Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI 48109, USA.
JAMA. 2013 Feb 27;309(8):792-9. doi: 10.1001/jama.2013.755.
Starting in 2006, the Centers for Medicare & Medicaid Services (CMS) has restricted coverage of bariatric surgery to hospitals designated as centers of excellence (COE) by 2 major professional organizations.
To evaluate whether the implementation of the COE component of the national coverage decision was associated with improved bariatric surgery outcomes in Medicare patients.
DESIGN, SETTING, AND PATIENTS: Retrospective, longitudinal study using 2004-2009 hospital discharge data from 12 states (n = 321,464 patients) of changes in outcomes in Medicare patients undergoing bariatric surgery (n = 6723 before and n = 15,854 after implementation of the policy). A difference-in-differences analytic approach was used to evaluate whether the national coverage decision was associated with improved outcomes in Medicare patients above and beyond existing time trends in non-Medicare patients (n = 95,558 before and n = 155,117 after implementation of the policy).
Risk-adjusted rates of any complication, serious complications, and reoperation.
Bariatric surgery outcomes improved during the study period in both Medicare and non-Medicare patients; however, this change was already under way prior to the CMS coverage decision. After accounting for patient factors, changes in procedure type, and preexisting time trends toward improved outcomes, there were no statistically significant improvements in outcomes after (vs before) implementation of the CMS national coverage decision for any complication (8.0% after vs 7.0% before; relative risk [RR], 1.14 [95% CI, 0.95-1.33]), serious complications (3.3% vs 3.6%, respectively; RR, 0.92 [95% CI, 0.62-1.22]), and reoperation (1.0% vs 1.1%; RR, 0.90 [95% CI, 0.64-1.17]). In a direct assessment comparing outcomes at hospitals designated as COEs (n = 179) vs hospitals without the COE designation (n = 519), no significant differences were found for any complication (5.5% vs 6.0%, respectively; RR, 0.98 [95% CI, 0.90-1.06]), serious complications (2.2% vs 2.5%; RR, 0.92 [95% CI, 0.84-1.00]), and reoperation (0.83% vs 0.96%; RR, 1.00 [95% CI, 0.86-1.17]).
Among Medicare patients undergoing bariatric surgery, there was no significant difference in the rates of complications and reoperation before vs after the CMS policy of restricting coverage to COEs. Combined with prior studies showing no association of COE designation and outcomes, these results suggest that Medicare should reconsider this policy.
自 2006 年以来，医疗保险和医疗补助服务中心 (CMS) 将减重手术的覆盖范围限制在由两个主要专业组织指定为卓越中心 (COE) 的医院。
评估医疗保险患者减重手术结果的国家覆盖决策的 COE 部分的实施是否与改善相关。
设计、地点和患者：使用来自 12 个州 (n = 321464 名患者) 的 2004-2009 年医院出院数据的回顾性纵向研究，评估在医疗保险患者 (n = 6723 名在政策实施前和 n = 15854 名在政策实施后) 中接受减重手术的患者结局的变化。采用差异-差异分析方法评估国家覆盖决策是否与医疗保险患者的结局改善相关，而不仅仅是在非医疗保险患者中已经存在的时间趋势 (n = 95558 名在政策实施前和 n = 155117 名在政策实施后)。
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，医疗保险和非医疗保险患者的减重手术结果都有所改善；然而，这一变化在 CMS 覆盖决策之前已经在进行。在考虑患者因素、手术类型变化以及已经存在的改善结局的时间趋势后，在 CMS 国家覆盖决策实施后 (8.0%比实施前 7.0%；相对风险 [RR]，1.14 [95%CI，0.95-1.33])，任何并发症的结局均无统计学意义改善，严重并发症 (分别为 3.3%和 3.6%；RR，0.92 [95%CI，0.62-1.22]）和再次手术（1.0%比 1.1%；RR，0.90 [95%CI，0.64-1.17]）。在对指定为 COE 的医院 (n = 179) 与没有 COE 指定的医院 (n = 519) 进行的直接比较中，任何并发症 (分别为 5.5%和 6.0%；RR，0.98 [95%CI，0.90-1.06])、严重并发症 (2.2%和 2.5%；RR，0.92 [95%CI，0.84-1.00])和再次手术 (0.83%和 0.96%；RR，1.00 [95%CI，0.86-1.17]) 无显著差异。
在接受减重手术的医疗保险患者中，CMS 将覆盖范围限制在 COE 后的并发症和再次手术发生率与之前相比没有显著差异。结合先前表明 COE 指定与结果无关的研究，这些结果表明，医疗保险应重新考虑这一政策。
