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Davis M, Gomez J, Sheck C, Slotman G. Variation in Weight and Obesity Comorbidities After Open Roux-en-Y Gastric Bypass by Health Insurance: Medicaid vs Medicare vs Private vs Self-Pay in 4225 Bariatric Outcomes Longitudinal Database Patients. JAMA Surg. 2017;152(1):105–109. doi:10.1001/jamasurg.2016.2932
Copyright 2017 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
Open Roux-en-Y gastric bypass (ORYGB) is performed primarily on patients with complicated intra-abdominal pathology, massive obesity not conducive to laparoscopy, or prohibitive medical conditions. Gomez et al1 reported significant variation in weight loss and resolution of medical problems in superobese patients after biliopancreatic diversion/duodenal switch. However, to our knowledge, whether health insurance status similarly influences the results of patients undergoing ORYGB is unknown. Therefore, the objective of this study was to identify variation in ORYGB outcomes by health insurance status.
Data from 4225 Surgical Review Corporation Bariatric Outcomes Longitudinal Database2 patients who underwent ORYGB were analyzed retrospectively in 4 groups: Medicaid (n = 272), Medicare (n = 632), private insurance (n = 3253), and self-pay (n = 68). General linear models included baseline and postoperative data and were modified for binomial distribution of dichotomous variables.3 This investigation was approved by the data access committee of the Surgical Review Corporation and the institutional review board of Our Lady of Lourdes Medical Center, Camden, New Jersey. This was a retrospective study, ruled exempt by both the data access committee of the Surgical Review Corporation and the institutional review board of Our Lady of Lourdes; therefore, no patient consent was required.
The mean (SD) age was 41 (11) years for Medicaid patients, 53 (11) years for Medicare patients, 40 (11) years for privately insured patients, and 40 (12) years for self-pay (P < .001). Medicaid patients were 84% women and 16% men, Medicare patients were 72% women and 28% men, private insurance was 75% women and 25% men, and self-pay was 63% women and 37% men (P < .001). Mean (SD) weight at 6 months was 113 (29) kg for Medicaid patients, 111 (31) kg for Medicare patients, 104 (25) kg for privately insured patients, and 115 (34) kg for self-pay (P < .05). Body mass index (calculated as weight in kilograms divided by height in meters squared) at 6 months was 40 (9) for all Medicaid, Medicare, and self-pay patients and was 37 (8) for privately insured patients. Weight and BMI did not vary among the 4 insurance groups after 6 months. Other results are displayed in Tables 1 and 2. Through 24 months, abdominal hernia, abdominal panniculitis, cholelithiasis, gastroesophigal reflux disease, dyslipidemia, and tobacco use varied significantly according to health insurance status. Hypertension, back pain, leg edema, musculoskeletal pain, impaired functional status, and asthma varied through 12 months as did depression through 18 months. Body mass index, obstructive sleep apnea, obesity hypoventilation syndrome, stress urinary incontinence, gout, and psychological impairment differed up to 6 months. Alcohol use increased in self-pay at 18 months. No other comorbidities varied.
The results of this study indicate that ORYGB outcomes vary by health insurance. Weight and body mass index were lowest among private patients through 6 months but did not vary significantly by insurance thereafter. Hypertension was lowest in self-pay through 12 months, with Medicaid carrying the highest rates of the 4 insurance types and hypertension affecting Medicaid and privately insured patients intermediate to the other groups. Early (6 months) obstructive sleep apnea resolved best for self-pay patients, followed closely by privately insured patients, but long-term post-ORYGB resolution did not vary further by insurance. Obesity hypoventilation syndrome varied only to 6 months and nearly disappeared in Medicaid, private, and self-pay patients but persisted at nearly 50% of preoperative rates in Medicare. Cholelithiasis increased in Medicaid and Medicare patients but did not change postoperatively in private and self-pay patients. Abdominal hernia resulted most frequently in Medicaid patients through 24 months at rates nearly double the other 3 groups. Abdominal panniculitis increased in self-pay patients to levels more than double the other groups by 24 months. Gastroesophigal reflux disease decreased in all insurance groups but remained higher in Medicaid and Medicare patients vs privately insured patients through 24 months. The significance of increased self-pay alcohol consumption at 24 months is not clear from the data.
Private and self-pay patients benefited more from ORYGB than did Medicaid or Medicare patients. Postoperatively, privately insured patients had the lowest rates of 5 weight-related comorbidities and highest in none. Self-pay patients were highest in 3 comorbidities but resolved 24 others to the lowest levels. Medicaid and Medicare patients were highest in 16 and 11 comorbidities, respectively. Medicare patients were lowest in abdominal hernia. Medicaid patients were lowest in none.
Our review of the literature reveals that these variations in outcomes following ORYGB have, to our knowledge, not been reported previously4-6 and are important findings of this study. This advance knowledge can forewarn surgeons of possible results and post-ORYGB problems that may facilitate optimal treatment of these fragile patients.
Corresponding Author: Gus Slotman, MD, Department of Surgery, Inspira Health Network, Vineland, NJ 08360 (firstname.lastname@example.org).
Published Online: September 28, 2016. doi:10.1001/jamasurg.2016.2932
Author Contributions: Dr Slotman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Gomez, Slotman.
Acquisition, analysis, or interpretation of data: Davis, Slotman, Sheck.
Drafting of the manuscript: Davis, Slotman.
Critical revision of the manuscript for important intellectual content: Gomez, Slotman, Sheck.
Statistical analysis: Slotman, Sheck.
Administrative, technical, or material support: Davis, Gomez.
Study supervision: Slotman.
Conflict of Interest Disclosures: None reported.
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