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Gastric Bypass Surgeries in New Hampshire, 1996-2007

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Gastric Bypass Surgeries in New Hampshire, 1996-2007 CDC - Preventing Chronic Disease: Volume 9, 2012: 11_0089 Page 1 of 6 ORIGINAL RESEARCH Gastric Bypass Surgeries in New Hampshire, 1996-2007 Sai S. Cherala, MD, MPH Suggested citation for this article: Cherala SS. Gastric bypass surgeries in New Hampshire, 1996-2007. Prev Chronic Dis 2012;9:110089. DOI: http://dx.doi.org/10.5888/pcd9.110089 . PEER REVIEWED Abstract Introduction Obesity is a national epidemic. Gastric bypass surgery may be the only option that provides significant long-term weight loss for people who are morbidly obese (body mass index [BMI] ≥40 kg/m2 ) or for people who have a BMI of 35 or higher and have an obesity-related comorbidity. The objective of this study was to assess trends in gastric bypass surgery in New Hampshire. Methods Data from 1996 to 2007 from the New Hampshire Inpatient Hospital Discharge data set were analyzed. Records for patients with a gastric bypass surgery code were identified, and data on patients and hospitalizations were collected. A joinpoint regression model was used to analyze trends in surgery rates. Differences between patients and payer types were analyzed by using the Cochran–Mantel–Haenszel χ2 test. Results The annual rate of gastric bypass surgery increased significantly from 3.3 to 22.4 per 100,000 adults between 1996 and 2007. The in-hospital death rate decreased significantly from 11% in 1996 to 1% in 2007. A greater proportion of women (78.1% during the study period) than men had this surgery. The average charge of a surgery decreased significantly from $44,484 in 1996 to $43,907 in 2007; by 2007, total annual charges were $13.9 million. Since 1996, private or “other” payers have been charged for nearly 80% of the total discharges. Conclusion The number of gastric bypass surgeries has increased in New Hampshire, and so have their cost. These increases may reflect a shortage in effective primary care and preventive measures to address the obesity epidemic. Introduction Obesity is a growing public health concern in the United States (1,2). The prevalence of obesity increased significantly between 1970 and 2008 among adults (from 15% to 34%), and children and adolescents (from 5% to 17%) (3-5). The prevalence of obesity in New Hampshire has followed a similar trend: the prevalence of morbidly obese adults (body mass index [BMI] ≥40 kg/m2 ) increased significantly from 1.3% in 1996 to 2.5% in 2007. In 2007, 25% of New Hampshire adults were obese (BMI ≥30) (S. Knight, MSPH, New Hampshire Department of Health and Human Services, e-mail communication, January 2011). Strategies have emerged to counter the increasing rates of obesity. At the population level, strategies include social marketing campaigns, environmental changes to encourage increased physical activity, and regulations, such as bans on sugar-sweetened beverages (6). At the individual level, strategies range from books and television shows on exercise and diet to surgery. Bariatric surgery has become a popular method of treating obesity; gastric bypass surgery has emerged as the most widely used of these surgical procedures (7-9). The National Heart, Lung, and Blood Institute’s Clinical Guidelines recommend weight-loss surgery as “an option for well- informed and motivated patients who have clinically severe obesity (BMI ≥40) or a BMI ≥35 and serious comorbid conditions” (10). Weight-loss surgery provides medically significant sustained weight loss for more than 5 years in most patients (11). Postoperative complications vary by type of surgery, baseline weight, and overall health of the patient. In the prospective Swedish Obese Subjects study, overall death rates in the surgery group decreased during an average 10.9 years of follow-up, compared with matched subjects in the control group (12). Most patients fared well after surgery and showed a significant improvement in quality of life. The objective of this study was to assess trends in gastric bypass surgery in New Hampshire. CDC - Preventing Chronic Disease: Volume 9, 2012: 11_0089 Page 2 of 6 Methods Inpatient and emergency department acute care hospital discharge data are collected under New Hampshire Revised Statutes Annotated (RSA) 126:25, which requires all facilities in New Hampshire to report discharge data to the New Hampshire Department of Health and Human Services. Records for New Hampshire residents who are discharged in Massachusetts, Maine, and Vermont are obtained by the department through special interstate data exchange agreements with the agencies in those states responsible for collection of discharge data. In 2009, 30 licensed general and specialty acute care hospitals in New Hampshire submitted their inpatient hospital data. For this study, inpatient discharge data from the New Hampshire Inpatient Hospital Discharge data set were analyzed; the data set captures hospitalization-related information, including information on charges, for all New Hampshire residents hospitalized in New Hampshire, Maine, Massachusetts, and Vermont. The data set provides high-quality data on hospitalizations, procedures, and diagnoses, and data are comparable from year to year. Data from 1996 through 2007 were collected for this study. Age- adjusted rates (per 100,000 area population) of hospitalizations related to gastric bypass surgery, by year, sex, and age, and the proportion of hospitalizations by expected primary payer were calculated. Institutional review board approval was not required for this study because it was done as part of public health surveillance. Variables Diagnoses and procedures for the hospitalizations were coded according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) (13). Discharge records with a gastric bypass surgery code of 44.31 (gastroenterostomy without gastrectomy; high gastric bypass), 44.38 (laparoscopic gastroenterostomy), 44.39 (gastroenterostomy without gastrectomy, other gastroenterostomy), or 44.95 (laparoscopic gastric restrictive procedure) in any procedure field were identified. Data on patients (ie, year of hospitalization, sex, and age) and hospitalizations (ie, length of stay, mean hospital charges, expected primary payer, and in-hospital death rate) were collected. The patient’s insurer at the time of data collection was identified as the expected payer. Payers were identified as Medicare, Medicaid, private or “other” payers, and self-pay. Data were reviewed to determine the relative proportions of the 2 main indications for surgery: a principal diagnosis of morbid obesity (ICD-9-CM, 278.01) or a principal diagnosis of an obesity-related comorbid condition, or both. The following obesity- related comorbid conditions, selected from the Charlson comorbidity index (14), were included in the analysis: cereberovascular disease, congestive heart failure, chronic pulmonary disease, diabetes, hypertension, liver disease (moderate to severe), myocardial infarction, peripheral vascular disease, and moderate to severe renal disease. Other conditions, such as endocrine and mental disorders, were also examined. Discharge records for people with an unknown residence or for people residing outside New Hampshire were excluded from this analysis. Records that had diagnosis codes from 150.0 to 159.9, corresponding to malignant neoplasm of digestive organs and peritoneum, were also excluded from analysis. Information on race and ethnicity is not consistently collected through the New Hampshire Inpatient Hospital Discharge data set, so analysis by race/ethnicity could not be performed. Statistical analysis The estimated annual number of gastric bypass surgeries was derived by counting the number of discharge records coded with a gastric bypass surgery in any of the procedure fields in the data. Annual population rates were age-adjusted for the 2000 US population. The estimated rates were not based on the population of overweight or obese residents and were not adjusted for the number of adults who may have previously had a gastric bypass surgery. Secondary analysis included calculating by year the proportion of gastric bypass surgeries associated with each type of payer, the total charges of surgery for each payer, and the frequency of each comorbidity. All charges were adjusted for inflation for 2007 by using the US Bureau of Labor Statistics inflation calculator, which uses the average Consumer Price Index for a given calendar year. A joinpoint regression model was used to analyze trends in the annual rates of gastric bypass surgery. The differences between female and male discharged patients and differences among payer types were analyzed by using the Cochran–Mantel–Haenszel χ2 test (15). Statistical significance was set at a P value of less than .05. All statistical tests were 2-sided, and all analyses were performed with SAS for Windows software (SAS Institute, Inc, Cary, North Carolina). Results From 1996 through 2007, the estimated annual number of gastric bypass surgeries increased significantly from 37 surgeries in 1996 to 318 in 2007 (Table 1), and the estimated annual rate of gastric bypass surgeries increased significantly from 3.3 to 22.4 per 100,000 people (Figure). The rate increased significantly by age in the 2 younger age categories but most notably among people aged 25 to 64 years: from 2.7 per 100,000 in 1996 to 39.2 per 100,000 in 2007. CDC - Preventing Chronic Disease: Volume 9, 2012: 11_0089 Page 3 of 6 Figure. Age-adjusted gastric bypass hospitalization rates in New Hampshire, 1996-2007. Source: New Hampshire Inpatient Discharge Data, New Hampshire Office of Health Statistics and Data Management. [A tabular version of this figure is also available.] A greater proportion of women (78.1% during the study period) than men had this surgery. The estimated total number of surgeries performed on women (2,202 surgeries) was more than 3 times the number performed on men (618 surgeries). The mean age for surgery was 46 years; nearly 29% of surgeries were performed in patients aged 35 to 44 years. The mean length of hospital stay decreased from 19 days in 1996 to 5 days in 2007. The in-hospital death rate decreased from 11% in 1996 to 1% in 2007.
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