Ibrahim Andrew M, Thumma Jyothi R, Dimick Justin B
Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.
Surgical Innovation Editor.
JAMA Surg. 2017 Sep 1;152(9):835-842. doi: 10.1001/jamasurg.2017.1093.
Following the US Food and Drug Administration approval for laparoscopic gastric band surgery in 2001, as many as 96 000 devices have been placed annually. The reported rates of reoperation range from 4% to 60% in short-term studies; however, to our knowledge, few long-term population-level data on outcomes or expenditures are known.
To describe the rate of device-related reoperations occurring after laparoscopic gastric band surgery as well as the associated payments in a longitudinal national cohort.
DESIGN, SETTINGS, AND PARTICIPANTS: This retrospective review of 25 042 Medicare beneficiaries who underwent gastric band placement between 2006 and 2013 identifies gastric band-related reoperations, including device removal, device replacement, or revision to a different bariatric procedure (eg, a gastric bypass or sleeve gastrectomy). The rates of reoperation were risk adjusted using a multivariable logistic regression model that included patient age, sex, race/ethnicity, Elixhauser comorbidities, and the year that the operation was performed.
Rate of device-related reoperation nationally and across individual hospital referral regions. Thirty-day total episode Medicare payments to hospitals for the index operation and any subsequent reoperations.
Of the 25 042 patients who underwent gastric band placement, 20 687 (82.61%) were white, 18 143 (72.45%) were women, and the mean age was 57.56 years. Patients (mean age, 57.5; 76.2% women) requiring reoperation had lower rates of hypertension (64.9% vs 73.4%; P < .001) and diabetes (40.4% vs 44.6%; P < .001) and were more likely to have their index operation at a for-profit hospital (34.6% vs 22.0%; P < .001). With an average of 4.5-year follow-up, 4636 patients (18.5%) underwent 17 539 reoperations (an average of 3.8 procedures/patient). Hospital referral regions demonstrated a 2.9-fold variation in risk- and reliability-adjusted rates of reoperation (lower quartile average, 13.3%; upper quartile average, 39.1%). During the study period, Medicare paid $470 million for laparoscopic gastric band associated procedures, of which $224 million (47.6%) of the payments were for reoperations. From 2006 to 2013, the proportion of payments from Medicare for reoperations increased from 16.4% to 77.3% of their annual spending on the gastric band device.
Among Medicare beneficiaries undergoing gastric band surgery, device-related reoperation was common, costly, and varied widely across hospital referral regions. These findings suggest that payers should reconsider their coverage of the gastric band device.
2001年美国食品药品监督管理局批准腹腔镜胃束带手术之后，每年植入的器械多达96000个。短期研究报告的再次手术率在4%至60%之间；然而，据我们所知，关于结局或费用的长期人群水平数据却很少。
描述腹腔镜胃束带手术后器械相关再次手术的发生率以及全国纵向队列中的相关费用。
设计、地点和参与者：这项对2006年至2013年间接受胃束带植入手术的25042名医疗保险受益人进行的回顾性研究，确定了与胃束带相关的再次手术，包括器械取出、器械更换或改为其他减肥手术（如胃旁路手术或袖状胃切除术）。使用多变量逻辑回归模型对再次手术率进行风险调整，该模型包括患者年龄、性别、种族/民族、埃利克斯豪泽合并症以及手术年份。
全国以及各个医院转诊地区器械相关再次手术的发生率。医疗保险为初次手术及任何后续再次手术向医院支付的30天总费用。
在接受胃束带植入手术的25042名患者中，20687名（82.61%）为白人，18143名（72.45%）为女性，平均年龄为57.56岁。需要再次手术的患者（平均年龄57.5岁；76.2%为女性）高血压发病率较低（64.9%对73.4%；P＜0.001），糖尿病发病率较低（40.4%对44.6%；P＜0.001），且更有可能在营利性医院接受初次手术（34.6%对22.0%；P＜0.001）。平均随访4.5年，4636名患者（18.5%）接受了17539次再次手术（平均每位患者3.8次手术）。医院转诊地区的风险和可靠性调整后的再次手术率存在2.9倍的差异（下四分位数平均值为13.3%；上四分位数平均值为39.1%）。在研究期间，医疗保险为腹腔镜胃束带相关手术支付了4.7亿美元，其中2.24亿美元（47.6%）用于再次手术。从2006年到2013年，医疗保险用于再次手术的支付比例从其每年在胃束带器械上的支出的16.4%增加到77.3%。
在接受胃束带手术的医疗保险受益人中，器械相关再次手术很常见，成本高昂，且在医院转诊地区差异很大。这些发现表明，支付方应重新考虑其对胃束带器械的覆盖范围。
