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For bariatric surgery, hospital doesn't matter

April 20, 2009 |  1:00 pm

Bariatric (weight-loss) surgery is unlike most other types of surgery in that it doesn't seem to matter where patients have it done. For most types of surgery, hospitals that perform the most operations generally have a better success rate and lower mortality. But that is not the case for bariatric surgery, according to a new analysis by Dr. Edward H. Livingston of the University of Texas Southwestern School of Medicine.

The American College of Surgeons and the American Society for Metabolic and Bariatric Surgery have developed nearly identical guidelines for what they consider Centers of Excellence for the procedure. Among other things, those guidelines require that the centers perform 125 such surgeries per year, have personnel to follow the patients long-term and enter outcomes into databases. "These criteria make intuitive sense," Livingston said, but there is no objective evidence to justify them. Nonetheless, since 2006, Medicare has paid for bariatric surgery only when it is performed at a Center of Excellence.

To examine the differences, Livingston studied data from the 2005 National Inpatient Survey on 19,363 patients who underwent bariatric surgery that year at 253 hospitals. About 28% of the patients had the procedures performed at Centers of Excellence.

One immediate conclusion, he reported Monday in the journal Archives of Surgery, is that the procedure has grown safer. In the past, about 0.5% of patients undergoing the procedure died on the operating table or immediately afterward. Overall, Livingston found, in 2005 only 0.1% of patients died.

Differences between the Centers of Excellence and other hospitals were generally small. At the centers, 0.17% of patients died and 6.3% developed complications during their hospital stay. At other hospitals, 0.09% died and 6.4% suffered complications. The difference in death rates may be attributable to the fact that the Centers of Excellence tend to operate on the most difficult cases and have an older patient population.

The biggest differences between the two groups were in numbers of cases per year and cost. Centers of Excellence, on average, performed 226 surgeries per year, compared with 79 at other hospitals. And even though patients spent an average of 2.6 days in the hospital in both groups, the average cost at Centers of Excellence was $11,527, compared with $10,984 at other hospitals.

"Designation as a bariatric surgery Center of Excellence does not ensure better outcomes," Livingston wrote. "Neither does high annual procedure volume. Extra expenses associated with Center of Excellence designation may not be warranted."

-- Thomas H. Maugh II

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