outcomes among older Medi-
care beneficiaries undergoing these
procedures compared with that of
We used a retrospective cohort design,
using Medicare National Claims His-
tory Part B data from January 1, 1996,
through December 31, 2002, that con-
See also pp 1909, 1918, 1957, and
1960, and Patient Page.
Salem, Broeckel Elrod, and Dellinger), Health Ser-
vision of Clinical Standards and Quality, Centers for
partment of Surgery, University of Washington, Box
356410, 1959 NE Pacific St, Seattle, WA 98195-
Context 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.
Objectives To evaluate the risk of early mortality among Medicare beneficiaries and
to determine the relative risk of death among older patients.
Design Retrospective cohort study.
Setting and Patients All fee-for-service Medicare beneficiaries, 1997-2002.
Main Outcome Measures Thirty-day, 90-day, and 1-year postsurgical all-cause
mortality among patients undergoing bariatric procedures.
Results A total of 16155 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 mor-
tality 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 comor-
bidity index, the odds of death within 90 days were 5-fold greater for older Medicare
beneficiaries (aged ?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.
Conclusions Among Medicare beneficiaries, the risk of early death after bariatric
surgery is considerably higher than previously suggested and associated with advanc-
ing 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 postopera-
tive period than younger patients.
©2005 American Medical Association. All rights reserved.
(Reprinted) JAMA, October 19, 2005—Vol 294, No. 15
at University Hospitals Of Clevel, on October 24, 2005 www.jama.com Downloaded from
65 years, comparisons of outcome be-
tween those aged 65 years or older and
younger patients may be biased. Medi-
years may have a higher burden of co-
morbid conditions than older patients
and this might be expected to act as a
conservative bias in that we demon-
the older population.
tem; rather, a specific disabling condi-
tion is required for coverage. This data
determine if obesity-related comorbid
extreme obesity are often the justifica-
tion for these disability claims. These
that the measure for surgeon volume
only counts procedures performed
ter 1996. These would tend to under-
estimate surgeons’ procedure volume
if they had performed any procedures
riod. This might have acted as a con-
servative bias given our findings link-
ing surgeon inexperience to adverse
outcomes, but surgeons who perform
more procedures among CMS benefi-
ciaries may be different in other ways
than other surgeons.
cedures to evaluate the relationship of
evaluations of other abdominal opera-
tions,26“hospital volume” effects are
largely related to “surgeon volume” ef-
fects and, when available, surgeon vol-
fore, appropriate measure of outcome
that relates to technical factors. While
multidisciplinary care and other hospi-
tal resources may play a role in adverse
these outcomes. Last, surgeon identifi-
ers used to derive the volume variable
were missing in approximately 11% of
Complete and incomplete cases were
be similar but the possibility that cases
not be excluded.
In conclusion, this study found that
Medicare beneficiaries undergoing bar-
iatric surgery was considerably higher
age, male sex, and lower surgeon vol-
verse outcomes against the anticipated
of older patients to surgeons who per-
form higher volume of bariatric proce-
expected to improve outcomes in this
Author Contributions: Dr Flum had full access to all of
rity of the data and the accuracy of the data analysis.
Study concept and design: Flum, Dellinger, Chan.
Acquisition of data: Flum, Salem, Dellinger, Chan.
Analysis and interpretation of data: Flum, Broeckel
Elrod, Dellinger, Cheadle, Chan.
Drafting of the manuscript: Flum, Dellinger, Chan.
Critical revision of the manuscript for important in-
tellectual content: Flum, Salem, Broeckel Elrod,
Dellinger, Cheadle, Chan.
Statistical analysis: Flum, Dellinger, Cheadle, Chan.
Obtained funding: Flum, Salem.
Administrative, technical, or material support: Flum,
Broeckel Elrod, Dellinger, Chan.
Study supervision: Flum, Chan.
Financial Disclosures: None reported.
tional Institute of Diabetes and Digestive and Kidney
Diseases grants 1UO1DK066568-01 and R21
Role of the Sponsor: The study’s sponsor had no role
in the design and conduct of the study, in the collec-
tion, analysis, and interpretation of the data, or in the
preparation, review, or approval of the manuscript.
of the authors and not necessarily those of the Cen-
ters for Medicare and Medicaid Services or the Uni-
editorial evaluation or decision to publish this article.
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EARLY MORTALITY IN MEDICARE PATIENTS WITH BARIATRIC PROCEDURES
JAMA, October 19, 2005—Vol 294, No. 15 (Reprinted)
©2005 American Medical Association. All rights reserved.
at University Hospitals Of Clevel, on October 24, 2005 www.jama.comDownloaded from