Objective:

To compare safety and healthcare utilization after sleeve gastrectomy versus Roux-en-Y gastric bypass in a national Medicare cohort.

Summary Background Data:

Though bariatric surgery is increasing among Medicare beneficiaries, no long-term, national studies examining comparative effectiveness between procedures exist. Bariatric outcomes are needed for shared decision-making and coverage policy concerns identified by the cMS Medicare Evidence Development and Coverage Advisory Committee.

Methods:

Retrospective instrumental variable analysis of Medicare claims (2012–2017) for 30,105 bariatric surgery patients entitled due to disability or age. We examined clinical safety outcomes (mortality, complications, and reinterventions), healthcare utilization [Emergency Department (ED) visits, rehospitalizations, and expenditures], and heterogeneity of treatment effect. We compared all outcomes between sleeve and bypass for each entitlement group at 30 days, 1 year, and 3 years.

Results:

Among the disabled (n= 21,595), sleeve was associated with lower 3-year mortality [2.1% vs 3.2%, absolute risk reduction (ARR) 95% confidence interval (CI):–2.2% to–0.03%], complications (22.2% vs 27.7%, ARR 95% CI:–8.5% to–2.6%), reinterventions (20.1% vs 27.7%, ARR 95% CI:–10.7% to–4.6%), ED utilization (71.6% vs 77.1%, ARR 95% CI:–8.5% to–2.4%), and rehospitalizations (47.4% vs 52.3%, ARR 95% Ci:–8.0% to–1.7%). Cumulative expenditures were $46,277 after sleeve and $48,211 after bypass (P= 0.22). Among the elderly (n= 8510), sleeve was associated with lower 3-year complications (20.1% vs 24.7%, ARR 95% CI:–7.6% to–1.7%), reinterventions (14.0% vs 21.9%, ARR 95% CI:–10.7% to–5.2%), ED utilization (51.7% vs 57.2%, ARR 95% CI:–9.1% to–1.9%), and rehospitalizations (41.8% vs 45.8%, ARR 95% Ci:–7.5% to–0.5%). Expenditures were $38,632 after sleeve and $39,270 after bypass (P= 0.60). Procedure treatment effect significantly differed by entitlement for mortality, revision, and paraesophageal hernia repair.

Conclusions:

Bariatric surgery is safe, and healthcare utilization benefits of sleeve over bypass are preserved across both Medicare elderly and disabled subpopulations.