Obesity Surgery Outcomes Worse in Older Patients

NEW YORK (Reuters Health) - Surgical procedures for the treatment of obesity are associated with substantial rates of rehospitalization and death, particularly among patients age 65 or older, according to reports in the Journal of the American Medical Association.

In one study, Dr. Heena P. Santry, from the University of Chicago, and her associates examined trends for elective obesity surgery in the United States using the Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project.

The number of procedures increased from 13,365 in 1998 to 72,177 in 2002. Gastric bypass accounted for 80 percent to 90 percent of all procedures. Patients were primarily female (81 percent to 84 percent).

The proportion of patients in the highest-level income group (more than $44,999/year) increased from 32 percent to 60 percent over the study period. Private insurance paid for 75 percent of surgeries in 1998 and 83 percent in 2002, while Medicare and Medicaid reimbursement decreased from 16 percent to 11 percent.

The rates of unexpected reoperations for surgical complications ranged between 7 percent and 9 percent. In-hospital deaths ranged from 0.1 percent to 0.2 percent, and pulmonary complications ranged from 4 percent to 7 percent. Otherwise, complication rates were low, Santry's group notes.

"In the absence of a nonsurgical option for morbid obesity, our findings regarding in-hospital safety of (obesity) surgery are promising while our findings regarding worsening sociodemographic disparities are worrisome," they write.

However, in another report, Dr. David R. Flum, from the University of Washington in Seattle, and his colleagues found that among Medicare beneficiaries, the risk of early death after obesity surgery is high, particularly among men and patients aged 65 years and older.

Flum's group evaluated the risk of death using the Medicare National Claims History Part B data from 1996 through 2002.

Their data showed 30-day, 90-day, and 1-year death rates of 2.0 percent, 2.8 percent and 4.6 percent, respectively. Results were worse for men (7.5 percent versus 3.7 percent among women at 1 year) and for patients age 65 or older versus younger patients (11.1 percent versus 3.9 percent at 1 year).

The results were also affected by surgeon experience. The odds of death within 90 days were 1.6 times higher when surgery was performed by surgeons with less than the average surgical volume than by those with more experience.

"Directing care of older patients to surgeons who perform higher volume of (obesity) procedures in Medicare beneficiaries might be expected to improve outcomes in this high-risk population," Flum's group concludes.

In a third paper in the Journal, Dr. David S. Zingmond and colleagues at the David Geffen School of Medicine at the University of California Los Angeles observe that Roux-en-Y gastric bypass is associated with increased hospital use after surgery, although the death rates were lower than those observed by Flum's group

Their data come from California's annual hospital Patient Discharge Database from 1995 to 2004. Overall in-hospital death was 0.18 percent, and 1-year mortality was 0.91 percent. In-hospital death for Medicare beneficiaries was 0.64 percent.

Among the nearly 25,000 patients with 3-year follow-up, the rates of hospitalization were 20.2 percent in the first year after surgery, 18.4 percent in the second year and 14.9 percent in the third year. In contrast, the rate of hospitalization in the year prior to surgery was 8.4 percent.

Zingmond and his colleagues also found that male gender, having Medicare or Medicaid insurance, pre-procedure hospitalization, the presence of other medical conditions, and treatment at lower-volume hospitals were associated with higher rates of readmission.

"Payers, clinicians, and patients must consider the not-inconsequential rate of rehospitalization after this type of surgery," Zingmond's group maintains.

In a related editorial, Dr. Bruce M. Wolfe, from Oregon Health & Science University in Portland and Dr. John M. Morton from Stanford University in California point out that results after medical treatment for obesity tend to be transient, while obesity surgery leads to sustained weight loss.

The JAMA studies "demonstrate that there are vulnerable patient populations and potential additional costs associated with surgery, but suggest that surgical volume helps mitigate these risks and costs."

The commentators suggest that the documented illness and death rates "must be seen as opportunities for improvement in (obesity) surgery, not as support for exclusionary practices by payors for patients in dire need."

SOURCE: JAMA, October 19, 2005.