Bariatric Surgery in an Integrated Healthcare Delivery System / Surgery for Obesity and Related Diseases 11 (2015) 1119–1126 [14] DeMaria EJ, Pate V, Warthen M, Winegar DA. Baseline data from American Society for Metabolic and Bariatric Surgery-designated Bariatric Surgery Centers of Excellence using the Bariatric Outcomes Longitudinal Database. S Obes Rel Dis 2010;6(4):347–55. [15] Rosenthal RJ. Readmissions after bariatric surgery: does operative technique and procedure choice matter? Surg Obes Rel Dis 2014;10 (3):385–6. [16] Nandipati K, Lin E, Husain F, et al. Factors predicting the increased risk for return to the operating room in bariatric patients: a NSQIP database study. Surg Endosc 2013;27(4):1172–7. [17] Flum DR, Belle SH, King WC, et al. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med 2009;361 (5):445–54. [18] Finks JF, Kole KL, Yenumula PR, et al. Predicting risk for serious complications with bariatric surgery. Ann Surg 2011;254(4):633–40. [19] Birkmeyer NJ, Dimick JB, Share, et al. Hospital complication rates with bariatric surgery in Michigan. JAMA 2010;304(4):435–42.
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[20] Masoomi H, Kim H, Reavis KM, Mills S, Stamos MJ, Nguyen NT. Analysis of factors predictive of gastrointestinal tract leak in laparoscopic and open gastric bypass. Arch Surg 2011;146(9):1048–51. [21] Nguyen NT, Nguyen B, Gebhart A, Hohmann S. Changes in the makeup of bariatric surgery: a national increase in use of laparoscopic sleeve gastrectomy. J Am Coll Surg 2013;216(2):252–7. [22] Coblijn UK, Goucham AB, Lagarde SM, Kuiken SD, van Wagensveld BA. Development of ulcer disease after Roux-en-Y gastric bypass, incidence, risk factors, and patient presentation: a systemic review. Obes Surg 2013;24(2):299–309. [23] Vidal P, Ramón JM, Goday A, et al. Laparoscopic gastric bypass versus laparoscopic sleeve gastrectomy as a definitive surgical procedure for morbid obesity. Mid-term results. Obes Surg 2013;23 (3):292–9. [24] Kehagias I, Karamanakos SN, Argentou M, Kalfarentzos F. Randomized clinical trial of laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for management of patients with BMI o 50 kg/m2. Obes Surg 2011;21(11):1650–6.
Editorial comment
Reporting clinical characteristics and adverse events outcomes from an integrated healthcare delivery system Many benefits are claimed when discussing integrated healthcare systems. Integration can be a continuum that promotes communication, navigation, and resource utilization through packaging preventive care services, multipurpose service delivery points, continuity of care clinics, vertical integration of services, joint policy-making and management, or working across sectors of the health system; however, integration can also mean that the insurance function and healthcare delivery system are provided by the same organization and may not necessarily be equitable. Within the context of an integrated healthcare delivery system, Li et al. [1] retrospectively reviewed prospectively collected data on 2399 patients who underwent a primary metabolic weight loss operation (1313 gastric bypass, 1018 sleeve gastrectomy, 68 adjustable gastric banding) over a 2-year period at 4 hospitals within Kaiser Permanente Northern California health system. Of note, 3 of those hospitals were certified as centers of excellence during the period of data collection. The authors set out to determine the frequency of short-term adverse outcomes, reoperation, and mortality among patients who underwent gastric bypass or sleeve gastrectomy. The authors were correct to exclude from analysis those patients who underwent adjustable gastric banding because longerterm follow-up is necessary to fully appreciate the high rate of adverse events and reoperation in this cohort [2]. During the study period, approximately 73% of patients were Caucasian with private health insurance, suggesting a relatively homogenous population with regard to race/ ethnicity and socioeconomic status. Gastric bypass patients
had significantly higher preoperative mean body mass index (42.2 versus 41 kg/m2) as well as higher rates of diabetes mellitus and hypertension compared with sleeve gastrectomy patients. Previous studies confirm that modifiable and nonmodifiable patient factors such as race/ethnicity, preoperative body mass index, co-morbidities, and payor source significantly affect outcomes (weight loss, morbidity, and, in-hospital mortality), so the cohorts are more difficult to compare and clinical outcomes may not be generalizable to other patient populations [3–5]. Analysis of the data using a propensity-matched cohort design would account for covariates that are known to affect outcomes. At 1 year, most patients in each cohort returned for follow-up (80% gastric bypass, 76% sleeve gastrectomy). By 12 months, major adverse events occurred with similar frequency in gastric bypass (2.4%) and sleeve gastrectomy (1.4%) patients. Not surprisingly, the gastrointestinal ulcer rate was significantly higher in gastric bypass patients (1.8% versus 0%). In the gastric bypass cohort, the preand postoperative treatment algorithms were similar across all hospitals, which may be a potential benefit of an integrated healthcare system, but operative technique as well as type and duration of gastrointestinal ulcer prophylaxis were not. Operative technique during gastric bypass can alter the risk of gastrointestinal ulcer [6,7], and variability in type and duration of perioperative acid suppression therapy may as well. The authors found significantly lower 30-day rates of gastrointestinal leak (.2% versus .9%), hemorrhage (.2% versus .8%), and reoperation (.5% versus 1.4%) among
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patients who underwent gastric bypass compared with sleeve gastrectomy. They correctly note that the higher rate of morbidity and reoperation after sleeve gastrectomy compared with gastric bypass stand in contrast to some published literature [8]. This variation may be due to the way in which complications were categorized or the early learning curve associated with sleeve gastrectomy, which the authors acknowledge as a limitation. These results are laudable overall; however, the authors suggest that these better-than-reported short-term outcomes are due to regionalization of complex patients and services in high-volume centers of a regional healthcare system, presumably Kaiser Permanente Northern California. The authors’ conclusion should be interpreted with perspective. Although an in-depth discussion of surgeon and hospital volume-outcome relationships and hospital accreditation are beyond the scope of this editorial, it seems too much to say that outcomes in this study are better than some published series because of the regionalization of care within 1 integrated health system. Published reports verify that higher-volume surgeons and centers have better outcomes compared with lower-volume surgeons and centers, whereas other publications note better outcomes with hospital accreditation more than procedure-specific volume [9–11]. The authors state that 3 of the 4 hospitals were accredited as bariatric centers of excellence. The volume of procedures was not separated by surgeon or by hospital, so it is challenging to define whether or not the quality outcomes in this study came from 1 or 2 high-volume surgeons primarily operating at 1 accredited, high-volume center of excellence or an equal mix of surgeons at accredited and nonaccredited centers caring for the patients. Although cohorts in this study may include higher risk patients, such as Medicare and Medicaid beneficiaries [3], the proportions of these patients within each cohort are unknown, making comparisons to large national database results more challenging. That said, the authors are to be congratulated on their excellent short-term clinical outcomes and their efforts to standardize perioperative management across multiple hospitals within an integrated health system. To assess the effect of regionalization of care within an integrated healthcare system, the authors might consider propensity matching to compare similar patient cohorts from that regional healthcare system to published national benchmarks or national databases, taking into account not only patientlevel factors but also hospital accreditation status and surgeon/center volume-outcome relationships.
Disclosures Dr. Bittner is a consultant for Bard Davol and Cook Medical. He receives research funding from Bard Davol, Cook Medical, and EnteroMedics for projects unrelated to this editorial. He receives educational support from the Foundation for Surgical Fellowships. James G. Bittner IV, M.D. Assistant Professor of Surgery, Department of Surgery Director, VCU Minimally Invasive Surgery Center Program Director, Minimally Invasive Surgery Fellowship Virginia Commonwealth University School of Medicine Division of Bariatric and Gastrointestinal Surgery Richmond, Virginia References [1] Li RA, Fisher DP, Dutta S, et al. Bariatric surgery results: reporting clinical characteristics and adverse outcomes from an integrated healthcare delivery system. Surg Obes Relat Dis 2015;11(5):1119–25. [2] Shen X, Zhang X, Yin K. Long-term complications requiring reoperations after laparoscopic adjustable gastric banding: a systematic review. Surg Obes Relat Dis. Epub 2014 Nov 21. [3] Limbach KE, Ashton K, Merrell J, Heniberg LJ. Relative contribution of modifiable versus nonmodifiable factors as predictors of racial variance in Roux-en-Y gastric bypass weight loss outcomes. Obes Surg 2014;24(8):1379–85. [4] Yuan X, Martin-Hawver LR, Ojo P, et al. Bariatric surgery in Medicare patients: greater risks but substantial benefits. Surg Obes Relat Dis 2009;5(3):299–304. [5] Nguyen GC, Patel AM. Racial disparities in mortality in patients undergoing bariatric surgery in the USA. Obes Surg 2013;23 (10):1508–14. [6] Coblijn UK, Goucham AB, Lagarde SM, Kuiken SD, van Wagensveld BA. Development of ulcer disease after Roux-en-Y gastric bypass, incidence, risk factors, and patient presentation: a systematic review. Obes Surg 2014;24(2):299–309. [7] Ribeiro-Parenti L, Arapis K, Chosidow D, Marmuse JP. Comparison of marginal ulcer rates between antecolic and retrocolic laparoscopic Roux-en-Y gastric bypass. Obes Surg 2015;25(2):215–21. [8] Hutter M, Schirmer B, Jones D, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg 2011;254(3):410–20. [9] Smith MD, Patterson E, Wahed AS, et al. Can technical factors explain the volume-outcome relationship in gastric bypass surgery? Surg Obes Relat Dis 2013;9(5):623–9. [10] Torrente JE, Cooney RN, Rogers AM, Hollenbeak CS. Importance of hospital versus surgeon volume in predicting outcomes for gastric bypass procedures. Surg Obes Relat Dis 2013;9(2):247–52. [11] Jafari MD, Jafari F, Young MT, Smith BR, Phalen MJ, Nguyen NT. Volume and outcome relationship in bariatric surgery in the laparoscopic era. Surg Endosc 2013;27(12):4539–46.
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[20] Masoomi H, Kim H, Reavis KM, Mills S, Stamos MJ, Nguyen NT. Analysis of factors predictive of gastrointestinal tract leak in laparoscopic and open gastric bypass. Arch Surg 2011;146(9):1048–51. [21] Nguyen NT, Nguyen B, Gebhart A, Hohmann S. Changes in the makeup of bariatric surgery: a national increase in use of laparoscopic sleeve gastrectomy. J Am Coll Surg 2013;216(2):252–7. [22] Coblijn UK, Goucham AB, Lagarde SM, Kuiken SD, van Wagensveld BA. Development of ulcer disease after Roux-en-Y gastric bypass, incidence, risk factors, and patient presentation: a systemic review. Obes Surg 2013;24(2):299–309. [23] Vidal P, Ramón JM, Goday A, et al. Laparoscopic gastric bypass versus laparoscopic sleeve gastrectomy as a definitive surgical procedure for morbid obesity. Mid-term results. Obes Surg 2013;23 (3):292–9. [24] Kehagias I, Karamanakos SN, Argentou M, Kalfarentzos F. Randomized clinical trial of laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for management of patients with BMI o 50 kg/m2. Obes Surg 2011;21(11):1650–6.
Editorial comment
Reporting clinical characteristics and adverse events outcomes from an integrated healthcare delivery system Many benefits are claimed when discussing integrated healthcare systems. Integration can be a continuum that promotes communication, navigation, and resource utilization through packaging preventive care services, multipurpose service delivery points, continuity of care clinics, vertical integration of services, joint policy-making and management, or working across sectors of the health system; however, integration can also mean that the insurance function and healthcare delivery system are provided by the same organization and may not necessarily be equitable. Within the context of an integrated healthcare delivery system, Li et al. [1] retrospectively reviewed prospectively collected data on 2399 patients who underwent a primary metabolic weight loss operation (1313 gastric bypass, 1018 sleeve gastrectomy, 68 adjustable gastric banding) over a 2-year period at 4 hospitals within Kaiser Permanente Northern California health system. Of note, 3 of those hospitals were certified as centers of excellence during the period of data collection. The authors set out to determine the frequency of short-term adverse outcomes, reoperation, and mortality among patients who underwent gastric bypass or sleeve gastrectomy. The authors were correct to exclude from analysis those patients who underwent adjustable gastric banding because longerterm follow-up is necessary to fully appreciate the high rate of adverse events and reoperation in this cohort [2]. During the study period, approximately 73% of patients were Caucasian with private health insurance, suggesting a relatively homogenous population with regard to race/ ethnicity and socioeconomic status. Gastric bypass patients
had significantly higher preoperative mean body mass index (42.2 versus 41 kg/m2) as well as higher rates of diabetes mellitus and hypertension compared with sleeve gastrectomy patients. Previous studies confirm that modifiable and nonmodifiable patient factors such as race/ethnicity, preoperative body mass index, co-morbidities, and payor source significantly affect outcomes (weight loss, morbidity, and, in-hospital mortality), so the cohorts are more difficult to compare and clinical outcomes may not be generalizable to other patient populations [3–5]. Analysis of the data using a propensity-matched cohort design would account for covariates that are known to affect outcomes. At 1 year, most patients in each cohort returned for follow-up (80% gastric bypass, 76% sleeve gastrectomy). By 12 months, major adverse events occurred with similar frequency in gastric bypass (2.4%) and sleeve gastrectomy (1.4%) patients. Not surprisingly, the gastrointestinal ulcer rate was significantly higher in gastric bypass patients (1.8% versus 0%). In the gastric bypass cohort, the preand postoperative treatment algorithms were similar across all hospitals, which may be a potential benefit of an integrated healthcare system, but operative technique as well as type and duration of gastrointestinal ulcer prophylaxis were not. Operative technique during gastric bypass can alter the risk of gastrointestinal ulcer [6,7], and variability in type and duration of perioperative acid suppression therapy may as well. The authors found significantly lower 30-day rates of gastrointestinal leak (.2% versus .9%), hemorrhage (.2% versus .8%), and reoperation (.5% versus 1.4%) among
1126
R. A. Li et al. / Surgery for Obesity and Related Diseases 11 (2015) 1119–1126
patients who underwent gastric bypass compared with sleeve gastrectomy. They correctly note that the higher rate of morbidity and reoperation after sleeve gastrectomy compared with gastric bypass stand in contrast to some published literature [8]. This variation may be due to the way in which complications were categorized or the early learning curve associated with sleeve gastrectomy, which the authors acknowledge as a limitation. These results are laudable overall; however, the authors suggest that these better-than-reported short-term outcomes are due to regionalization of complex patients and services in high-volume centers of a regional healthcare system, presumably Kaiser Permanente Northern California. The authors’ conclusion should be interpreted with perspective. Although an in-depth discussion of surgeon and hospital volume-outcome relationships and hospital accreditation are beyond the scope of this editorial, it seems too much to say that outcomes in this study are better than some published series because of the regionalization of care within 1 integrated health system. Published reports verify that higher-volume surgeons and centers have better outcomes compared with lower-volume surgeons and centers, whereas other publications note better outcomes with hospital accreditation more than procedure-specific volume [9–11]. The authors state that 3 of the 4 hospitals were accredited as bariatric centers of excellence. The volume of procedures was not separated by surgeon or by hospital, so it is challenging to define whether or not the quality outcomes in this study came from 1 or 2 high-volume surgeons primarily operating at 1 accredited, high-volume center of excellence or an equal mix of surgeons at accredited and nonaccredited centers caring for the patients. Although cohorts in this study may include higher risk patients, such as Medicare and Medicaid beneficiaries [3], the proportions of these patients within each cohort are unknown, making comparisons to large national database results more challenging. That said, the authors are to be congratulated on their excellent short-term clinical outcomes and their efforts to standardize perioperative management across multiple hospitals within an integrated health system. To assess the effect of regionalization of care within an integrated healthcare system, the authors might consider propensity matching to compare similar patient cohorts from that regional healthcare system to published national benchmarks or national databases, taking into account not only patientlevel factors but also hospital accreditation status and surgeon/center volume-outcome relationships.
Disclosures Dr. Bittner is a consultant for Bard Davol and Cook Medical. He receives research funding from Bard Davol, Cook Medical, and EnteroMedics for projects unrelated to this editorial. He receives educational support from the Foundation for Surgical Fellowships. James G. Bittner IV, M.D. Assistant Professor of Surgery, Department of Surgery Director, VCU Minimally Invasive Surgery Center Program Director, Minimally Invasive Surgery Fellowship Virginia Commonwealth University School of Medicine Division of Bariatric and Gastrointestinal Surgery Richmond, Virginia References [1] Li RA, Fisher DP, Dutta S, et al. Bariatric surgery results: reporting clinical characteristics and adverse outcomes from an integrated healthcare delivery system. Surg Obes Relat Dis 2015;11(5):1119–25. [2] Shen X, Zhang X, Yin K. Long-term complications requiring reoperations after laparoscopic adjustable gastric banding: a systematic review. Surg Obes Relat Dis. Epub 2014 Nov 21. [3] Limbach KE, Ashton K, Merrell J, Heniberg LJ. Relative contribution of modifiable versus nonmodifiable factors as predictors of racial variance in Roux-en-Y gastric bypass weight loss outcomes. Obes Surg 2014;24(8):1379–85. [4] Yuan X, Martin-Hawver LR, Ojo P, et al. Bariatric surgery in Medicare patients: greater risks but substantial benefits. Surg Obes Relat Dis 2009;5(3):299–304. [5] Nguyen GC, Patel AM. Racial disparities in mortality in patients undergoing bariatric surgery in the USA. Obes Surg 2013;23 (10):1508–14. [6] Coblijn UK, Goucham AB, Lagarde SM, Kuiken SD, van Wagensveld BA. Development of ulcer disease after Roux-en-Y gastric bypass, incidence, risk factors, and patient presentation: a systematic review. Obes Surg 2014;24(2):299–309. [7] Ribeiro-Parenti L, Arapis K, Chosidow D, Marmuse JP. Comparison of marginal ulcer rates between antecolic and retrocolic laparoscopic Roux-en-Y gastric bypass. Obes Surg 2015;25(2):215–21. [8] Hutter M, Schirmer B, Jones D, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann Surg 2011;254(3):410–20. [9] Smith MD, Patterson E, Wahed AS, et al. Can technical factors explain the volume-outcome relationship in gastric bypass surgery? Surg Obes Relat Dis 2013;9(5):623–9. [10] Torrente JE, Cooney RN, Rogers AM, Hollenbeak CS. Importance of hospital versus surgeon volume in predicting outcomes for gastric bypass procedures. Surg Obes Relat Dis 2013;9(2):247–52. [11] Jafari MD, Jafari F, Young MT, Smith BR, Phalen MJ, Nguyen NT. Volume and outcome relationship in bariatric surgery in the laparoscopic era. Surg Endosc 2013;27(12):4539–46.
