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To compare safety and healthcare utilization after sleeve gastrectomy versus Roux-en-Y gastric bypass in a national Medicare cohort.Though bariatric surgery is increasing among Medicare beneficiaries, no long-term, national studies examining comparative effectiveness between procedures exist. Bariatric outcomes are needed for shared decision-making and coverage policy concerns identified by the cMS Medicare Evidence Development and Coverage Advisory Committee.Retrospective instrumental variable analysis of Medicare claims (2012-2017) for 30,105 bariatric surgery patients entitled due to disability or age. We examined clinical safety outcomes (mortality, complications, and reinterventions), healthcare utilization [Emergency Department (ED) visits, rehospitalizations, and expenditures], and heterogeneity of treatment effect. We compared all outcomes between sleeve and bypass for each entitlement group at 30 days, 1 year, and 3 years.Among the disabled (n = 21,595), sleeve was associated with lower 3-year mortality [2.1% vs 3.2%, absolute risk reduction (ARR) 95% confidence interval (CI): -2.2% to -0.03%], complications (22.2% vs 27.7%, ARR 95%CI: -8.5% to -2.6%), reinterventions (20.1% vs 27.7%, ARR 95%CI: -10.7% to -4.6%), ED utilization (71.6% vs 77.1%, ARR 95%CI: -8.5% to -2.4%), and rehospitalizations (47.4% vs 52.3%, ARR 95%Ci: -8.0% to -1.7%). Cumulative expenditures were $46,277 after sleeve and $48,211 after bypass (P = 0.22). Among the elderly (n = 8510), sleeve was associated with lower 3-year complications (20.1% vs 24.7%, ARR 95%CI: -7.6% to -1.7%), reinterventions (14.0% vs 21.9%, ARR 95%CI: -10.7% to -5.2%), ED utilization (51.7% vs 57.2%, ARR 95%CI: -9.1% to -1.9%), and rehospitalizations (41.8% vs 45.8%, ARR 95%Ci: -7.5% to -0.5%). Expenditures were $38,632 after sleeve and $39,270 after bypass (P = 0.60). Procedure treatment effect significantly differed by entitlement for mortality, revision, and paraesophageal hernia repair.Bariatric surgery is safe, and healthcare utilization benefits of sleeve over bypass are preserved across both Medicare elderly and disabled subpopulations.

As survivorship following kidney transplant continues to improve, so does the probability of intervening on common surgical conditions, such as ventral or incisional hernia, in this population. Ventral hernia management is known to vary across institutions and this variation has an impact on patient outcomes. We sought to evaluate hospital level variation of ventral or incisional hernia repair (VIHR) in the kidney transplant population.We performed a retrospective review of 100% inpatient Medicare claims to identify patients who underwent kidney transplant between 2007 and 2018. The primary outcome was 1- and 3-year ventral or incisional risk- and reliability-adjusted VIHR rates. Patient and hospital characteristics were evaluated across risk- and reliability-adjusted VIHR rate tertiles. Models were adjusted for age, sex, race, and Elixhauser comorbidities.Overall, 139,741 patients underwent kidney transplant during the study period with a mean age (SD) of 51.6 (13.7) years. 84,717 (60.6%) were male, and 72,657 (52.0%) were white. Median follow up time was 5.4 years. 2098 (1.50%) patients underwent VIHR. the 1 year risk- and reliability-adjusted hernia repair rates were 0.49% (95% Conf idence Interval (CI) 0.48-0.51, range 0.31-0.59) in tertile 1, 0.63% (95% CI 0.62-0.63, range 0.59-0.68) in tertile 2, and 0.98 (95% CI 0.91-1.05, range 0.68-2.94) in tertile 3. Accordingly, compared to hospitals in tertile 1, the odds of post-transplant hernia repair tertile 2 hospitals were 1.78 (95% CI 1.37-2.31) and at tertile 3 hospitals 3.53 (95% CI 2.87-4.33).In a large cohort of Medicare patients undergoing kidney transplant, the overall cumulative incidence of hernia repair varied substantially across hospital tertiles. Patient and hospital characteristics varied across tertile, most notably in diabetes and obesity. Future research is needed to understand if program and surgeon level factors are contributing to the observed variation in treatment of this common disease.

In the United States, the Organ Procurement and Transplant Network (OPTN) uses 1-year mortality as the primary measure of transplant center quality. We sought to evaluate the reliability of mortality outcomes in lung transplantation and to compare statistical methods of program performance evaluation.We used the Standard Transplant Analysis and Research files from the United Network for Organ Sharing to identify lung transplant recipients from 2013 to 2018 in the United States. We stratified hospitals on the basis of 30-day, 1-year, and 5-year survival by risk adjustment, reliability adjustment with empirical Bayes technique, and hierarchical bayesian mixed effects models currently used by the OPTN. We measured variation in mortality rates and identification of performance outliers between techniques.We identified 12,769 recipients in 69 centers. Reliability adjustment reduced variation in hospital outcomes and had a large impact on hospital mortality rankings. For example, with 1-year mortality, 28% (5 hospitals) of the "best" hospitals (top 25%) and 18% (3 hospitals) of the "worst" hospitals (bottom 25%) were reclassified after reliability adjustment. The overall reliability of 1-year mortality was low at 0.42. Compared with the bayesian method used by the OPTN, reliability adjustment identified fewer outliers. The 5-year survival reached a higher reliability plateau with a lower volume of cases required.The reliability of 1-year mortality in lung transplantation is low, whereas 5-year survival estimates may be more reliable at lower case volumes. Reliability adjustment yielded more conservative measures of center performance and fewer outliers compared with current bayesian methods.

To compare out-of-pocket (OOP) costs for patients up to 3 years after bariatric surgery in a large, commercially-insured population.More information on OOP costs following bariatric surgery may affect patients' procedure choice.Retrospective study using the IBM MarketScan commercial claims database, representing patients nationally who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) January 1, 2011 to December 31, 2017. We compared total OOP costs after the surgical episode between the 2 procedures using difference-in-differences analysis adjusting for demographics, comorbidities, operative year, and insurance type.Of 63,674 patients, 64% underwent SG and 36% underwent RYGB. Adjusted OOP costs after SG were $1083, $1236, and $1266 postoperative years 1, 2, and 3. For RYGB, adjusted OOP costs were $1228, $1377, and $1369. In our primary analysis, SG OOP costs were $122 (95%CI: -$155 to -$90) less than RYGB year 1. This difference remained consistent at -$119 (95%CI: -$158 to -$79) year 2 and -$80 (95%CI: -$127 to -$35) year 3. These amounts were equivalent to relative differences of -7%, -7%, and -5% years 1, 2, and 3. Plan features contributing the most to differences were co-insurance years 1, 2, and 3.. The largest clinical contributors to differences were endoscopy and outpatient care year 1, outpatient care year 2, and emergency department use year 3.Our study is the first to examine the association between bariatric surgery procedure and OOP costs. Differences between procedures were approximately $100 per year which may be an important factor for some patients deciding whether to pursue SG or gastric bypass.

To characterize incidence and outcomes for bariatric surgery patients who give birth.Patients of childbearing age comprise 65% of bariatric surgery patients in the United States, yet data on how often patients conceive and obstetric outcomes are limited.Using the IBM MarketScan database, we performed a retrospective cohort study of female patients ages 18-52 undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass from 2011-2017. We determined incidence of births in the first two years after bariatric surgery using Kaplan-Meier estimates. We then restricted the cohort to those with full two-year follow-up to examine obstetric outcomes and bariatric-related reinterventions. We reported event rates of adverse obstetric outcomes and delivery type. Adverse obstetric outcomes include pregnancy complications, severe maternal morbidity, and delivery complications. We performed multivariable logistic regression to examine associations between birth and risk of reinterventions.Of 69,503 patients who underwent bariatric surgery, 1,464 gave birth. The incidence rate was 2.5 births per 100 patients in the 2 years after surgery. 85% of births occurred within 21 months after surgery. For 38,922 patients with full two-year follow-up, adverse obstetric event rates were 4.5% for gestational diabetes and 14.2% for hypertensive disorders. 48.5% were first-time Cesarean deliveries. Almost all reinterventions during pregnancy were biliary. Multivariable logistic regression analysis showed no association between post-bariatric birth and reintervention rate (OR: 0.93, 95%CI: 0.78-1.12).In this first national U.S. cohort, we find giving birth was common in the first 2 years after bariatric surgery and was not associated with increased risk of reinterventions. Clinicians should consider shifting the dialogue surrounding pregnancy after surgery to shared decisionmaking with maternal safety as one component.

IMPORTANCE: Sleeve gastrectomy and gastric bypass are the most common bariatric surgical procedures in the world; however, their long-term medication discontinuation and comorbidity resolution remain unclear. OBJECTIVE: To compare the incidence of medication discontinuation and restart of diabetes, hypertension, and hyperlipidemia medications up to 5 years after sleeve gastrectomy or gastric bypass. DESIGN, SETTING, AND PARTICIPANTS: This comparative effectiveness research study of adult Medicare beneficiaries who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass between January 1, 2012, to December 31, 2018, and had a claim for diabetes, hypertension, or hyperlipidemia medication in the 6 months before surgery with a corresponding diagnosis used instrumental-variable survival analysis to estimate the cumulative incidence of medication discontinuation and restart. Data analyses were performed from February to June 2021. EXPOSURES: Laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass. MAIN OUTCOMES AND MEASURES: The primary outcome was discontinuation of diabetes, hypertension, and hyperlipidemia medication for any reason. Among patients who discontinued medication, the adjusted cumulative incidence of restarting medication was calculated up to 5 years after discontinuation. RESULTS: Of the 95 405 patients included, 71 348 (74.8%) were women and the mean (SD) age was 56.6 (11.8) years. Gastric bypass compared with sleeve gastrectomy was associated with a slightly higher 5-year cumulative incidence of medication discontinuation among 30 588 patients with diabetes medication use and diagnosis at the time of surgery (74.7% [95% CI, 74.6%-74.9%] vs 72.0% [95% CI, 71.8%-72.2%]), 52 081 patients with antihypertensive medication use and diagnosis at the time of surgery (53.3% [95% CI, 53.2%-53.4%] vs 49.4% [95% CI, 49.3%-49.5%]), and 35 055 patients with lipid-lowering medication use and diagnosis at the time of surgery (64.6% [95% CI, 64.5%-64.8%] vs 61.2% [95% CI, 61.1%-61.3%]). Among the subset of patients who discontinued medication, gastric bypass was also associated with a slightly lower incidence of medication restart up to 5 years after discontinuation. Specifically, the 5-year cumulative incidence of medication restart was lower after gastric bypass compared with sleeve gastrectomy among 19 599 patients who discontinued their diabetes medication after surgery (30.4% [95% CI, 30.2%-30.5%] vs 35.6% [95% CI, 35.4%-35.9%]), 21 611 patients who discontinued their antihypertensive medication after surgery (67.2% [95% CI, 66.9%-67.4%] vs 70.6% [95% CI, 70.3%-70.9%]), and 18 546 patients who discontinued their lipid-lowering medication after surgery (46.2% [95% CI, 46.2%-46.3%] vs 52.5% [95% CI, 52.2%-52.7%]). CONCLUSIONS AND RELEVANCE: Findings of this study suggest that, compared with sleeve gastrectomy, gastric bypass was associated with a slightly higher incidence of medication discontinuation and a slightly lower incidence of medication restart among patients who discontinued medication. Long-term trials are needed to explain the mechanisms and factors associated with differences in medication discontinuation and comorbidity resolution after bariatric surgery.

OBJECTIVE To evaluate the association of historical racist housing policies and modern-day healthcare outcomes. SUMMARY OF BACKGROUND DATA In 1933 the United States Government Home Owners Loan Corporation (HOLC) used racial composition of neighborhoods to determine creditworthiness and labeled them "Best", "Still Desirable", "Definitely Declining", and "Hazardous." Although efforts have been made to reverse these racist policies that structurally disadvantage those living in exposed neighborhoods, the lasting legacy on modern day healthcare outcomes is uncertain. METHODS We performed a cross-sectional retrospective review of 212,179 Medicare beneficiaries' living in 171,930 unique neighborhoods historically labeled by the HOLC who underwent 1 of 5 of common surgical procedures - coronary artery bypass, appendectomy, colectomy, cholecystectomy, and hernia repair - between 2012 and 2018. We compared 30-day mortality, complications, and readmissions across HOLC grade and Area Deprivation Index (ADI) of each neighborhood. Outcomes were risk-adjusted using a multivariable logistical regression model accounting for patient factors (age, sex, Elixhauser comorbidities), admission type (elective, urgent, emergency), type of operation, and each neighborhoods ADI; a modern day measure of neighborhood disadvantage that includes education, employment, housing-quality, and poverty measures. RESULTS Overall, 212,179 Medicare beneficiaries (mean age, 71.2 years; 54.2% women) resided in 171,930 unique neighborhoods historically graded by the HOLC. Outcomes worsened in a stepwise fashion across HOLC neighborhoods. Overall, 30-day postoperative mortality was 5.4% in "Best" neighborhoods, 5.8% in "Still Desirable", 6.1% in "Definitely Declining", and 6.4% in "Hazardous" (Best vs Hazardous Odds Ration: 1.23, 95% CI: 1.13-1.24, P < 0.001). The same stepwise pattern was seen from "Best" to "Hazardous" neighborhoods for complications (30.5% vs 32.2%; OR: 1.12 [95% CI: 1.07-1.17]; P < 0.001) and Readmissions (16.3% vs 17.1%; OR: 1.06 [95% CI: 1.01-1.11]; P = 0.023). After controlling for modern day deprivation using ADI, the patterns persisted with "Hazardous" neighborhoods having higher mortality (OR: 1.17 [95% CI: 1.08-1.27]; P < 0.001) and complications (OR: 1.07 [95% CI: 1.02-1.12]; P = 0.003), but not for readmissions (OR: 1.02 [95% CI: 0.97-1.07]; P = 0.546). CONCLUSIONS Patients residing in neighborhoods previously "redlined" or labeled "Hazardous" were more likely to experience worse outcomes after inpatient hospitalization compared to those living in "Best" neighborhoods, even after taking into account modern day measures of neighborhood disadvantage.

This cohort study evaluates trends in the adoption of robotic surgery among Medicare beneficiaries and privately insured patients for common general surgical procedures.

OBJECTIVE To assess risk-adjusted outcomes and participant perceptions following a statewide coaching program for bariatric surgeons. SUMMARY OF BACKGROUND DATA Coaching has emerged as a new approach for improving individual surgeon performance, but lacks evidence linking to clinical outcomes. METHODS This program took place between October 2015 and February 2018 in the Michigan Bariatric Surgery Collaborative. Surgeons were categorized as coach, participant, or nonparticipant for an interrupted time series analysis. Multilevel logistic regression models included patient characteristics, time trends, and number of sessions. Risk-adjusted overall and surgical complication rates are reported, as are within-group relative risk ratios and 95% confidence intervals. We also compared operative times and report risk differences and 95% confidence intervals. Iterative thematic analysis of semi-structured interviews examined participant and coach perceptions of the program. RESULTS The coaching program was viewed favorably by most surgeons and many participants described numerous technical and nontechnical practice changes. The program was not associated with significant change in risk-adjusted complications with relative risks for coaches, participants, and nonparticipants of 0.99 (0.62-1.37), 0.91 (0.64-1.17), and 1.15 (0.83-1.47), respectively. Operative times did improve for participants, but not coaches or nonparticipants, with risk differences of -14.0 (-22.3, -5.7), -1.0 (-4.5, 2.4), and -2.6 (-6.9, 1.7). Future coaching programmatic design should consider dose-complexity matching, hierarchical leveling, and optimizing video review. CONCLUSIONS This statewide surgical coaching program was perceived as valuable and surgeons reported numerous practice changes. Operative times improved, but there was no significant improvement in risk-adjusted outcomes.

OBJECTIVE To compare the safety of sleeve gastrectomy and gastric bypass in a large cohort of commercially insured bariatric surgery patients from the IBM MarketScan claims database, while accounting for measurable and unmeasurable sources of selection bias in who is chosen for each operation. SUMMARY OF BACKGROUND DATA Sleeve gastrectomy has rapidly become the most common bariatric operation performed in the United States, but its longer-term safety is poorly described, and the risk of worsening gastroesophageal reflux requiring revision may be higher than previously thought. Prior studies comparing sleeve gastrectomy to gastric bypass are limited by low sample size (in randomized trials) and selection bias (in observational studies). METHODS Instrumental variables analysis of commercially insured patients in the IBM MarketScan claims database from 2011 to 2018. We studied patients undergoing bariatric surgery from 2012 to 2016. We identified re-interventions and complications at 30 days and 2 years from surgery using Comprehensive Procedural Terminology and International Classification of Disease (ICD)-9/10 codes. To overcome unmeasured confounding, we use the prior year's sleeve gastrectomy utilization within each state as an instrumental variable-exploiting variation in the timing of payers' decisions to cover sleeve gastrectomy as a natural experiment. RESULTS Among 38,153 patients who underwent bariatric surgery between 2012 and 2016, the share of sleeve gastrectomy rose from 52.6% (2012) to 75% (2016). At 2 years from surgery, patients undergoing sleeve gastrectomy had fewer re-interventions (sleeve 9.9%, bypass 15.6%, P < 0.001) and complications (sleeve 6.6%, bypass 9.6%, P = 0.001), and lower overall healthcare spending ($47,891 vs $55,213, P = 0.003), than patients undergoing gastric bypass. However, at the 2-year mark, revisions were slightly more common in sleeve gastrectomy than in gastric bypass (sleeve 0.6%, bypass 0.4%, P = 0.009). CONCLUSIONS AND RELEVANCE In a large cohort of commercially insured patients, sleeve gastrectomy had a superior safety profile to gastric bypass up to 2 years from surgery, even when accounting for selection bias. However, the higher risk of revisions in sleeve gastrectomy merits further exploration.

OBJECTIVE To evaluate sources of 90-day episode spending variation in Medicare patients undergoing bariatric surgery and whether spending variation was related to quality of care. SUMMARY OF BACKGROUND DATA Medicare's bundled payments for care improvement-advanced program includes the first large-scale episodic bundling program for bariatric surgery. This voluntary program will pay bariatric programs a bonus if 90-day spending after surgery falls below a predetermined target. It is unclear what share of bariatric episode spending may be due to unnecessary variation and thus modifiable through care improvement. METHODS Retrospective analysis of fee-for-service Medicare claims data from 761 acute care hospitals providing inpatient bariatric surgery between January 1, 2011 and September 30, 2016. We measured associations between patient and hospital factors, clinical outcomes, and total Medicare spending for the 90-day bariatric surgery episode using multivariable regression models. RESULTS Of 64,537 patients, 46% underwent sleeve gastrectomy, 22% revisited the emergency department (ED) within 90 days, and 12.5% were readmitted. Average 90-day episode payments were $14,124, ranging from $12,220 at the lowest-spending quintile of hospitals to $16,887 at the highest-spending quintile. After risk adjustment, 90-day episode spending was $11,447 at the lowest quintile versus $15,380 at the highest quintile (difference $3932, P < 0.001). The largest components of spending variation were readmissions (44% of variation, or $2043 per episode), post-acute care (19% or $871), and index professional fees (15% or $450). The lowest spending hospitals had the lowest complication, ED visit, post-acute utilization, and readmission rates (P < 0.001). CONCLUSIONS AND RELEVANCE In this retrospective analysis of Medicare patients undergoing bariatric surgery, the largest components of 90-day episode spending variation are readmissions, inpatient professional fees, and post-acute care utilization. Hospitals with lower spending were associated with lower rates of complications, ED visits, post-acute utilization, and readmissions. Incentives for improving outcomes and reducing spending seem to be well-aligned in Medicare's bundled payment initiative for bariatric surgery.

Hiatal hernia repair performed at the time of laparoscopic sleeve gastrectomy (LSG) may reduce post-operative reflux symptoms. It is unclear whether intra-operative diagnosis of hiatal hernia varies among surgeons or if it affects outcomes. Surgeons (n = 38) participating in a statewide bariatric surgery quality improvement collaborative reviewed 33 videos of LSG in which no hiatal hernia repair was performed. Reviewers were blinded to patient information and were asked whether they perceived a hiatal hernia. Surgeon characteristics and surgeon-specific patient outcomes for LSG were compared between surgeons who identified at least one hiatal hernia during video review and those who did not. Ten surgeons (26%) identified at least one hiatal hernia after reviewing the videos. There were no significant differences in operative experience or practice type between surgeons who did and did not identify hiatal hernias. Surgeons who identified a hiatal hernia more often performed concurrent hiatal hernia repair in their practice when compared to those who did not (43.0% versus 36.5%, p

To evaluate the association of historical racist housing policies and modern-day healthcare outcomes.In 1933 the United States Government Home Owners Loan Corporation (HOLC) used racial composition of neighborhoods to determine creditworthiness and labeled them "Best", "Still Desirable", "Definitely Declining", and "Hazardous." Although efforts have been made to reverse these racist policies that structurally disadvantage those living in exposed neighborhoods, the lasting legacy on modern day healthcare outcomes is uncertain.We performed a cross-sectional retrospective review of 212,179 Medicare beneficiaries' living in 171,930 unique neighborhoods historically labeled by the HOLC who underwent 1 of 5 of common surgical procedures - coronary artery bypass, appendectomy, colectomy, cholecystectomy, and hernia repair - between 2012 and 2018. We compared 30-day mortality, complications, and readmissions across HOLC grade and Area Deprivation Index (ADI) of each neighborhood. Outcomes were risk-adjusted using a multivariable logistical regression model accounting for patient factors (age, sex, Elixhauser comorbidities), admission type (elective, urgent, emergency), type of operation, and each neighborhoods ADI; a modern day measure of neighborhood disadvantage that includes education, employment, housing-quality, and poverty measures.Overall, 212,179 Medicare beneficiaries (mean age, 71.2 years; 54.2% women) resided in 171,930 unique neighborhoods historically graded by the HOLC. Outcomes worsened in a stepwise fashion across HOLC neighborhoods. Overall, 30-day postoperative mortality was 5.4% in "Best" neighborhoods, 5.8% in "Still Desirable", 6.1% in "Definitely Declining", and 6.4% in "Hazardous" (Best vs Hazardous Odds Ration: 1.23, 95% CI: 1.13-1.24, P0.001). The same stepwise pattern was seen from "Best" to "Hazardous" neighborhoods for complications (30.5% vs 32.2%; OR: 1.12 [95% CI: 1.07-1.17]; P0.001) and Readmissions (16.3% vs 17.1%; OR: 1.06 [95% CI: 1.01-1.11]; P = 0.023). After controlling for modern day deprivation using ADI, the patterns persisted with "Hazardous" neighborhoods having higher mortality (OR: 1.17 [95% CI: 1.08-1.27]; P0.001) and complications (OR: 1.07 [95% CI: 1.02-1.12]; P = 0.003), but not for readmissions (OR: 1.02 [95% CI: 0.97-1.07]; P = 0.546).Patients residing in neighborhoods previously "redlined" or labeled "Hazardous" were more likely to experience worse outcomes after inpatient hospitalization compared to those living in "Best" neighborhoods, even after taking into account modern day measures of neighborhood disadvantage.

Sleeve gastrectomy is the most widely used bariatric operation; however, its long-term safety is largely unknown.To compare the risk of mortality, complications, reintervention, and health care use 5 years after sleeve gastrectomy and gastric bypass.This retrospective cohort study included adult patients in a national Medicare claims database who underwent sleeve gastrectomy or gastric bypass from January 1, 2012, to December 31, 2018. Instrumental variables survival analysis was used to estimate the cumulative incidence of outcomes up to 5 years after surgery.Laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.The main outcome was risk of mortality, complications, and reinterventions up to 5 years after surgery. Secondary outcomes were health care use after surgery, including hospitalization, emergency department (ED) use, and total spending.Of 95 405 patients undergoing bariatric surgery, 57 003 (60%) underwent sleeve gastrectomy (mean [SD] age, 57.1 [11.8] years), of whom 42 299 (74.2%) were women; 124 (0.2%) were Asian; 10 101 (17.7%), Black; 1951 (3.4%), Hispanic; 314 (0.6%), North American Native; 43 194 (75.8%), White; 534 (0.9%), of other race or ethnicity; and 785 (1.4%), of unknown race or ethnicity. A total of 38 402 patients (40%) underwent gastric bypass (mean [SD] age, 55.9 [11.7] years), of whom 29 050 (75.7%) were women; 109 (0.3%), Asian; 6038 (15.7%), Black; 1215 (3.2%), Hispanic; 278 (0.7%), North American Native; 29 986 (78.1%), White; 373 (1.0%), of other race or ethnicity; and 404 (1.1%), of unknown race or ethnicity. Compared with patients undergoing gastric bypass, at 5 years after surgery, patients undergoing sleeve gastrectomy had a lower cumulative incidence of mortality (4.27%; 95% CI, 4.25%-4.30% vs 5.67%; 95% CI, 5.63%-5.69%), complications (22.10%; 95% CI, 22.06%-22.13% vs 29.03%; 95% CI, 28.99%-29.08%), and reintervention (25.23%; 95% CI, 25.19%-25.27% vs 33.57%; 95% CI, 33.52%-33.63%). Conversely, patients undergoing sleeve gastrectomy had a higher cumulative incidence of surgical revision at 5 years (2.91%; 95% CI, 2.90%-2.93% vs 1.46%; 95% CI, 1.45%-1.47%). The adjusted hazard ratio (aHR) of all-cause hospitalization and ED use was lower for patients undergoing sleeve gastrectomy at 1 year (hospitalization, aHR, 0.83; 95% CI, 0.80-0.86; ED use, aHR, 0.87; 95% CI, 0.84-0.90) and 3 years (hospitalization, aHR, 0.94; 95% CI, 0.90-0.98; ED use, aHR, 0.93; 95% CI, 0.90-0.97) after surgery but similar between groups at 5 years (hospitalization, aHR, 0.99; 95% CI, 0.94-1.04; ED use, aHR, 0.97; 95% CI, 0.92-1.01). Total health care spending among patients undergoing sleeve gastrectomy was lower at 1 year after surgery ($28 706; 95% CI, $27 866-$29 545 vs $30 663; 95% CI, $29 739-$31 587), but similar between groups at 3 ($57 411; 95% CI, $55 239-$59 584 vs $58 581; 95% CI, $56 551-$60 611) and 5 years ($86 584; 95% CI, $80 183-$92 984 vs $85 762; 95% CI, $82 600-$88 924).In a large cohort of patients undergoing bariatric surgery, sleeve gastrectomy was associated with a lower long-term risk of mortality, complications, and reinterventions but a higher long-term risk of surgical revision. Understanding the comparative safety of these operations may better inform patients and surgeons in their decision-making.

Women of childbearing age comprise approximately 65% of all patients who undergo bariatric surgery in the USA. Despite this, data on maternal reintervention and obstetric outcomes after surgery are limited especially with regard to comparative effectiveness between sleeve gastrectomy and Roux-en-Y gastric bypass, the most common procedures today.Using IBM MarketScan claims data, we performed a retrospective cohort study of women ages 18-52 who gave birth after undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass with 2-year continuous follow-up. We balanced the cohort on observable characteristics using inverse probability weighting. We utilized multivariable logistic regression to examine the association between procedure selection and outcomes, including risk of reinterventions (revisions, enteral access, vascular access, reoperations, other) or adverse obstetric outcomes (pregnancy complications, severe maternal morbidity, and delivery complications). In all analyses, we controlled for age, U.S. state, and Elixhauser or Bateman comorbidities.From 2011 to 2016, 1,079 women gave birth within the first two years after undergoing bariatric surgery. Among these women, we found no significant difference in reintervention rates among those who had gastric bypass compared to sleeve gastrectomy (OR 1.41, 95% CI 0.91-2.21, P = 0.13). We then examined obstetric outcomes in the patients who gave birth after bariatric surgery. Compared to patients who underwent sleeve gastrectomy, those who had Roux-en-Y gastric bypass were not significantly more likely to experience any adverse obstetric outcomes.In this first national cohort of females giving birth following bariatric surgery, no significant difference was observed in persons who underwent Roux-en-Y gastric bypass versus sleeve gastrectomy with respect to either reinterventions or obstetric outcomes. This suggests possible equipoise between these two procedures with regards to safety within the first two years following a bariatric procedure among women who may become pregnant, but more research is needed to confirm these findings in larger samples.

To assess risk-adjusted outcomes and participant perceptions following a statewide coaching program for bariatric surgeons.Coaching has emerged as a new approach for improving individual surgeon performance, but lacks evidence linking to clinical outcomes.This program took place between October 2015 and February 2018 in the Michigan Bariatric Surgery Collaborative. Surgeons were categorized as coach, participant, or nonparticipant for an interrupted time series analysis. Multilevel logistic regression models included patient characteristics, time trends, and number of sessions. Risk-adjusted overall and surgical complication rates are reported, as are within-group relative risk ratios and 95% confidence intervals. We also compared operative times and report risk differences and 95% confidence intervals. Iterative thematic analysis of semi-structured interviews examined participant and coach perceptions of the program.The coaching program was viewed favorably by most surgeons and many participants described numerous technical and nontechnical practice changes. The program was not associated with significant change in risk-adjusted complications with relative risks for coaches, participants, and nonparticipants of 0.99 (0.62-1.37), 0.91 (0.64-1.17), and 1.15 (0.83-1.47), respectively. Operative times did improve for participants, but not coaches or nonparticipants, with risk differences of -14.0 (-22.3, -5.7), -1.0 (-4.5, 2.4), and -2.6 (-6.9, 1.7). Future coaching programmatic design should consider dose-complexity matching, hierarchical leveling, and optimizing video review.This statewide surgical coaching program was perceived as valuable and surgeons reported numerous practice changes. Operative times improved, but there was no significant improvement in risk-adjusted outcomes.

Sleeve gastrectomy has become the most common procedure performed for weight loss. But emerging data indicate that this procedure can result in lifestyle-limiting gastroesophageal reflux disease. The influence of these gastroesophageal reflux disease symptoms on patient satisfaction with the procedure has not been explored.Using a statewide, bariatric-specific data registry, we studied 6,608 patients who underwent laparoscopic sleeve gastrectomy from 2013 to 2017. We used the Gastroesophageal Reflux Disease Health-Related Quality of Life questionnaire, which is 10 questions, each ranging from 0 (no symptoms) to 5 (severe symptoms). To assess the impact of sleeve gastrectomy on patient satisfaction, we calculated the change in this score at baseline versus 1 year after the procedure. We stratified the change in the gastroesophageal reflux disease score into 5 even-sized groups (quintiles). We then examined the relationship between change in the gastroesophageal reflux disease score and patient satisfaction at 1 year. We used generalized linear mixed models to assess the variation in patient satisfaction explained by the change in the gastroesophageal reflux disease score, excess body weight loss at 1 year, and other patient outcomes (serious complications, readmission, and reoperations). We controlled for patient factors (age, sex, race, and comorbidities) and year of sleeve gastrectomy.The average change in the gastroesophageal reflux disease score was 1.62 (range: -48 to 48); however, the change in the gastroesophageal reflux disease score varied across quintiles with a -7.3-point (range: -48 to -3) worsening in the bottom quintile versus a 2.6-point (range: 7 to 48) improvement in the top quintile. Overall, 77.7% of patients were satisfied, but the proportion of patients satisfied was highly dependent on whether their reflux symptoms improved or worsened. Only 48.9% in the bottom quintile were satisfied, compared with 78.1% in the top quintile (.0001). In the multivariate model, changes in patient-reported gastroesophageal reflux disease score were the most predictive of patient satisfaction, explaining 10.1% of the variation in 1 year satisfaction. Among patients in the bottom quintile, reflux symptoms explained 30.2% of variation compared with 2.3% in quintiles with little change or improvement in reflux. Moreover, excess body weight loss explained only 2% of variation in satisfaction and1% was explained by patient outcomes (serious complications, readmissions, reoperations, or surgical complications).In this statewide study of sleeve gastrectomy, we demonstrated that gastroesophageal reflux symptoms are an important determinant of 1 year satisfaction, particularly among patients whose symptoms worsened the most.

OBJECTIVE To assess whether a hospital's percentage of Black patients associates with variations in FY2017 overall/domain-specific Hospital Acquired-Condition Reduction Program (HACRP) scores and penalty receipt. Differences in socioeconomic status and receipt of disproportionate share hospital payments (a marker of safety-net status) were also assessed. SUMMARY OF BACKGROUND DATA In FY2015, Medicare began reducing payments to hospitals with high adverse event rates. Concern has been expressed that HACRP penalties could adversely affect minority-serving hospitals, leading to reductions in resources and exasperation of disparities among hospitals with the greatest need. METHODS 100% Medicare FFS claims from 2013 to 2014 identified older adult inpatients, aged ≥65 years, presenting for 8 common surgical conditions. Multilevel mixed-effects regression determined differences in FY2017 HACRP scores/penalties among hospitals managing the highest decile of minority patients. RESULTS A total of 695,775 patients from 2923 hospitals were included. As a hospital's percentage of Black patients increased, climbing from 0.6% to 32.5% (lowest vs highest decile), average HACRP scores also increased, rising from 5.33 to 6.36 (higher values indicate worse scores). Increases in HACRP penalties did not follow the same stepwise increase, instead exhibiting a marked jump within the highest decile of racial minority-serving extent (45.7% vs 36.7%; OR [95% CI]: 1.45[1.42-1.47]). Similar patterns were observed for high disproportionate share hospital (OR [95% CI]: 1.44 [1.42-1.47]; absolute difference: +7.4 percentage-points) and low socioeconomic status-serving (1.38[1.35-1.40]; +7.3% percentage-points) hospitals. Restricted analyses accounting for the influence of teaching status and severity of patient case-mix both accentuated disparities in HACRP penalties when limiting hospitals to those at the highest known penalty-risk (more residents-to-beds, more severe), absolute differences +13.9, +20.5 percentage-points. Restriction to high operative volume, in contrast, reduced the penalty difference, +6.6 percentage-points. CONCLUSIONS Minority-serving hospitals are being disproportionately penalized by the HACRP. As the program continues to develop, efforts are needed to identify and protect patients in vulnerable institutions to ensure that disparities do not increase.

Prior studies have demonstrated an increase in gastroesophageal reflux after laparoscopic sleeve gastrectomy (LSG). However, it is unknown whether symptom severity varies or if outcomes are surgeon-specific. A validated reflux symptom survey was obtained at baseline and at 1 year after primary LSG on 7358 patients participating in a state-wide quality improvement collaborative between 2013 and 2018. Patients with worsening symptoms after surgery were divided into terciles based on the degree of increase in survey score (0 = no symptoms, 50 = max symptoms). Surgeon-level data was obtained on 52 bariatric surgeons performing at least 25 LSG cases/year during the study period. Surgeon characteristics, operative experience, and risk-adjusted 30-day complication rates were compared between surgeons in the highest tercile for moderate worsening of symptoms vs those in the lowest. A total of 2294 (31.2%) patients had worsening symptoms of reflux after sleeve gastrectomy. Overall mean increase in severity score was 6.11 (range 1 to 48) and patients with minimal, mild, and moderate symptoms had a mean increase of 1.4, 4.2, and 13.8, respectively. There were no significant differences in surgeon-specific characteristics when comparing surgeons in the highest tercile for moderate worsening of symptoms (44.7% of patients) vs those in the lowest tercile (18.7% of patients). In addition, there were no significant differences in risk-adjusted rates of overall complications (3.70% vs. 4.33%, p = 0.686), endoscopic dilations (2.83% vs. 1.91%, p = 0.417), or concurrent hiatal hernia repair (34.3% vs. 27.0%, p = 0.415) between surgeons in the highest and lowest terciles. We found that 1/3 of patients had worsening symptoms of reflux after LSG and that severity of symptoms varied. Surgeons with the highest rates of worsening reflux had similar operative experience and complication rates than those with the lowest. Further assessment of operative technique and skill may be informative.

BACKGROUND Prior studies have demonstrated a correlation between surgical skill and complication rates after laparoscopic Roux-en-Y gastric bypass. However, the impact of surgical skill on a similar but less technically challenging procedure such as sleeve gastrectomy (SG) is unknown. METHODS Practicing bariatric surgeons (n = 25) participating in a statewide quality improvement collaborative submitted an unedited deidentified video of a representative laparoscopic SG. Videos were obtained between 2015 and 2016 and were rated by bariatric surgeons in a blinded fashion using a validated instrument that assesses surgical skill. Overall scores were based on a 5-point Likert scale with 5 representing a "master surgeon" and 1 representing a "surgeon-in-training." Risk-adjusted 30-day complication rates, 1-year weight loss among cases performed during the study period, and operative technique were compared between surgeons rated in the top and bottom quartiles according to skill. RESULTS Surgeon ratings for skill varied between 2.73 and 4.60. Ratings for skill did not correlate with overall 30-day risk-adjusted complication rates (Pearson correlation coefficient, 0.213, P = 0.303). However, surgeons with higher skill ratings had lower rates of specific surgical complications, including postoperative obstruction (0.13% vs 0.3%, P = 0.017), hemorrhage (0.85% vs 1.27%, P = 0.005), and reoperation (0.24% vs 0.92%, P < 0.0001). Surgeons ranked in the top quartile for skill had faster operating times for SG (59.0 vs 82.1 min, P < 0.0001) and higher annual case volumes for both SG and any bariatric procedure (224.3 cases/yr vs 73.4 cases/yr, P = 0.009 and 244.9 cases/yr and 93.9 cases/yr, P = 0.009) when compared with surgeons in the bottom quartile. When comparing operative technique, top rated surgeons were noted to have a higher likelihood of using buttressing (83.3% vs 0%, P = 0.0041) and intraoperative endoscopy (83.3% vs 0%, P = 0.0041). CONCLUSIONS Peer ratings for surgical skill varied for laparoscopic sleeve gastrectomy but did not have a significant impact on overall complication rates. Top rated surgeons had lower rates of obstruction, hemorrhage, and reoperation; however, severe morbidity remained extremely low among all surgeons.

The aim of this study was to determine the feasibility of "hot spotting" in elective surgical populations.Prospective identification of high-cost patients, known as "hot spotting," is well developed in medical populations, but has not been performed in surgical populations. Population-based management of surgical expenditures requires identification of high-cost surgical patients to allow for effective implementation of cost-saving strategies.Using 100% Medicare claims data for 2010 to 2013, we identified patients aged 65 to 99 years undergoing elective surgical procedures. We calculated price-standardized Medicare payments for the surgical episode from the index admission through 30 days after discharge. Patient-level factors associated with payments were analyzed by multivariable linear regression.Medicare patients in the highest decile of spending accounted for a disproportionate share of aggregate costs: 30% in Colectomy (COL), 22% in coronary artery bypass grafting (CABG), 19% in Total Hip Arthroplasty, and 18% in Total Knee Arthroplasty. Medicare expenditure differences between the highest and lowest deciles were because of a 5-fold difference for COL and 3-fold difference for CABG in index hospitalization cost. In contrast, for orthopedic procedures, there were 47- to 80-fold post-acute care expenditures between highest and lowest deciles. In multivariable analyses, patients with ≥3 comorbidities had significantly higher costs than healthier patients.We found that a subset of multimorbid patients was responsible for a disproportionate share of total Medicare spending, but the individual components of spending vary by procedure. These findings suggest that targeting high-cost Medicare patients (ie, hot spotting) for cost containment efforts would be a potentially effective strategy to reduce costs in surgical populations.

RESEARCH OBJECTIVE: In 1933 the United States Government Home Owners Loan Corporation used racial composition of neighborhoods to determine creditworthiness and labeled them “Best”, “Still Desirable”, “Definitely Declining” and “Hazardous.” Although efforts have been made to reverse these racist policies that structurally disadvantage Black Americans, the lasting legacy on modern day healthcare outcomes is uncertain. The objective of this study was to evaluate the association of historical racist housing policies and modern day healthcare outcomes. STUDY DESIGN: Cross‐sectional retrospective review of Medicare beneficiaries' who underwent one of five of common surgical procedures across neighborhoods historically labeled by the Home Owners Loan Corporation. Outcomes were risk‐adjusted using a multivariable logistical regression model accounting forpatient factors (age, sex, Elixhauser comorbidities), admission type (elective, urgent, emergency), and type of operation. POPULATION STUDIED: 525,690 Medicare beneficiaries' admissions between 2012 and 2016 who underwent one of five of common surgical procedures ‐ coronary artery bypass, appendectomy, colectomy, cholecystectomy and hernia repair – across neighborhoods historically labeled by the Home Owners Loan Corporation. PRINCIPAL FINDINGS: Overall, 473,732 Medicare beneficiaries (mean age, 74.6 years; 49.8% women) underwent 520,690 operations within neighborhoods that had been historically graded by the Home Owners Loan Corporation. Mortality increased in a stepwise fashion across neighborhoods. Overall, 30‐day postoperative mortality was 4.3% in “Best” neighborhoods, 4.7% in “Still Desirable”, 4.8% in “Definitely Declining” and 5.1% in “Hazardous” (Best vs. Hazardous Odds Ratio = 1.21 [1.16–1.26]; P

In any surgical procedure, various aspects of technique may affect patient outcomes. As new procedures enter practice, it is difficult to evaluate the association of each aspect of technique with patient outcomes.To examine the associations between technique and outcomes in laparoscopic sleeve gastrectomy.In this cohort study of bariatric surgery programs participating in a statewide surgical quality improvement collaborative, 30 surgeons submitted intraoperative videos from representative sleeve gastrectomies performed on 6915 patients with morbid obesity. These videos were reviewed by blinded peer surgeons on key technical elements, and 605 reviews were linked to sleeve gastrectomy outcomes of all of the surgeons' patients from January 1, 2015, to December 31, 2016.Surgeons' technical approaches to 5 controversial aspects of laparoscopic sleeve gastrectomy: dissection of the proximal stomach, sleeve caliber, sleeve anatomy, staple line reinforcement, and leak testing.The 30-day outcomes were rate of postoperative hemorrhage and staple line leak. The 1-year outcomes were percentage of total weight lost and reflux severity (Gastroesophageal Reflux Disease Health-Related Quality of Life instrument).A total of 30 surgeons submitted 46 videos of operations performed on 6915 patients (mean [SD] age, 45.4 [11.7] years; 5494 [79.5%] female; 4706 [68.1%] White). Complete dissection of the proximal stomach was associated with reduced hemorrhage rates (higher ratings for complete mobilization of fundus were associated with a decrease in hemorrhage rate from 2.1% [25th percentile] to 1.0% [75th percentile], P = .01; higher ratings for visualization of the left crus were associated with a decrease in hemorrhage rate from 1.5% to 0.94%, P = .006; and higher ratings for complete division of the short gastrics were associated with a decrease in hemorrhage rate from 2.8% to 1.2%, P = .03). The reduction in hemorrhage rates came at the expense of higher leak rates (higher ratings for complete mobilization of fundus were associated with an increase in leak rate from 0.05% [25th percentile] to 0.16% [75th percentile], P .001; higher ratings for visualization of the left crus were associated with an increase in leak rate from 0.1% to 0.2%, P = .003; and higher ratings for complete division of the short gastrics were associated with an increase in leak rate from 0.02% to 0.1%, P = .01). Surgeons who stapled more tightly to the bougie had smaller decreases in reflux than those who stapled less tightly (-2.0 to -1.3 on a 50-point scale, P = .002). Staple line reinforcement (buttressing and oversewing) was associated with a small (2 of 1000 cases) decrease in hemorrhage rates. Staple line buttressing was also associated with a similarly small increase in leak rates (1 of 1000 cases). Leak testing was associated with a statistically insignificant change in the staple line leak rate (0.16%-0.22%, P = .47).Variations in surgical technique can be measured by video review and are associated with differences in patient outcomes.

To assess patient-reported gastroesophageal reflux disease (GERD) severity before and after SG and Roux-en-Y gastric bypass (RYGB).Development of new-onset or worsening GERD symptoms after bariatric surgery varies by procedure, but there is a lack of patient-reported data to help guide decision-making. Methods: Retrospective cohort study of patients undergoing bariatric surgery in a statewide quality collaborative between 2013 and 2017. We used a validated GERD survey with symptom scores ranging from 0 (no symptoms) to 5 (severe daily symptoms) and included patients who completed surveys both at baseline and 1-year after surgery (n = 10,451). We compared the rates of improved and worsened GERD symptoms after SG and RYGB.Within our study cohort, 8680 (83%) underwent SG and 1771 (17%) underwent RYGB. Mean baseline score for all patients was 0.94. Patients undergoing SG experienced similar improvement in GERD symptoms when compared to RYGB (30.4% vs 30.8%, P = 0.7015). However, SG patients also reported higher rates of worsening symptoms (17.8% vs 7.5%, P0.0001) even though they were more likely to undergo concurrent hiatal hernia repair (35.1% vs 20.0%, P0.0001). More than half of patients (53.5%) did not report a change in their score.Although SG patients reported higher rates of worsening GERD symptoms when compared to RYGB, the majority of patients (80%) in this study experienced improvement or no change in GERD regardless of procedure. Using clinically relevant patient-reported outcomes can help guide decisions about procedure choice in bariatric surgery for patients with GERD.

Objective To evaluate variation in self vs. peer-assessments of surgical skill using surgical videos and compare surgeon-specific outcomes with bariatric surgery. Summary background data Prior studies have demonstrated that surgeons with lower peer-reviewed ratings of surgical skill had higher complication rates after bariatric surgery. Methods This is a retrospective cohort study of 25 surgeons who voluntarily submitted a video of a typical laparoscopic sleeve gastrectomy (SG) between 2015-2016. Videos were self and peer-rated using a validated instrument based on a 5-point Likert scale (5="master surgeon" and 1="surgeon-in-training"). Risk adjusted 30-day complication rates were compared between surgeons who over-rated and under-rated their skill based on data from 24,186 SG cases as well as 12,888 gastric bypass (GBP) cases. Results Individual overall self-rating of surgical skill varied between 2.5 to 5. Surgeons in the top quartile for self:peer ratings (n=6, ratio 1.58) had lower overall mean peer-scores (2.98 vs 3.79, p = 0.0150) than surgeons in the lowest quartile (n = 6, ratio 0.94). Complication rates between top and bottom quartiles were similar after SG, however leak rates were higher with GBP among surgeons who over-rated their skill with sleeve gastrectomy (0.65 vs 0.27, p = 0.0181). Surgeon experience was similar between comparison groups. Conclusions and relevance Self-perceptions of surgical skill varied widely. Surgeons who over-rated their skill had higher leak rates for more complex procedures. Video assessments can help identify surgeons with poor self-awareness who may benefit from a surgical coaching program.

Background Global assessments of technical skill have been associated with surgical outcomes. More detailed understanding of which specific aspects of technique combine to make the “optimal” sleeve gastrectomy are necessary to help surgeons improve their practice. Study Design Practicing bariatric surgeons (n = 30) voluntarily submitted a de-identified video of a typical sleeve gastrectomy that was reviewed by a minimum of 10 peer surgeons on the technical quality of 9 operative maneuvers (ie mobilization of the fundus, stapler location, and sleeve width). An “optimal sleeve gastrectomy score” (OSGS) was calculated as a percentage of the total possible optimal maneuvers performed. Risk-adjusted 30-day complication rates and 1-year weight loss were compared between surgeons in the top and bottom quartile for OSGS for all patients who underwent sleeve gastrectomy during the time period. Results OSGS ranged from 49.1% to 82.9%. Surgeons in the top quartile for OSGS had lower rates of surgical complications (1.54% vs 2.75%; odds ratio 0.56; 95% CI 0.35 to 0.88; p = 0.013), hemorrhage (0.61% vs 1.48%; odds ratio 0.49; 95% CI 0.28 to 0.86; p = 0.013) and reoperation (0.37% vs 0.91%; odds ratio 0.4; 95% CI 0.20 to 0.81; p = 0.010) compared with surgeons in the bottom quartile. The median bougie size was 34F and the optimal location of the stapler near the pylorus and incisura was 5 cm and 2.25 cm, respectively. Conclusions Sleeve gastrectomy videos thought to have “optimal” technique by peer surgeons were associated with lower complication rates. Understanding how to quantify and assess optimal vs suboptimal techniques can serve as a guide for surgeons to improve their practice.

Hiatal hernia repair performed at the time of laparoscopic sleeve gastrectomy (LSG) may reduce post-operative reflux symptoms. It is unclear whether intra-operative diagnosis of hiatal hernia varies among surgeons or if it affects outcomes.Surgeons (n = 38) participating in a statewide bariatric surgery quality improvement collaborative reviewed 33 videos of LSG in which no hiatal hernia repair was performed. Reviewers were blinded to patient information and were asked whether they perceived a hiatal hernia. Surgeon characteristics and surgeon-specific patient outcomes for LSG were compared between surgeons who identified at least one hiatal hernia during video review and those who did not.Ten surgeons (26%) identified at least one hiatal hernia after reviewing the videos. There were no significant differences in operative experience or practice type between surgeons who did and did not identify hiatal hernias. Surgeons who identified a hiatal hernia more often performed concurrent hiatal hernia repair in their practice when compared to those who did not (43.0% versus 36.5%, p 0.001). Although complication rates were similar between surgeon groups, there were higher rates of de novo reflux symptoms (13.6% versus 11.1%, p = 0.032) and lower rates of antacid discontinuation at one-year (71.0% versus 77.2%, p = 0.043) among surgeons who identified hiatal hernias.Surgeons who identified hiatal hernias during video review had a higher rate of concurrent hiatal hernia repairs in their practice. This was not associated with improved patient-reported reflux symptoms after LSG. Standardizing identification and management of hiatal hernias during bariatric surgery may help improve reflux outcomes post-operatively.

BACKGROUND Surgical resection is a cornerstone of curative-intent therapy for patients with solid organ malignancies. With increasing attention paid to the costs of surgical care, there is a new focus on variations in the costs of cancer surgery. This study evaluated the potential interactive effect of hospital quality and patient risk on expenditures for cancer resections. METHODS With 100% Medicare claim data for 2010-2013, patients aged 65 to 99 years who had undergone cancer resection were identified. Medicare payments were calculated for the surgical episode from the index admission through 30 days after discharge. Risk- and reliability-adjusted hospital rates of serious complications and mortality within 30 days of the index operation were assessed to categorize high- and low-quality hospitals. RESULTS There was no difference in patient characteristics between the highest and lowest quality hospitals. There were substantial increases in expenditures for procedures performed at the lowest quality hospitals for each procedure. Increased expenditures at the lowest quality hospitals were found for all patients, but they were highest for the highest risk patients. At low-quality hospitals, low-risk patients undergoing pancreatectomy had payments of $29,080, whereas high-risk patients had average payments of $62,687; this was a difference of $33,607 per patient episode. CONCLUSIONS Total episode expenditures for cancer resections were lower when care was delivered at low-complication, high-quality hospitals. Expenditure differences were particularly large for high-risk patients, and this suggests that the selective referral of high-risk patients to high-quality centers may be an effective strategy for optimizing value in cancer surgery. Cancer 2018;124:826-32. © 2017 American Cancer Society.

To evaluate the relationship between hospital teaching intensity, Medicare payments, and perioperative outcomes.Several emerging payment policies penalize hospitals for low-value healthcare. Teaching hospitals may be at a disadvantage given the perception that they deliver care less efficiently.Using Medicare Provider and Analysis Review files, we studied patients from age 65 to 100 years who underwent abdominal aortic aneurysm (AAA) repair (n = 71,422), pulmonary resection (n = 93,056), or colectomy (n = 277,619) from 2009 to 2012. Patients' hospitals were categorized into quintiles of teaching intensity (very major, major, minor, very minor, and nonteaching hospitals) based on the resident-to-bed ratio. Risk-adjusted 30-day Medicare payments were price-standardized to account for graduate medical education payments, disproportionate share costs, and regional wage-index adjustments. Risk-adjusted perioperative outcomes were also assessed.Comparing risk-adjusted Medicare payments per episode of surgery, very major teaching hospitals were $14,145 more expensive than nonteaching hospitals for AAA repair ($45,570 vs $31,426; P0.001), $9,812 more expensive for pulmonary resection ($39,550 vs $29,738; P0.001), and $19,147 more expensive for colectomy ($51,893 vs $32,746; P0.001). However, after accounting for social subsidies and regional variation in Medicare spending, risk-adjusted Medicare payments were not statistically different between very major teaching hospitals and nonteaching hospitals for AAA repair ($29,946 vs $27,993; P = 0.18) and pulmonary resection ($25,407 vs $26,813; P = 1.00); a statistically significant but attenuated difference persisted for colectomy ($34,949 vs $30,352; P0.001). Very major teaching hospitals generally had higher risk-adjusted rates of serious complications and readmissions, but lower risk-adjusted rates of failure to rescue and 30-day mortality than did nonteaching hospitals.After price-standardization to account for intended differences in Medicare spending, risk-adjusted Medicare payments for an episode of surgical care were similar at teaching hospitals and nonteaching hospitals for three complex inpatient operations.

The Hospital Readmissions Reduction Program, announced in 2010 to penalize excess readmissions for patients with selected medical diagnoses, was expanded in 2013 to include targeted surgical diagnoses, beginning with hip and knee replacements. Whether these surgical penalties reduced procedure-specific readmissions is not well understood. Using Medicare claims, we evaluated the penalty announcements' effects on risk-adjusted readmission rates, episode payments, lengths-of-stay, and observation status use. Risk-adjusted readmission rates declined for both procedures from 7.6 percent in 2008 to 5.5 percent in 2016. These rates were decreasing before the program was announced, but the rate of reductions doubled after the announcement of medical penalties in March 2010 (from -0.05 percentage points to -0.10 percentage points per quarter). After targeted surgical penalties were announced in August 2013, readmission reductions returned to near the baseline trend. During the same time period, mean episode payments and lengths-of-stay decreased substantially, and trends in observation status were unchanged. This suggests that medical readmission penalties led to readmission reductions for surgical patients as well, that targeted surgical penalties did not have an additional effect, and that readmission reductions are approaching a "floor" below which further reductions may be unlikely.

To evaluate whether hospital participation in accountable care organizations (ACOs) is associated with reduced Medicare spending for inpatient surgery.ACOs have proliferated rapidly and now cover more than 32 million Americans. Medicare Shared Savings Program (MSSP) ACOs have shown modest success in reducing medical spending. Whether they have reduced surgical spending remains unknown.We used 100% Medicare claims from 2010 to 2014 for patients aged 65 to 99 years undergoing 6 common elective surgical procedures [abdominal aortic aneurysm (AAA) repair, colectomy, coronary artery bypass grafting (CABG), hip or knee replacement, or lung resection]. We compared total Medicare payments for 30-day surgical episodes, payments for individual components of care (index hospitalization, readmissions, physician services, and postacute care), and clinical outcomes for patients treated at MSSP ACO hospitals versus matched controls at non-ACO hospitals. We accounted for preexisting trends independent of ACO participation using a difference-in-differences approach.Among 341,675 patients at 427 ACO hospitals and 1,024,090 matched controls at 1531 non-ACO hospitals, patient and hospital characteristics were well-balanced. Average baseline payments were similar at ACO versus non-ACO hospitals. ACO participation was not associated with reductions in total Medicare payments [difference-in-differences estimate=-$72, confidence interval (CI95%): -$228 to +$84] or individual components of payments. ACO participation was also not associated with clinical outcomes. Duration of ACO participation did not affect our estimates.Although Medicare ACOs have had success reducing spending for medical care, they have not had similar success with surgical spending. Given that surgical care accounts for 30% of total health care costs, ACOs and policymakers must pay greater attention to reducing surgical expenditures.

If Asian American and Pacific Islanders (AAPIs) are not recognized within patients in health services research, we miss an opportunity to ensure health equity in patient outcomes. However, it is unknown what the rates are of AAPIs inclusion in surgical outcomes research.Through a scoping review, we used Covidence to search MEDLINE, EMBASE, PsycINFO, Web of Science, Scopus, and CINAHL for studies published in 2008-2018 using NSQIP data. NSQIP was chosen because of its national scope, widespread use in research, and coding inclusive of AAPI patients. We examined the proportion of studies representing AAPI patients in the demographic characteristics and Methods, Results, or Discussion section. We then performed multivariable logistic regression to examine associations between study characteristics and AAPI inclusion.In 1,264 studies included for review, 62% included race. Overall, only 22% (n = 278) of studies included AAPI patients. Of studies that included race, 35% represented AAPI patients in some component of the study. We found no association between sample size or publication year and inclusion. Studies were significantly more likely to represent AAPI patients when there was a higher AAPI population in the region of the first author's institution (lowest vs highest tercile; p0.001). Studies with a focus on disparities were more likely to include AAPI patients (p = 0.001).Our study is the first to examine AAPI representation in surgical outcomes research. We found75% of studies examine race, despite availability within NSQIP. Little more than one-third of studies including race reported on AAPI patients as a separate group. To provide the best care, we must include AAPI patients in our research.

Considerable technical variation exists when performing laparoscopic sleeve gastrectomy (LSG). However, little is known about which techniques are associated with optimal outcomes. To compare technical variation among surgeons with the lowest complication rates and whose patients achieved the most weight loss. Practicing bariatric surgeons (n = 30) voluntarily submitted a video of a typical LSG performed between 2015 and 2016. Technique-specific data captured from videos and a questionnaire included bougie size, stapler vendor, number of staple loads, use of staple line reinforcement, fibrin sealant, intraoperative leak test, endoscopy, and drain placement. Surgeon-specific outcomes were obtained from cases performed by surgeons during the study period (n = 7023) using a state-wide bariatric-specific data registry. Surgeons were ranked based on 30-day risk-adjusted surgical complication rates (“safety”) and excess body weight loss (EBWL) % (“efficacy”) at 1 year after surgery. Technique-specific variables were compared between surgeons ranked in the top and bottom quartile for both safety and efficacy. Surgical complication rates ranged from 0 to 4.32% while EBWL varied from 45.3 to 65.3%. There was no correlation between surgeon rankings for safety and efficacy (Pearson’s r = 0.063, p = 0.741). Surgeons ranked in the top quartile for safety and efficacy had significantly shorter mean operative times than surgeons ranked in the bottom quartile (65 min vs. 69 min, p

Evaluate the current status of Hepatopancreatobiliary (HPB) Surgery workforce in North America.HPB fellowships have proliferated, with HPB surgeons entering the field through 3 pathways: transplant surgery, surgical oncology, or HPB surgery training. Impact of this growth is unknown.An anonymous survey was distributed to 654 is used as HPB surgeons from October 2012 to January 2013. Questions evaluated satisfaction with job availability after training and description of current practice. Nationwide Inpatient Sample (NIS) data from 2003 to 2010 was queried to describe the growth of HPB cases in the United States; these data were compared to prior HPB workforce projections performed using 2003 NIS data.A total of 416 HPB surgeons responded (66%). HPB surgeons are concentrated in a small number of states/provinces with a lack of HPB surgeon workforce in central United States. HPB graduates from 2008 to 2012 report increased difficulty in identifying an HPB-focused practice versus prior to 2008. Mature HPB surgery practices report a composition of 25% to 50% non-HPB operative cases. Fifty-one percent of respondents reported an opinion that current HPB Surgeon production was excessive; however, 2010 NIS data demonstrate that major HPB surgery cases have grown significantly more than was previously projected using 2003 NIS data.A cohesive strategy for responsibly responding to the HPB surgical workforce requirements of North America is needed. Elevation of training standards, standardization of requirements for certification, and careful modeling that accounts for regionalization of care should be pursued to prevent overtraining and decentralization of HPB surgical care in the future.

In 2006, the Centers for Medicare and Medicaid Services (CMS) issued a national coverage decision restricting bariatric surgery to designated centers of excellence (COE). Although prior studies show mixed results on complications and reoperations, no prior studies evaluated whether this policy reduced spending for bariatric surgery. We sought to determine whether the coverage restriction to COE-designated hospitals was associated with lower payments from CMS. We utilized national Medicare claims data to examine 30-day episode payments for patients who underwent bariatric surgery from 2003 to 2010 (n = 72,117 patients). We performed an interrupted time series analysis, adjusting for patient factors, preexisting temporal trends, and changes in procedure type, to determine whether the 2006 coverage decision was associated with lower Medicare payments above and beyond any existing secular trends. For these analyses, we included payments for the index hospitalization, readmissions, physician services, and post-discharge ancillary care. After accounting for patient factors, preexisting temporal trends, and changes in procedure type, there were no statistically significant improvements in episode payments after (US$14,720) vs before (US$14,283) the coverage decision (+US$437, 95 % CI, −US$10 to +US$883). In a direct assessment of payments for COE-designated hospitals (US$14,481) vs non-COE-designated hospitals (US$14,756), no significant differences in episode payments were found (−US$275, 95 % CI, −US$696 to +US$145). We found no significant reductions in 30-day episode payments after vs before restricting coverage to COE-designated hospitals. Center of excellence status is not a proxy for savings to the healthcare system.

Over the past decade, there has been a rapid decline in adverse events after bariatric surgery. As a result, it is possible that the influence of hospital volume on outcomes has attenuated over time. The objective of the present study was to examine whether the relationship between hospital volume and adverse events has persisted in the era of laparoscopic surgery. This study is based on analysis of State Inpatient Databases (SID) for 12 states from 2006 through 2011, which included 446,127 patients.Using hospital discharge data, changes in serious complications, reoperations and mortality over time, and the impact of hospital volume on outcomes among patients undergoing laparoscopic adjustable gastric band (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) were studied. Hospitals were stratified by operative volume, and using multivariable logistic regression to adjust for patient characteristics and procedure-type, the relationships between hospital volume and outcomes during 3 2-year periods were examined: 2006-2007, 2008-2009, and 2010-2011.The rate of reoperations and mortality were low, and there were no significant differences between the highest (125 cases/yr) and lowest (50 cases/yr) volume hospitals for both LAGB and LRYGB. The volume-outcome relationship was most prominent when examining rates of adjusted odds ratios for serious complications at the lowest volume hospitals compared with the highest volume hospitals (LAGB: 1.65 [CI: 1.18, 2.30] for 2006-2007, 1.81 [CI: 1.36, 2.41] for 2008-2009, and 2.08 [CI:1.40, 3.09] for 2010-2011; LRYGB: 1.55 [CI:1.23, 1.95] for 2006-2007, 1.39 [CI:1.09, 1.76], and 1.39 [CI:1.07, 1.80] for 2010-2011).Outcomes improved over the study period at both high- and low-volume volume hospitals. There remain significant differences in serious complications between the highest and lowest volume hospitals for both stapled and nonstapled procedures.

To determine the temporal relationship between reducing surgical complications and costs, using the study population of bariatric surgery.Understanding the relationship between quality and costs has significant implications for the business case of investing in performance improvement. An unprecedented focus on safety in bariatric surgery has led to substantial reductions in complication rates over time, making it an ideal patient population in which to examine this relationship.We performed a retrospective review of Medicare beneficiaries undergoing bariatric surgery in the years 2005 to 2006 and 2013 to 2014 (total N = 37,329 patients, 562 hospitals). Hospitals were ranked into quintiles based on their degree of improvement in risk and reliability-adjusted 30-day rates of serious complications across the time periods. Multivariable regression was used to calculate corresponding changes in average price-standardized payments for each quintile of hospitals.We found a strong association between reductions in complications and decreased Medicare payments. The top 20% of hospitals had a decrease in average serious complication rate of 7.3% (10.0%-2.7%; P0.001) and an average per-patient savings of $4861 (95% confidence interval $3921-5802). Conversely, the bottom 20% of hospitals had smaller decrease in complication rate of 0.8% (4.4% to 3.6%; P0.001) and a smaller average savings of $2814 (95% confidence interval $2139-3490).When analyzing Medicare patients undergoing bariatric surgery, hospitals with the largest reductions in serious postoperative complications had the greatest decrease in per-patient payments. This study demonstrates the potential savings associated with quality improvement in high-risk surgical procedures.

We sought to assess hospital cost variation for elective inpatient surgical procedures within small geographic areas.Previous studies have documented cost variation for inpatient surgical procedures on a national basis, suggesting opportunities for savings. Cost variation within small geographic areas is more relevant to policymakers, providers, and patients, but it has not been studied.Using Medicare payment data, we identified elderly patients undergoing 1 of 7 elective inpatient surgical procedures during 2010-2012. We calculated 30-day surgical episode costs including payments for the index hospitalization, readmission, physician services, and post-acute care. Using hierarchical regression models, we identified hospitals with significantly higher average costs than the least expensive hospitals in their metropolitan statistical areas.The proportion of patients undergoing surgery at the lowest-cost hospitals in their metropolitan statistical areas ranged from 10% for hip replacement to 25% for coronary artery bypass grafting. In contrast, the proportion of patients undergoing surgery at significantly higher-cost hospitals ranged from 5.0% for bariatric surgery to 64% for hip replacement. These high-cost hospitals had higher complication and readmission rates than their lowest-cost peers. Surgery at high-cost hospitals resulted in Medicare expenditures that were $4427 to $10,417 higher than those at the lowest-cost hospitals, increasing episode costs by 25% to 47% per case.Significant excess expenditures are incurred due to care at hospitals with substantially higher average costs than their nearby peers. This finding highlights the potential for substantial savings without the need to refer patients over long distances. Some of the procedures studied may represent appropriate targets for future Medicare bundled payment initiatives.

Surgical resection is a cornerstone of curative-intent therapy for patients with solid organ malignancies. With increasing attention paid to the costs of surgical care, there is a new focus on variations in the costs of cancer surgery. This study evaluated the potential interactive effect of hospital quality and patient risk on expenditures for cancer resections.With 100% Medicare claim data for 2010-2013, patients aged 65 to 99 years who had undergone cancer resection were identified. Medicare payments were calculated for the surgical episode from the index admission through 30 days after discharge. Risk- and reliability-adjusted hospital rates of serious complications and mortality within 30 days of the index operation were assessed to categorize high- and low-quality hospitals.There was no difference in patient characteristics between the highest and lowest quality hospitals. There were substantial increases in expenditures for procedures performed at the lowest quality hospitals for each procedure. Increased expenditures at the lowest quality hospitals were found for all patients, but they were highest for the highest risk patients. At low-quality hospitals, low-risk patients undergoing pancreatectomy had payments of $29,080, whereas high-risk patients had average payments of $62,687; this was a difference of $33,607 per patient episode.Total episode expenditures for cancer resections were lower when care was delivered at low-complication, high-quality hospitals. Expenditure differences were particularly large for high-risk patients, and this suggests that the selective referral of high-risk patients to high-quality centers may be an effective strategy for optimizing value in cancer surgery. Cancer 2018;124:826-32. © 2017 American Cancer Society.

To understand the impact of the Hospital Readmission Reduction Program on both future targeted and nontargeted surgical procedures.The Hospital Readmission Reduction Program, established under the Affordable Care Act in March of 2010, placed financial penalties on hospitals with higher than expected rates of readmission beginning in 2012 for targeted medical conditions. Multiple studies have suggested a "spill-over" effect into other conditions, but the extent of that effect for specific surgical procedures is unknown.A retrospective review 5,122,240 Medicare beneficiaries who underwent future targeted procedures (total hip replacement, total knee replacements) or nontargeted procedures (colectomy, lung resection, abdominal aortic aneurysm repair, coronary artery bypass graft, aortic valve replacement, mitral valve repair) using an interrupted time series model to assess the rates of readmission before the Hospital Readmission Reduction Program was announced (2008-2010), whereas the program was being implemented (2010-2012) and after penalties were initiated (2012-2014). We also explored if the change in readmission rates were correlated with changes in index length of stay, use of observation status, or discharge to a skilled nursing facility.From 2008 to 2014 rates of readmission declined for both target conditions (6.8%-4.8%; slope change -0.07 to -0.10, P0.001) and nontarget conditions (17.1%-13.4%; slope change -0.04 to -0.11, P0.001). The rate of reduction was most prominent after announcement of the program between 2010 and 2012 for both targeted and nontargeted conditions. During the same time period, mean hospital length of stay decreased; nontargeted conditions (10.4-8.4 days) and targeted conditions (3.6-2.8 days). There was no correlation between hospital reduction in readmissions and use of observation-only admissions (Pearson correlation coefficient = 0.01) or discharge to a skilled nursing facility (Pearson correlation coefficient = 0.05).Trends in readmissions after inpatient surgery are consistent with hospitals responding to financial incentives announced in the Hospital Readmission Reduction Program. There appears to be both an anticipatory effect (future targeted procedures reducing readmission before payments implemented) and a spillover effect (nontargeted procedures also reducing readmissions).

Following the US Food and Drug Administration approval for laparoscopic gastric band surgery in 2001, as many as 96 000 devices have been placed annually. The reported rates of reoperation range from 4% to 60% in short-term studies; however, to our knowledge, few long-term population-level data on outcomes or expenditures are known.To describe the rate of device-related reoperations occurring after laparoscopic gastric band surgery as well as the associated payments in a longitudinal national cohort.This retrospective review of 25 042 Medicare beneficiaries who underwent gastric band placement between 2006 and 2013 identifies gastric band-related reoperations, including device removal, device replacement, or revision to a different bariatric procedure (eg, a gastric bypass or sleeve gastrectomy). The rates of reoperation were risk adjusted using a multivariable logistic regression model that included patient age, sex, race/ethnicity, Elixhauser comorbidities, and the year that the operation was performed.Rate of device-related reoperation nationally and across individual hospital referral regions. Thirty-day total episode Medicare payments to hospitals for the index operation and any subsequent reoperations.Of the 25 042 patients who underwent gastric band placement, 20 687 (82.61%) were white, 18 143 (72.45%) were women, and the mean age was 57.56 years. Patients (mean age, 57.5; 76.2% women) requiring reoperation had lower rates of hypertension (64.9% vs 73.4%; P .001) and diabetes (40.4% vs 44.6%; P .001) and were more likely to have their index operation at a for-profit hospital (34.6% vs 22.0%; P .001). With an average of 4.5-year follow-up, 4636 patients (18.5%) underwent 17 539 reoperations (an average of 3.8 procedures/patient). Hospital referral regions demonstrated a 2.9-fold variation in risk- and reliability-adjusted rates of reoperation (lower quartile average, 13.3%; upper quartile average, 39.1%). During the study period, Medicare paid $470 million for laparoscopic gastric band associated procedures, of which $224 million (47.6%) of the payments were for reoperations. From 2006 to 2013, the proportion of payments from Medicare for reoperations increased from 16.4% to 77.3% of their annual spending on the gastric band device.Among Medicare beneficiaries undergoing gastric band surgery, device-related reoperation was common, costly, and varied widely across hospital referral regions. These findings suggest that payers should reconsider their coverage of the gastric band device.

OBJECTIVE The aim of this study was to compare the surgical outcomes of emergency operations performed at critical access and non-critical access hospitals. BACKGROUND Critical access hospitals are often the only source of surgical care for rural populations. Previous studies have demonstrated that patients undergoing common, elective operations at these rural hospitals have similar outcomes to their urban counterparts. Little is known, however, about the quality of care these hospitals provide for emergency operations for which they are most essential. METHODS We performed a cross-sectional retrospective review of 219,170 urgent or emergency colon resections among Medicare beneficiaries between 2009 and 2012. We compared mortality, serious complications, reoperation, and readmission rates at critical access and non-critical access hospitals using a multivariable logistic regression to adjust for patient factors (age, sex, race, Elixhauser comorbidities,) indication (cancer, diverticulitis, obstruction, inflammatory bowel disease, bleeding), year of operation, and type of operation. RESULTS Operative indications were similar at both critical access and non-critical access hospitals with the most common being cancer (38.5% vs 31.1%) followed by diverticulitis (26.9% vs 28.0%). Compared with patients treated at non-critical access hospitals, patients undergoing surgery at critical access hospitals were less likely to have multiple comorbid diseases (% of patients with 2 or more comorbid conditions, 67.5% vs 75.9%; P < 0.01). After accounting for these differences, patients in critical access hospitals had lower risk-adjusted 30-day mortality rates (14.3% vs 16.2%; P = 0.012) and lower rates of serious complications (11.1% vs 27.2%; P < 0.001). However, critical access hospitals had higher rates of reoperation (2.1% vs 1.4%; P = 0.009) and readmissions (22.3% vs 19.4%; P < 0.001). CONCLUSIONS For emergency colectomy procedures, Medicare beneficiaries in critical access hospitals experienced lower mortality rates but more frequent reoperation and readmission. These findings suggest that critical access hospitals provide safe, essential emergency surgical care, but may need more resources for postoperative care coordination in these high-risk operations.