Department of Surgery, Detroit Medical Center, Wayne State University, 3990 John R, Detroit, MI, 48201, USA.
Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.
Surg Endosc. 2023 Nov;37(11):8570-8576. doi: 10.1007/s00464-023-10411-4. Epub 2023 Oct 23.
Although patients with lower socioeconomic status are at higher risk of obesity, bariatric surgery utilization among patients with Medicaid is low and may be due to program-specific variation in access. Our goal was to compare bariatric surgery programs by percentage of Medicaid cases and to determine if variation in distribution of patients with Medicaid could be linked to adverse outcomes.
Using a state-wide bariatric-specific data registry that included 43 programs performing 97,207 cases between 2006 and 2020, we identified all patients with Medicaid insurance (n = 4780, 4.9%). Bariatric surgery programs were stratified into quartiles according to the percentage of Medicaid cases performed and we compared program-specific characteristics as well as baseline patient characteristics, risk-adjusted complication rates and wait times between top and bottom quartiles.
Program-specific distribution of Medicaid cases varied between 0.69 and 22.4%. Programs in the top quartile (n = 11) performed 18,885 cases in total, with a mean of 13% for Medicaid patients, while programs in the bottom quartile (n = 11) performed 32,447 cases in total, with a mean of 1%. Patients undergoing surgery at programs in the top quartile were more likely to be Black (20.2% vs 13.5%, p < 0.0001), have diabetes (35.1% vs 29.5%, p < 0.0001), hypertension (55.1% vs 49.6%, p < 0.0001) and hyperlipidemia (47.6% vs 45.2%, p < 0.0001). Top quartile programs also had higher complication rates (8.4% vs 6.6%, p < 0.0001), extended length of stay (5.6% vs 4.0%, p < 0.0001), Emergency Department visits (8.1% vs 6.5%, p < 0.0001) and readmissions (4.7% vs 3.9%, p < 0.0001). Median time from initial evaluation to surgery date was also significantly longer among top quartile programs (200 vs 122 days, p < 0.0001).
Bariatric surgery programs that perform a higher proportion of Medicaid cases tend to care for patients with greater disease severity who experience delays in care and also require more resource utilization. Improving bariatric surgery utilization among patients with lower socioeconomic status may benefit from insurance standardization and program-centered incentives to improve access and equitable distribution of care.
尽管社会经济地位较低的患者肥胖风险更高，但医疗补助计划中的患者接受减重手术的比例较低，这可能是由于该计划在获取途径方面存在特定的差异。我们的目标是通过 Medicaid 病例比例来比较减重手术项目，并确定 Medicaid 患者分布的差异是否与不良结果有关。
我们使用了一个全州范围的专门的减重数据登记处，该登记处包含了 2006 年至 2020 年间进行的 43 个项目的 97207 例病例，其中包括所有拥有医疗补助保险的患者（n=4780，占 4.9%）。根据 Medicaid 病例所占比例，将减重手术项目分为四分位组，我们比较了各项目的特征以及基线患者特征、风险调整后并发症发生率和高低四分位组之间的等待时间。
各项目 Medicaid 病例的分布比例在 0.69%至 22.4%之间。排名前四分之一（n=11）的项目共完成了 18885 例手术，其中 Medicaid 患者的比例平均为 13%，而排名后四分之一（n=11）的项目共完成了 32447 例手术，其中 Medicaid 患者的比例平均为 1%。在排名前四分之一的项目中接受手术的患者更有可能是黑人（20.2%比 13.5%，p<0.0001），患有糖尿病（35.1%比 29.5%，p<0.0001）、高血压（55.1%比 49.6%，p<0.0001）和高血脂（47.6%比 45.2%，p<0.0001）。排名前四分之一的项目的并发症发生率也更高（8.4%比 6.6%，p<0.0001），住院时间延长（5.6%比 4.0%，p<0.0001）、急诊就诊（8.1%比 6.5%，p<0.0001）和再次入院（4.7%比 3.9%，p<0.0001）。排名前四分之一的项目中，从最初评估到手术日期的中位时间也显著延长（200 天比 122 天，p<0.0001）。
进行更多 Medicaid 病例的减重手术项目往往会照顾到病情更严重的患者，这些患者的治疗会出现延误，同时也需要更多的资源利用。改善社会经济地位较低的患者的减重手术利用率可能需要通过保险标准化和以项目为中心的激励措施来改善获取途径，并实现公平的医疗服务分配。
