Bariatric Surgery in Medicare Patients: Examining Safety and Healthcare Utilization in the Disabled and Elderly.
Bariatric Surgery in Medicare Patients: Examining Safety and Healthcare Utilization in the Disabled and Elderly.
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DOI：
10.1097/sla.0000000000004526
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发表时间：
2022-07-01
影响因子：
9
通讯作者：
Dimick JB
中科院分区：
文献类型：
--
作者：
Chao GF;Chhabra KR;Yang J;Thumma JR;Arterburn DE;Ryan AM;Telem DA;Dimick JB
在国家医疗保险队列中比较袖状胃切除术与Roux-en-Y胃旁路术后的安全性和医疗保健利用。虽然减肥手术在医疗保险受益人中越来越多，但没有长期的全国性研究来检查手术之间的比较有效性。CMS医疗保险证据开发和覆盖咨询委员会确定的共同决策和覆盖政策问题需要减肥结果。回顾性工具变量分析的医疗保险索赔（2012-2017年）30,105减肥手术患者有权由于残疾或年龄。我们检查了临床安全性结局（死亡率、并发症和再干预）、医疗保健利用（艾德就诊、再住院和费用）和治疗效果的异质性。我们比较了每个权利组在30天、1年和3年时套筒和旁路之间的所有结局。在残疾人中（n= 21，595），袖套与较低的3年死亡率相关（2.1% vs 3.2%，ARR 95%CI：−2.2%至−0.03%），并发症（22.2% vs 27.7%，ARR 95%CI：−8.5%至−2.6%），再次干预（20.1% vs 27.7%，ARR 95%CI：−10.7%至−4.6%）、艾德利用率（71.6% vs 77.1%，ARR 95%CI：−8.5%至−2.4%）和再住院率（47.4% vs 52.3%，ARR 95%CI：−8.0%至−1.7%）。套筒术后累计支出为46，277美元，旁路术后为48，211美元（P= 0.22）。在老年患者（n= 8，510）中，袖套与3年并发症的发生率较低相关（20.1% vs 24.7%，ARR 95%CI：−7.6%至−1.7%），再次干预（14.0% vs 21.9%，ARR 95%CI：−10.7%至−5.2%）、艾德利用率（51.7% vs 57.2%，ARR 95%CI：−9.1%至−1.9%）和再住院率（41.8% vs 45.8%，ARR 95%CI：−7.5%至−0.5%）。套筒术后支出为38，632美元，旁路术后支出为39，270美元（P= 0.60）。手术治疗效果因死亡率、翻修和食管旁疝修补的权利而显著不同。减肥手术是安全的，并且在Medicare老年人和残疾人亚群中保留了袖状旁路的医疗保健利用益处。本研究比较了Medicare残疾人和老年受益人中腹腔镜袖状胃切除术和Roux-en-Y胃旁路术术后30天、1年和3年的安全性和医疗保健利用结局。为了解释未测量的混杂因素，我们使用了工具变量法。我们发现，在3年时，无论权利原因如何，袖带都比旁路更安全，导致患者的医疗保健利用率更低。
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 (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%, ARR 95%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=.22). Among the elderly (n=8,510), 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=.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. This study compared 30-day, 1-year, and 3-year post-operative safety and healthcare utilization outcomes between laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass in Medicare disabled and elderly beneficiaries. To account for unmeasured confounding, we used an instrumental variable method. We found at 3 years, sleeve was safer and led to less healthcare utilization than bypass for patients regardless of entitlement reason.