Thirty-day death rates from bariatric surgery in California, rose from 1.3 per 1,000 patients to 1.5 between 2005 and 2008, according to a report released Wednesday.
One-year death rates were 3.3 per 1,000 or about 33 deaths. About 12.4% of patients experienced a complication, such as hemorrhage, or had to undergo a repeat surgery, an improvement from 13.1% in 2005.
California is the only state besides New Jersey that publicly tracks the procedure by hospital.
The report found that while some hospitals do a lot of bariatric procedures, many hospitals are doing relatively few. Of the 94 hospitals performing bariatric procedures, 55 hospitals performed fewer than the 125 in 2009, which is the minimum volume required for ASMBS accreditation, according to the American Society for Metabolic and Bariatric Surgery's president Robin Blackstone, MD. Of the 94 hospitals, 38 performed fewer than 60 and 16 did 10 or less.
"With this report, we provide the state average risk of death, complications, and hospital readmission rates for each type of bariatric procedure and how that's changed," said Joe Parker, director of the Healthcare Outcomes Center at the California Office of Statewide Health Planning and Development, which produced the report. "And we also let everyone know what hospitals are doing what kinds of procedures and how many."
Parker acknowledges that although there is some information in the medical literature linking the number of procedures a hospital or surgeon does with better outcomes, it is inconclusive. Nevertheless, he said, "we provide this information to physicians and consumers and let them discuss how important that may be in their decision-making."
Parker said, "patients seeking bariatric surgery usually don't have access to this kind of information on the safety of these procedures, except what's provided by the physicians. And the physician's information is also often generally limited to what's out there in the research world, and what their experience is in just their own hospital."
The report lists volumes and percentages for each of five types of weight-loss surgeries for each hospital: laparoscopic Roux-en-Y gastric bypass (Lap RYGB, the most common representing 68.1%), Lap Band, Vertical Sleeve Gastrectomy (VSG), Open RYGB, and Biliopancreatic Diversion (BPD).
According to the report, RYGB and BPD "were associated with the highest complication and death rates and the longest hospital lengths of stay," while Lap Band procedures had the lowest.
Readmissions from all bariatric bariatric procedures occurred for 6.4% of patients, compared with 2.6% readmission rate for all inpatient procedures (excluding childbirth, procedures in newborns, and for cancer patients.)
And while there were troublesome readmission rates for bariatric surgery, they have declined since 2005. Readmissions were most common in RYGB operations, averaging 10.5%, followed by VSG, 9.2%; BPD, 9% and Lap RYGB, 6.8%.
There was wide variation in what types of procedures certain hospitals specialize in.
For example, the Fresno Heart and Surgical Hospital performs the most bariatric procedures, 878, of any hospital in the state, 878, but 699, or 80%, are done with Lap RYGB. Fresno surgeons only did two open RYGB procedures 10 VSG, 7 BPD and 160 Lap Band.
The second highest volume hospital, Scripps Mercy in San Diego, performed 834, but 94.6% were Lap RYGB.
And at Cedars Sinai Medical Center in Los Angeles, 53.1% of the hospital's 699 bariatric procedures were Lap Band, while at Kaiser Foundation Hospital in Harbor City, 59.3% of 400 procedures were performed as VSG.
The state did not reveal specific death and complication rates for each of the 94 hospitals, which it does for other hospital procedures such as coronary artery bypass grafts. That's because to date, there isn't an acceptable risk-adjustment formula that accurately takes into consideration how sick patients who undergo this procedure really are. However, he says, "it's something we'd eventually like to do" when someone comes up with a well-vetted algorithm.
Parker says the state would like to separate reasons for patient mortality from those related to surgery or post-surgical issues versus unrelated circumstances, such as accidents or violence.
As bariatric procedures are increasingly accepted as a medically sound alternative to dieting and exercise for obese people with one or more co-morbidities, more procedures are being done nationally and in California. For 2010, the number of procedures in the state will reach 14,600. Since 2005, the number of bariatric procedures has risen nearly 7% to 13,500 procedures in 2009.
Nationally the number of procedures is expected to exceed 109,000 this year, as more insurance companies and state Medicaid programs cover the procedure as a way to reduce disease complications and costs that are otherwise likely to follow a morbidly obese individual.
Last year, Parker says, the Centers for Medicare & Medicaid Services lowered the criteria for bariatric surgery coverage. Instead of a BMI of 35 and one co-morbidity, one need only have a BMI of 30 and one co-morbidity now.
The California report was not mandated by the state legislature, as many other OSHPD reports are. But Parker says that the agency felt "it made a lot of sense for us, because of the growing obesity epidemic in the nation, to look at the different risk profiles for these different procedures and see which ones were higher.
"We expect the number of these surgeries to increase," he said.
A routine bariatric surgery is estimated to cost about $25,000 per patient, although billed charges can be as high as $50,000. Complication-free lengths of stay vary between one day, for simpler Lap procedures, two three days, Parker said.