Gastric bypass outcomes differ by health insurance

Last Updated: 2016-10-06

By Marilynn Larkin

NEW YORK (Reuters Health) - Outcomes of open Roux-en-Y gastric bypass (RYGB) vary depending on the patient's health insurance, New Jersey-based researchers say.

Open RYGB "is performed primarily on patients with complicated intra-abdominal pathology, massive obesity not conducive to laparoscopy, or prohibitive medical conditions," write Dr. Gus Slotman and colleagues at Inspira Health Network in Vineland.

Dr. Slotman told Reuters Health, "Previously, we reported significant variation of post-operative results by insurance status among super-obese patients who had bilio-pancreatic diversion/duodenal switch."

"The present investigation identified statistically and clinically significant differences in weight, BMI and in many weight-related medical problems between open RYGB patients covered by Medicaid versus Medicare versus private insurance versus self-pay," he said by email.

Using the Surgical Review Corporation Bariatric Outcomes Longitudinal Database the team studied 4,225 patients who underwent open RYGB: 272 with Medicaid coverage, 632 with Medicare, 3,253 with private insurance, and 68 who were self-pay.

As reported online September 28 in JAMA Surgery, at six months after surgery, Medicaid patients weighed an average of 113 kg, Medicare patients weighed 111 kg, privately insured patients weighed 104 kg, and self-pay patients weighed 115 kg. At the same point, Medicaid, Medicare and self-pay patients had an average body mass index (BMI) of 40, while privately insured patients had a BMI of 37. Weight and BMI did not vary among the groups in subsequent followup.

Characteristics such as hypertension, back pain, leg edema, musculoskeletal pain, functional status and asthma also varied by insurance through the first year. For example, hypertension was lowest in the self-pay group, while Medicaid carried the highest rates of the four insurance types.

Two years after surgery, conditions such as abdominal hernia, abdominal panniculitis, cholelithiasis, gastroesophageal reflux disease, dyslipidemia, and tobacco use all varied significantly according to health insurance status. For example, abdominal hernia was most common in Medicaid patients, at rates nearly double the other three groups.

Dr. Slotman said, "We are finding that the patient populations who choose each of the most common bariatric operations vary clinically, and that, within each operation, patient characteristics and outcomes after surgery also vary by insurance status."

"Of course, this is not a cause and effect phenomenon, but, rather, reflects the patient groups who become covered by the four health insurance types we studied," he observed.

Patients having open RYGB are "usually a more fragile cohort," he continued, and in this group, "Medicaid and Medicare patients had the highest persistence of a large number of weight-related medical problems, and developed gallstones at higher rates than did privately insured patients or self-pay."

He added, "Since Medicare patients were significantly older than the other insurances, one might speculate that the number of years one is obese could make weight-related problems more difficult to resolve after (open) RYGB. Medicaid patients, though younger than Medicare, similarly had high rates of somatic complaints, hypertension, and functional challenges, suggesting increased medical fragility."

Dr. Slotman concluded, "Overall, the clinical importance of this study is to identify trends in clinical conditions and (open) RYGB outcomes by insurance status that may give bariatric surgeons advance, individualized knowledge of what post-operative challenges will be. Acting on this increased index of suspicion could facilitate improved (open) RYGB outcomes."

Dr. Dimitrios Stefanidis, chief of bariatric surgery at Indiana University Health in Indianapolis, told Reuters Health he believes the data have been misinterpreted.

"The main issue is that the patient groups had significant differences at baseline that appear to carry over to follow-up. Thus, rather than insurance status being the factor influencing these differences, it appears, to me, that baseline differences explain any identified differences," he said by email.

"Additionally, data detailed in the study becomes very weak as follow-up increases, since the study has very few patients in some groups; as a result, this makes several comparisons less meaningful," he observed.

"While differences are described among the four groups, no pairwise comparisons have been included to indicate which specific groups really differ from each other," he said.

Dr. Stefanidis added that similar studies have shown "that insurance status does not really matter, which, as explained above, is what this study shows, in my opinion."

Dr. George Mueller, medical director of bariatric surgery at Sharp Memorial Hospital in San Diego, California, told Reuters Health, "This study raises questions of patient selection and compliance abilities related to being in a specific insurance group. Are Medicaid patients less compliant than other patients? Are the differences shown by Medicare patients due to their age? Cash-pay differences could be due to greater motivation to succeed, as these patients are paying out of pocket for the surgery."

"Many of the outcomes are more related to technical issues of the surgeries, which I wouldn't expect to be varied by insurance if the cohorts are matched, which did appear to be the case," he said by email. "It would be interesting to see if these patients had psychology evaluations preoperatively. This is a standard of the American College of Surgeons and American Society for Metabolic and Bariatric Surgery."

"Overall, open gastric bypass is relatively rare at this time," Dr. Mueller noted. "More than 99% of these procedures at (our hospital) are performed laparoscopically. Incidences of infection and hernia postoperatively would be expected to be higher in open bypass versus laparoscopic surgeries."

Dr. Mueller concluded, "It would be interesting to perform this study on laparoscopic gastric bypass patients using the same parameters and criteria. If similar results were obtained in laparoscopic gastric bypass versus insurance type, it would have definite relevance for today's bariatric surgery practices. It would also be nice to further separate out the 'private pay' patients into HMO versus PPO."

SOURCE: http://bit.ly/2cWhw2R

JAMA Surg 2016.