Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence.
Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence.
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DOI：
10.1001/jama.2013.755
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发表时间：
2013-02-27
影响因子：
120.7
通讯作者：
Birkmeyer, John D.
中科院分区：
文献类型：
--
作者：
Dimick, Justin B.;Nicholas, Lauren H.;Ryan, Andrew M.;Thumma, Jyothi R.;Birkmeyer, John D.
从2006年开始，医疗保险和医疗补助服务中心（CMS）将减肥手术的覆盖范围限制在两个主要专业组织指定的“卓越中心”（COE）。我们试图评估实施全国覆盖决定的COE部分是否与改善医疗保险患者的减肥手术结果相关。使用2004-09年来自12个州的出院数据（n=321,464例患者），我们研究了接受减肥手术的医疗保险患者的结局变化。使用差异中的差异分析方法，我们评估了国家覆盖范围的决定是否与医疗保险患者的改善结果相关，超过了非医疗保险患者的现有时间趋势。任何并发症、严重并发症和再次手术的风险调整率。在研究期间，减肥手术的结果改善了医疗保险和非医疗保险的患者，这一变化是在CMS覆盖决定之前进行的。在考虑了患者因素、手术类型的变化和预先存在的改善结局的时间趋势后，实施CMS全国覆盖决定（与之前相比）：任何并发症（治疗后8.0% vs.治疗前7.0%;相对风险[RR]，1.14，95%置信区间[CI]，0.95 - 1.33），严重并发症（3.3% vs. 3.6%; RR 0.92，95% CI，0.62 - 1.22）和再次手术（1.0% vs. 1.1%; RR 0.90，95% CI，0.64 - 1.17）。在一项直接评估中，比较了指定为COE的医院与未指定为COE的医院的结局，我们发现三种结局中的任何一种都没有显著差异：任何并发症（5.5% vs. 6.0%; RR，0.98，95%，0.90 - 1.06），严重并发症（2.2%与2.5%; RR 0.92，95%CI，0.84至1.00）和再次手术（0.83%与0.96%; RR，1.00，95%CI，0.86至1.17）。将减肥手术限制在指定为COE的医院并没有改善医疗保险受益人的手术结果。取消CMS全国覆盖决定的这一组成部分可以在不危及患者安全的情况下提高获得性。
Starting in 2006, the Center for Medicare and Medicaid Services (CMS) has restricted coverage of bariatric surgery to hospitals designated as “Centers of Excellence” (COE) by two major professional organizations. We sought to evaluate whether the implementation of the COE component of the national coverage decision was associated with improved bariatric surgery outcomes in Medicare patients. Using 2004–09 hospital discharge data from 12 states (n=321,464 patients), we studied changes in outcomes in Medicare patients undergoing bariatric surgery. Using a difference-in-difference analytic approach, we evaluated whether the national coverage decision was associated with improved outcomes in Medicare patients above and beyond existing time trends in non-Medicare patients. Risk-adjusted rates of any complication, serious complications, and reoperations. Over the study period, bariatric surgery outcomes improved in both Medicare and non-Medicare patients and this change was underway prior to the CMS coverage decision. After accounting for patient factors, changes in procedure type, and pre-existing time trends toward improved outcomes, there were no statistically significant improvements in outcomes after (vs. before) implementation of the CMS national coverage decision: any complications (8.0% after vs. 7.0% before; Relative Risk [RR], 1.14, 95% Confidence Interval [CI], 0.95 to 1.33), serious complications (3.3% vs. 3.6%; RR 0.92, 95% CI, 0.62 to 1.22), and reoperation (1.0% vs. 1.1%; RR 0.90, 95% CI, 0.64 to 1.17). In a direct assessment comparing outcomes at hospitals designated as COEs vs. hospitals without COE designation, we found no significant difference in any of the three outcomes: any complications (5.5% vs. 6.0%; RR, 0.98, 95%, 0.90 to 1.06), serious complications (2.2% vs. 2.5%; RR 0.92, 95%CI, 0.84 to 1.00), and reoperations (0.83% vs. 0.96%; RR, 1.00, 95% CI, 0.86 to 1.17). Restricting bariatric surgery to hospitals designated as COEs has not improved surgical outcomes for Medicare beneficiaries. Eliminating this component of the CMS national coverage decision could enhance access without jeopardizing patient safety.
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