Post Surgical Health
Post-Surgical
Care Expenditures
p
and
Weight
g Loss Following
g
Bariatric Surgery
g y
Matthew L. Maciejewski, PhD
Durham VA & Duke University
AcademyHealth ARM
Sunday June 27, 2010
Acknowledgements
g
Collaborators
Maren Olsen, Leila Kahwati, Valerie Smith, Andrew Kavee: VA
David Arterburn: Group Health Cooperative
William Henderson: University of Colorado
Edward Livingston: UT-Southwestern
Funding
F
di
VA HSR&D
Bariatric Surgery
Evidence Base for Bariatric Surgery
•Most effective treatment for weight loss,
comorbidity reduction,
reduction and improved QoL
•Low mortality (30-day: 0.28%, 1 yr: 1%)
Bariatric surgery increased in 10 years
•Medicare
M di
covered
d starting
t ti in
i 2005
Increasing Surgical Volume
Davis, Slish, 2006; Encinosa, Bernard, 2005; Santry, Gillen, Lauderdale, 2005; Thomson, 2007
What We Know and
Current Research Question
•From prior work, we found…
•Mortality rate at one year: 3.4% (Arch Surg 2009)
•Higher if BMI≥ 50 or greater overall disease burden
•Post-surgical discontinuation rates of lipid-lowering
(40%) & diabetes Rx (52%) at 1 yr (under review)
•Research Question
•Examine
a
e whether
e e p
pre-surgical
e su g ca and
a d post-surgical
pos su g ca health
ea ca
care
eu
utilization
a o a
and
d
expenditures differ
•Examine whether post-surgical expenditures vary by weight loss
Veterans Health Administration in 2009
•Largest vertically and horizontally integrated health care system in US
•153 hospitals in each of the 50 states, District of Columbia and Puerto Rico
•900+ outpatient clinics & 135 nursing homes
•47 residential rehabilitation treatment centers
•108 comprehensive home-care programs
•7.9 million enrollees, 5.5 million unique users, and 60 million outpatient visits
•Annual budget
g of $48 billion in 2010
•Divided into 21 regional networks
National Surgical Quality
I
Improvement
t Program
P
(NSQIP)
•VA
VA Initiative
I iti ti to
t Monitor,
M it Compare
C
and
d
p
Surgical
g
Q
Quality
y
Improve
•Founded in 1994
•Trained surgical clinical nurses extract
data on major surgical procedures using
standardized protocol
•Demographics
Demographics, pre-op
pre op comorbidities & labs
•30-day post-op complications & mortality
Study Design and Data
•Study Design
•Retrospective cohort of surgical cases from 12
VA bariatric surgical centers
•Identified by CPT codes
•Sensitivity:
y 99.2%, Specificity:
p
y 99.9%
•Administrative and clinical data
•VA utilization/cost: OPC, PTF, HERC Average Cost
•Longitudinal
L
it di l weight:
i ht C
Corporate
t D
Data
t W
Warehouse
h
•Covariates: Pre/post, age, gender, race, ASA, baseline BMI, smoking status, marital
status, taking of diabetes or lipid-lowering Rx, DCG score
Economic Outcomes
Type of Care
Utilization
Expenditures
Primary Care
Visits
√
Specialty Care
Visits
√
Mental Health
Visits
√
Medications
30‐dayy equivalents
q
√
Inpatient
# admissions, LOS
√
Total Outpatient
√
O
Overall
ll
√
Descriptive Statistics
Demographic and Preoperative Characteristics
Age
Male (%)
C
Caucasian
i (%)
Non-Caucasian (%)
Married (%)
P i l or Never
Previously
N
Married
M i d (%)
BMI
Super Obese (BMI ≥ 50) (%)
DCG
ASA physical status classification 4 (%)
Smoker within year prior to surgery (%)
Laparoscopic Procedure (%)
Patients with 3 pre-surgical, 3 post-surgical years of data (%)
Patients with 3 pre-surgical, 2 post-surgical years of data (%)
Patients with 3 pre
pre-surgical,
surgical, 1 post
post-surgical
surgical years of data (%)
Patients with 2 pre-surgical, 3 post-surgical years of data (%)
Patients with 2 pre-surgical, 2 post-surgical years of data (%)
pre-surgical,
g , 1 ppost-surgical
g
years
y
of data (%)
( )
Patients with 2 p
Patients with 1 pre-surgical, 3 post-surgical years of data (%)
Patients with 1 pre-surgical, 2 post-surgical years of data (%)
Patients with 1 pre-surgical, 1 post-surgical years of data (%)
Surgical Cases (n = 846)
51.3 (8.2)
73.0
77.5
16.3
52.5
47 3
47.3
48.5 (7.7)
35.9
0 76 (1.04)
0.76
(1 04)
7.1
13.6
24 7
24.7
61.1
15.5
3.4
14.1
1.4
0.6
3.4
0.4
0.1
Utilization Results
Utilization significantly lower post-surgery
Utilization significantly higher post-surgery
Utilization similar pre- & post-surgery
Expenditure Results
Expenditures significantly lower post-surgery
Expenditures significantly higher post-surgery
Expenditures similar pre- & post-surgery
Specification for Weight Change & Expenditures
•Specification in prior analysis (6 years)
Costt = f(Demog, Hlth, pre/post, time, pre*time)
•Modified specification to examine impact of weight change on expenditures at one
year
Cost1 = f(Wgt 1, Demog, Hlth, post time)
Post-Surgical Expenditures and Weight Change at 1 Year
Expe
enditures (u
unadjusted))
$16,000
T t l OP Costs
Total
C t
IP Costs
C t
T t l Costs
Total
C t
$12 000
$12,000
$8,000
$4,000
$0
1
2
3
T til off % Weight
Tertile
W i ht Change
Ch
(1
(1stt ttertile=most
til
t weight
i ht loss)
l
)
Sample = 385
Limitations
•May not generalize beyond veterans in 2000-2006 seen at 12 bariatric surgery
centers
t
•May generalize male Medicare/Medicaid cases
•Non-VA
•Non
VA utilization & expenditures not included
•Current analysis satisfies VA payer perspective
•Cannot address social perspective
Conclusion
•No reduction in total VA expenditures three years after surgery for older male
p
patients
•Longer term follow-up might find reductions
•These results differ from prior studies
•Post-surgical
P t
i l expenditures
dit
influenced
i fl
d by
b baseline
b
li weight
i ht and
d amountt off weight
i ht
loss
•Post-surgical expenditures at one year highest for those with greatest weight loss
Questions?
VA Response to Obesity
Managing Overweight/Obese Veterans
Everywhere
((MOVE!)) started 2005-2006
•Multidisciplinary, evidence-based, stepped-care,
primary care based program for identifying &
primary-care
intervening with overweight and obese patients
•Population-based approach to ID at risk patients
by screening all PC patients using BMI
•In 2007, bariatric surgery became 5th and final
level of MOVE! intervention for patients who don’t
success in prior less intensive levels