Surgical Outcomes Research Center in the Department of Surgery and the Department of Health Services, University of Washington, Seattle, Washington.
Surg Obes Relat Dis. 2013 Sep-Oct;9(5):617-22. doi: 10.1016/j.soard.2012.11.002. Epub 2012 Dec 3.
The objective of this study was to examine how much of the impact of the Centers for Medicare and Medicaid Services' national coverage decision (NCD) on bariatric surgery was driven by the restriction of reimbursements to Centers of Excellence (COE). We used inpatient care data of those with employer-sponsored insurance plans across United States using the MarketScan Commercial Claims and Encounter Database (2003-2009).
We performed a retrospective cohort study evaluating the impact of the accreditation on subjects with a difference-in-difference approach (removing the temporal changes occurring in non-COEs) on rates of inpatient mortality, 90-day reoperations, complications, readmissions, and total payments.
A total of 30,755 patients (43.9 ± 11.0 years; 79.9% women) had bariatric surgery. A total of 17,896 patients underwent procedures at sites that became COEs (8455 pre-NCD and 9441 post-NCD, [+10.4%]) compared with 12,859 at non-COEs (6534 pre-NCD and 6325 post-NCD, [-3.3%]). Of the total number of bariatric procedures, laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable band procedures increased from 42.9% and 3.1% pre-NCD to 64.5% and 19.7% post-NCD, respectively. In the COEs, there were reductions in inpatient mortality (.3% to .1%; P = .02), 90-day reoperations (.8% to .5%; P = .006), complications (36.4% to 27.6%; P<.001), and readmissions (10.8% to 8.8%; P<.001) while payments remained similar ($24,543 ± $40,145 to $24,510 ± $37,769; P = .9). After distinguishing from temporal trends and differences occurring at non-COEs, 90-day reoperation (-.8%; P = .02) and complication rates (-2.7%; P = .01) were lower at the COEs after the NCD.
The accreditation-based NCD in bariatric surgery was associated with lower rates of reoperations and complications. Such policies may become a powerful tool to improve surgical safety and quality.
本研究旨在探讨医疗保险和医疗补助服务中心（CMS）的全国覆盖决策（NCD）对减重手术的影响有多大，是由限制向卓越中心（COE）报销驱动的。我们使用美国雇主赞助保险计划的住院患者护理数据，使用 MarketScan 商业索赔和遭遇数据库（2003-2009 年）。
我们采用回顾性队列研究，采用差异法（消除非 COE 中发生的时间变化）评估认证对住院死亡率、90 天再手术率、并发症、再入院率和总支付的影响。
共有 30755 名患者（43.9±11.0 岁；79.9%为女性）接受了减重手术。共有 17896 名患者在成为 COE 的场所接受了手术（NCD 前 8455 例，NCD 后 9441 例，[+10.4%]），而 12859 名患者在非 COE 接受了手术（NCD 前 6534 例，NCD 后 6325 例，[-3.3%]）。在所有减重手术中，腹腔镜 Roux-en-Y 胃旁路术和腹腔镜可调带术的比例从 NCD 前的 42.9%和 3.1%分别增加到 NCD 后的 64.5%和 19.7%。在 COE 中，住院死亡率（0.3%至 0.1%；P=0.02）、90 天再手术率（0.8%至 0.5%；P=0.006）、并发症（36.4%至 27.6%；P<.001）和再入院率（10.8%至 8.8%；P<.001）均有所下降，而支付金额保持相似（24543±40145 美元至 24510±37769 美元；P=0.9）。在区分了 COE 中的时间趋势和非 COE 中的差异后，NCD 后，90 天再手术率（-0.8%；P=0.02）和并发症发生率（-2.7%；P=0.01）较低。
基于认证的减重手术 NCD 与较低的再手术率和并发症发生率相关。此类政策可能成为提高手术安全性和质量的有力工具。
