NATIONAL HARBOR, MD. — Disabled Medicare patients who undergo bariatric surgery may have higher operative mortality and a greater rate of complications than those outside of the federal program, but these risks appear to be counterbalanced by a substantial improvement in health, according to a single-center, retrospective study.
Perceptions of the risks and benefits of bariatric surgery in Medicare patients (or older patients in general) have tipped back and forth in various studies since 2004, when a report found that patients older than 55 years had elevated 30-day mortality from the procedures, especially at low-volume centers (Ann. Surg. 2004;240:586-93), said Dr. James W. Maher of the division of general surgery at Virginia Commonwealth University (VCU), Richmond.
At the annual meeting of the American Society for Metabolic and Bariatric Surgery, Dr. Maher reviewed the results of bariatric procedures performed at VCU during 1981–2006. Prior to 1999, most bariatric procedures at VCU consisted of open Roux-en-Y gastric bypass (RYGB) or vertical banded gastroplasty. Since then, the university's surgeons have performed mostly laparoscopic RYGB and a small number of laparoscopic adjustable gastric banding procedures.
Dr. Maher and his coinvestigators compared the outcomes of 282 Medicare patients with those of 3,169 non-Medicare patients.
All but 27 of the Medicare patients were on disability. Of the 282 Medicare patients, 175 had received open RYGB and 107 had received laparoscopic RYGB.
Compared with non-Medicare patients at baseline, Medicare patients had a significantly higher mean age and mean body mass index, as well as significantly higher rates of hypertension, diabetes, obstructive sleep apnea, and obesity-hypoventilation (pickwickian) syndrome, according to Dr. Maher.
Among all patients, those with Medicare coverage lost a significantly lower percentage of excess weight than did those who were not covered by Medicare (60% vs. 66%, respectively). Hypertension resolved more often among non-Medicare patients than among Medicare patients (65% vs. 49%), but diabetes resolved at similar rates between the groups (77% vs. 65%).
Men in both groups lost a similar percentage of excess weight, and diabetes resolved at similar rates (30% for Medicare vs. 23% for non-Medicare). But hypertension was resolved in 56% of men with Medicare coverage, compared with 30% of men not covered by Medicare, a significant difference.
Mortality at 30 days was significantly higher among Medicare patients than among non-Medicare patients (2.5% vs. 0.8%). There was an even greater disparity in mortality between male Medicare patients than male non-Medicare patients (5.6% vs. 1.5%). Of the 27 Medicare patients not on disability, no one older than 65 years died.
Compared with non-Medicare patients, those who were covered had a slightly higher rate of anastomotic leak but a lower rate of pulmonary embolism, possibly because they had a higher rate of preoperative insertion of inferior vena cava filters, Dr. Maher said.