Gastric Bypass as Treatment for Obesity: Trends ... - Wiley Online Library

Risk Factors and Chronic Disease

Gastric Bypass as Treatment for Obesity: Trends, Characteristics, and Complications Judith A. Shinogle, Maria F. Owings, and Lola Jean Kozak

Abstract SHINOGLE, JUDITH A., MARIA F. OWINGS, AND LOLA JEAN KOZAK. Gastric bypass as treatment for obesity: trends, characteristics, and complications. Obes Res. 2005;13:2202–2209. Objective: This paper describes national trends in gastric bypass procedures from 1998 through 2003 and explores the demographic and health profile of those who receive this procedure. Short-term outcomes such as length of stay and in-hospital complication rates are also examined. Research Methods and Procedures: Data on obese hospital inpatients who had gastric bypass were obtained from the 1998 to 2003 National Hospital Discharge Survey. Gastric bypass was reported for an estimated 288,000 discharges during the 6-year study period. Trends within the 6-year period were tested using weighted regression. Characteristics of gastric bypass patients were compared with those of other inpatients using a ␹2 test of independence and the two-sided t test. Results: The estimated number of hospital discharges with gastric bypass increased significantly, from 14,000 in 1998 to 108,000 in 2003. During this period, the average length of stay declined by 56% from 7.2 to 3.2 days. Gastric bypass patients were primarily women (84%), 25 to 54 years of age (82%), and privately insured (76%). A 1 in 10 complication rate was found for discharges with gastric bypass. Discussion: Gastric bypass procedures in the United States have increased rapidly since 1998, whereas the average hospital stay has decreased. The decreasing length of stay needs to be evaluated in conjunction with potential complication rates and the permanent change in anatomy and lifestyle that must accompany this procedure. Monitoring trends in use of this procedure is important, especially if

Received for review February 18, 2005. Accepted in final form September 28, 2005. RTI International, National Center for Health Statistics, Centers for Disease Control and Prevention, Washington, DC. Address correspondence to Judith A. Shinogle, RTI International, 1615 M Street NW, Suite 740, Washington, DC 20036-3209. E-mail: [email protected] Copyright © 2006 NAASO

2202

OBESITY RESEARCH Vol. 13 No. 12 December 2005

reimbursement policies change and the epidemic of obesity continues. Key words: National Hospital Discharge Survey, length of stay, payment source, comorbidities, race

Introduction Obesity is currently a pressing health issue, with 30% of adults considered obese in 1999 to 2000 (1). This is a significant increase from the 23% found to be obese in 1988 to 1994 (1,2). Obesity is defined as having a BMI (weight in kilograms divided by the square of height in meters) of ⱖ30. Even more troubling than the overall obesity growth rate is the significant increase in morbid obesity (defined as BMI ⬎ 40) during this same time period, from ⬃3% to 5% (1). Bariatric surgical procedures are among the few current treatments to produce sustained weight loss (3). The most common surgical procedures performed include adjustable gastric banding and Roux-en-Y gastric bypass. A recent meta-analysis found that bariatric procedures not only cause significant weight loss but also lead to improvement in many associated conditions such as diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea (4). Gastric bypass involves creating a small stomach pouch in the upper quadrant of the stomach using staples to permanently close the remaining area of the stomach. This pouch is then connected to the small bowel. The stomach volume is decreased to ⬍30 mL, which requires a permanent change in eating habits. Continuing patient follow up and adherence to a new dietary regimen are important components to the success of this operation (5). Gastric bypass has received increased publicity due to famous celebrities discussing their weight loss (Today Show’s Al Roker, American Idol’s Randy Johnson, and singer Carnie Wilson), and most evidence points to decreased morbidity and mortality as a result of the procedure (6,7). However, it is controversial as a means of cost savings in health (8 –11). In addition to the debate over costs, recent reports of complications and deaths have raised concerns about the safety of the procedure (4,12–14). To improve

Gastric Bypass as Treatment for Obesity, Shinogle, Owings, and Kozak

outcomes and reduce complications and errors, an expert panel on weight loss surgery provided recommended steps, best practice, and clinical guidelines (15). At the same time, the Centers for Medicare and Medicaid Services announced that they will remove language from their regulations that obesity is not a disease (16), leaving open the possibility that Medicare may cover the cost of gastric bypass. Using data from its members, the American Society of Bariatric Surgery has estimated that the number of gastrointestinal surgical procedures for obesity grew from 16,000 in 1992 to 103,000 in 2003 (17). Pope et al. (18) examined data from the Nationwide Inpatient Sample and found a significant increase in the rate of gastric bypass between 1990 and 1997 from 2.7 to 6.3 per 100,000 adults and a decline in the median length of stay from 5 to 4 days. They also found that in 1997, 84% of gastric bypass patients were women, the median age was 40 years, and 31% had one or more comorbid conditions, although the mortality rate was only 0.37 per 100 discharges. Livingston and Ko (19) used the 2000 National Health Interview Survey to determine the characteristics of the population eligible for gastric bypass and compared these results with the 2000 Healthcare Cost and Utility Project data and the 2000 National Hospital Discharge Survey (NHDS).1 They found that although African Americans accounted for 21% of all individuals eligible for bariatric procedures, they made up only 9% of those undergoing bariatric procedures. Using the 1996 through 2001 NHDS, Livingston (20) examined in-hospital complication rates associated with bariatric procedures. He found a clinically significant complication rate of 10%. His research provided some information regarding comorbidities and complications of discharges who had this procedure, but was limited by small sample sizes. The public health significance of obesity and the rapid developments surrounding its surgical treatment point to the need for more information about gastric bypass. Our research explores current trends in gastric bypass, characteristics of patients receiving gastric bypass, and complications after gastric bypass. These data supply valuable information for tracking use of this procedure and the patient population it serves, evaluating the safety of gastric bypass, and providing baseline information before possible changes in Medicare reimbursement policies. Our study provides nationally representative estimates from public data to compare with previous research in this area. The results reported here also update and expand on Pope’s (18) and Livingston’s (19,20) figures. We use more

1 Nonstandard abbreviations: NHDS, National Hospital Discharge Survey; ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification.

recent data and include all age groups. Reports now show that gastric bypass is being performed on persons under 18 years of age (21).

Research Methods and Procedures Data for this analysis were from the 1998 to 2003 NHDS conducted annually by the National Center for Health Statistics since 1965. The data were collected from a sample of inpatient records obtained from a national probability sample of hospitals. Only general hospitals, children’s general hospitals, or hospitals with an average length of stay of fewer than 30 days for all patients were included in the survey. Federal hospitals were excluded. During 1998 to 2003, an annual average of 448 hospitals participated in the survey for an average response rate of 93%. These hospitals provided information on ⬃316,000 sampled discharges per year. The data could be analyzed only for 1998 and subsequent years because in earlier years, the annual number of discharges with gastric bypass sampled in the survey was too few to make reliable national estimates. A description of the estimation process and other aspects of the survey’s design and operation have been published (22). Items collected in the NHDS include age, sex, and race of the patient; expected principal source of payment and length of stay for the hospitalization; geographic region of the hospital; and up to seven diagnoses and four surgical or non-surgical operations or procedures performed during the hospitalization. Diagnoses and procedures are coded according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) (23). The NHDS does not collect information regarding height and weight; therefore, discharges were included in this analysis if they had a principal or secondary diagnosis of obesity (ICD-9-CM code 278.0) and a high gastric bypass (code 44.31) or other gastroenterostomy (code 44.39) performed during the hospitalization. High gastric bypass is defined as a procedure that connects the middle part of the small intestine to the upper stomach, and the category specifically includes Printen and Mason gastric bypass. A variety of other bariatric procedures, such as gastric banding and biliopancreatic diversion, may also have been coded as 44.31 or 44.39 because codes for other specific bariatric procedures were not available during the period covered by this study. The obesity diagnostic code included both unspecified (278.00) and morbid obesity (278.01). We limited our study to those who were identified as obese to exclude patients who received gastroenterostomies for other conditions such as cancer, ulcers, and other stomach-related disorders. Only about one-half of patients with gastroenterostomies (code 44.39) had an obesity diagnosis. In contrast, 98% of the patients who had high gastric bypass (ICD-9-CM code 44.31) during 1998 to 2003 had obesity or morbid obesity as OBESITY RESEARCH Vol. 13 No. 12 December 2005

2203


a diagnosis. Unlike Pope (18), we included discharges for all ages who met the selection criteria named above because gastric bypass is being performed on younger patients (21). To further understand the risks associated with gastric bypass that were reported by Livingston (20), and to place them into context with other procedures, complication rates for discharges with gastric bypass were compared with those for discharges with other surgical procedures. A discharge with any ICD-9-CM diagnosis code 996 to 999 or E87 was counted as having a complication. Standard errors for the estimates were obtained using SUDAAN software (24). Trends in annual discharge rates and average lengths of stay during 1998 to 2003 were tested using weighted least squares regression for complex surveys (25). Data for the 6-year period were grouped to allow reliable examination of characteristics of patients with gastric bypass. Discharge rates for gastric bypass patients were produced for sex, age, race, and regional groups to compare demographic differences in use of this procedure. Rates were calculated by dividing the estimated number of discharges in each group by the midyear civilian resident population for that group, expressed per 100,000 population. The population estimates were obtained from the U.S. Census Bureau. Percentage distributions by sex, age, race, region, and expected principal source of payment were compared to examine how discharges receiving gastric bypass differed from other hospital discharges. Contingency table analysis was used for these comparisons, and significance was determined by means of a ␹2 test of independence. Comorbidities were selected for analysis because a large number of discharges reported the diagnosis or because the diagnosis was of special interest in obesity research. Percentages of gastric bypass discharges and other discharges with these comorbidities were compared with a two-sided t test. Because multiple comparisons were made, the Bonferroni adjustment was used, with an overall level of significance set at 0.05. Over the 6-year period studied, 2573 discharges had ICD-9-CM codes indicating obesity and gastric bypass. Sampled cases were weighted to produce national statistics using multistage estimation procedures. This produced a weighted national estimate of obese patients with gastric bypass of 288,000.

Figure 1: Discharge rate for obese inpatients with gastric bypass, United States, 1998 to 2003.

average length of stay for all patients declined by only 6% during this period, from 5.1 days in 1998 to 4.8 days in 2003. During 1998 to 2003, patients receiving gastric bypass had different characteristics than other inpatients. They were more likely to be women (84% vs. 60% for non-gastric bypass patients) and 25 to 54 years of age (82% vs. 34%). They were also more likely than other discharges to have private or other commercial insurance, including health maintenance organizations and preferred provider organizations (76% vs. 36%), as the principal expected source of payment (Table 1). As reported in previous research, women had a higher rate of gastric bypass discharges per 100,000 population than men, 27.9 compared with 5.7 (Table 1). Gastric bypass

Results The number of gastric bypass procedures has grown significantly from an estimated 14,000 in 1998 to an estimated 108,000 in 2003. The rate of gastric bypass per 100,000 population grew from 5.3 to 37.1 during the 6-year period (Figure 1). At the same time, the average length of a hospital stay for a gastric bypass discharge decreased 56%, from 7.2 days in 1998 to 3.2 days in 2003 (Figure 2). The 2204


Figure 2: Average length of stay in days for obese discharges with gastric bypass and for all other discharges, United States, 1998 to 2003.


Table 1. Characteristics of obese discharges who received gastric bypass and all other discharges, United States, 1998 through 2003 Obese discharges with gastric bypass (N ⴝ 288,000)

All discharges Sex† Men Women Age† Under 25 years 25 to 39 years 40 to 54 years 55 years and over Race† White Black Other races Race not stated Region Northeast Midwest South West Expected principal source of payment† Medicare Medicaid Private insurance¶ Other sources储 Source not stated

All other discharges (N ⴝ 196,493,000)

Rate per 100,000 population

SE

Distribution (%)

SE

Distribution (%)

SE

17.1

1.8

100.0

*

100.0

*

5.7 27.9

0.8 2.9

16.4 83.6

1.3 1.3

39.6 60.4

0.3 0.3

2.9 28.0 36.4 9.8

0.5 3.2 4.3 1.3

5.9 35.9 46.0 12.3

0.9 1.7 1.7 1.0

16.6 17.3 16.3 49.8

0.8 0.2 0.2 0.7

13.6 13.1 6.0 ‡

1.7 2.1 1.0 ‡

64.7 9.8 2.1 23.4

4.0 1.3 0.4 4.3

62.5 11.7 4.3 21.5

1.9 0.6 0.4 2.0

18.9 16.5 17.6 §

3.4 2.8 3.1 §

20.9 22.1 36.8 20.1

3.7 3.7 5.1 5.5

21.4 22.7 38.0 17.8

1.1 1.6 1.3 0.9

‡ ‡ ‡ ‡ ‡

‡ ‡ ‡ ‡ ‡

5.2 6.3 75.5 9.8 3.3

0.8 1.1 2.2 1.5 0.9

39.1 14.3 36.2 9.0 1.4

0.6 0.6 0.6 0.3 0.2

SE, standard error. * Not applicable. † Percentage distribution of gastric bypass discharges significantly different from distribution of other discharges, ␹2 test of independence significant at p ⫽ 0.001. ‡ Denominators not available. § Estimate not reliable; relative SE greater than 30%. ¶ Includes HMOs and PPOs, BlueCross BlueShield, and other private or commercial insurance. 储 Includes workers compensation, other government sources, self-pay, no charge, and other unspecified sources.

discharge rates were higher for those 25 to 39 and 40 to 54 years old than for older or younger persons. The median age for a gastric bypass patient was 42 years during 1998 to 2003. Gastric bypass rates were not significantly different for black and white patients or across geographic regions.

Almost all obese patients who received gastric bypass during 1998 to 2003 had a first listed diagnosis of morbid obesity. They had an average of 3.7 diagnoses in addition to morbid obesity. Comorbidites for obese patients receiving gastric bypass during 1998 to 2003 are shown in Figure 3. OBESITY RESEARCH Vol. 13 No. 12 December 2005

2205


Figure 3: Percentage of obese discharges with and without gastric bypass surgery with selected comorbidities, United States, 1998 to 2003.

Essential hypertension was reported for 44% of these patients; 33% had joint diseases and related disorders, including osteoarthritis; esophageal reflux was mentioned for 28% of gastric bypass discharges; sleep apnea for 24%; and diabetes for 20%. Disorders of lipid metabolism, depression, and asthma were reported for 10% or more of gastric bypass discharges. Two-thirds of the gastric bypass patients had two or more of these comorbidities. For comparison, percentages of discharges that did not have gastric bypass are also shown in Figure 3. The percentage with each obesity-related comorbidity was significantly higher for gastric bypass discharges than for all other discharges. The outcome of gastric bypass cannot be fully measured with hospitalization data, but we can examine complications that arise in the hospital during the operation and the immediate postoperative period. One of every 10 discharges with gastric bypass had a medical or surgical complication reported during their hospitalization. These complications included conditions such as intestinal obstruction, accidental puncture or laceration, aspiration pneumonia, hemorrhage, postoperative infection, and cardiac complications. Figure 4 presents complication rates per 100 discharges with selected surgical procedures. Also shown are rates for discharges who received gastric bypass and for all those who received surgical procedures. The complication rate for gastric bypass patients was similar to that for all discharges with surgical procedures, ⬃10%. It was not significantly different from rates for specific procedures such as prostatectomy, appendectomy, hip or knee replacement, abdominal hysterectomy, or cholecystectomy but was lower than rates for procedures such as repair of hernia, partial excision of large intestine, and coronary artery bypass graft. Surgical complications tend to increase with age (26); thus, the complication rates for gastric bypass and other procedures for those ⬍55 years of age were also analyzed. 2206


Figure 4: Rate of discharges with complications for selected types of surgery, United States, 1998 to 2003.

The majority of the gastric bypass discharges (88%) were under age 55 in 1998 to 2003, but only one-half of discharges with other surgical procedures fell into this age category. This analysis revealed a similar pattern as seen in comparing the overall rates. Two exceptions were that the gastric bypass complication rate was higher than complication rates for appendectomy or knee replacement in this age group (data available from authors).

Discussion As seen in previous research, our data showed that the number and rate of gastric bypass procedures are increasing. Data from the NHDS estimate a median age of 42 for 1998 to 2003, similar to Pope et al.’s (18) median age of 40. In addition, the percentage of gastric bypass discharges that were women was almost identical in this and Pope’s analyses. Our study found that three-quarters of the gastric bypass procedures were paid, in part or in full, by private health insurance, as was found in previous research. The trend in private health insurance coverage should be monitored because recent reports suggest a re-examination of coverage by private health insurers (27). Nevertheless, trends in the demographics and financing of gastric bypass have been generally stable. Similar to Livingston and Ko (19), we found a discrepancy between the distribution of obesity in the population and the profile of patients who received gastric bypass. From 1999 to 2000, among the non-Hispanic population, 15% of black women were classified as extremely obese compared with only 5% of white women (1). (For men, the estimated percentage of extremely obese black men was not reliable, but 3% of white men were extremely obese.) However, we found no significant difference in rates of gastric bypass per 100,000 population by race. We also examined the rates by race separately for men and women and again


found no significant race differences. Race data were not available for 24% of gastric bypass discharges, and previous research has found that white patients have been underreported to a greater extent than patients of other races in the NHDS (28). If the gastric bypass rates were adjusted for underreporting, white discharges could have a higher rate of gastric bypass than black discharges, despite their lower level of obesity. No significant differences were found in gastric bypass procedures by region, which contrasts with a 1999 study that found variation in obesity prevalence by geographic areas, from 14.1% in the Mountain Region to 20.0% in the Eastern South Central Region (29). This difference may be related to the sampling methods of the NHDS, which are designed to produce estimates only for the four large Census regions. Other factors such as variation in medical practice or insurance coverage may also affect the relationship between the prevalence of obesity in an area and its gastric bypass rate. Patients electing to receive gastric bypass procedures had health conditions typically associated with obesity, including essential hypertension, joint disorders, esophageal reflux, sleep apnea, diabetes, and lipid disorders. It is notable that 13% of patients who underwent gastric bypass had a diagnosis of depression. Obesity may be associated with depression (30), although one study found that depression does not affect the outcome of gastric bypass surgery (31). Future research should further examine depression’s effects on outcomes after bariatric procedures. Our data show that gastric bypass is often performed on women of childbearing age. Patients who have received gastric bypass are advised not to become pregnant for up to 18 months after surgery (32). Women who have had gastric bypass need to be monitored closely during pregnancy for possible severe side effects such as internal herniation and gastric necrosis and for nutritional deficiencies affecting both the mother and the fetus (12,32). Most obesity treatments are behavioral or preventive health measures such as diet and physical activity that are not typically covered by traditional indemnity insurance (33). Information about the extent to which health insurance plans cover nutritional and exercise programs is difficult to obtain because of wide variation among plans in the benefits and services they offer. One small study found that 17% of health plans surveyed covered evaluation and diet treatment for obesity (34). Nevertheless, McCaig (35), examining data from the National Ambulatory Medical Care Survey, found that weight or diet counseling was provided at 69% of obesity-related doctors’ visits, and exercise counseling was provided at 46% of these visits. Only a few prescription drugs are available to treat obesity, and most employer groups do not cover these drugs (36). On the other hand, surgical treatment for obesity is generally covered by pri-

vate health insurance for those patients who fit the criteria of BMI ⬎ 40 or those with BMI between 35 and 40 with high-risk comorbidities (32). We found that three-quarters of gastric bypass procedures had private insurance as the expected principal source of payment. Because publicly funded health care such as Medicare and Medicaid are changing their policies to classify obesity as a disease, there may be a dramatic shift in who pays for gastric bypass procedures. Policymakers will also have an opportunity to consider expanding coverage beyond surgery to a range of additional options for the prevention and treatment of obesity. Finally, we found that the complication rate for gastric bypass was similar to the rate for all surgical procedures and lower than the rate for some other abdominal procedures. Although our data do not allow reliable estimates of specific types of complications, we found reports of complications such as intestinal obstruction, accidental puncture or laceration, aspiration pneumonia, hemorrhage, postoperative infection, and cardiac complications. These results are similar to those reported by Livingston (20), but in neither case were the data for specific complications reliable as national estimates. Furthermore, these are only in-hospital complications, and studies that follow patients over time could find additional complications that occur subsequent to discharge. A single state study conducted between 1987 and 2001 found that the short-term mortality rate (30 days postprocedure) was only 1.9%. The mortality rate did not increase over time but was associated with the volume of procedures the surgeon performed. This same study found that bariatric patients survived longer than patients with an inpatient diagnosis of obesity without the procedure (6). Another study found that bariatric surgery reduced the relative risk of death by 89% (7). Previous national studies have not compared the inpatient complication rates for gastric bypass with other procedure complication rates. A meta-analysis of case studies did find a range of adverse events associated with bariatric procedures from 10% to 20%, which puts our estimate of inhospital complications at the lower end of the range (14). Limitations This study is limited by a lack of information on gastric bypass procedures done in ambulatory settings. We examined the National Survey of Ambulatory Surgery to garner more information, but in 1996, the most recent year available, not enough gastroenterostomy procedures were performed in ambulatory settings to produce reliable national estimates. These procedures may be increasing in outpatient and inpatient settings, especially as laparoscopic technology has become an option (37). Identification of obesity-related operations was hampered by the lack of specific ICD-9-CM codes for bariatric procedures, especially newly developed procedures. Although OBESITY RESEARCH Vol. 13 No. 12 December 2005

2207


the gastric bypass and other gastroenterostomy codes used in this study identified the bulk of obesity-related procedures, some may have been coded as other repair of stomach (code 44.69) or other operation on stomach (code 44.99), categories we considered too general to include. Additional codes for specific bariatric procedures were recently added to the coding system and will be in use in the 2005 NHDS. Another limitation is that the diagnosis of obesity appears to be underreported in hospital medical records. Unless the physician listed it as a diagnosis, it would not have been included in this study. Although the number of discharges with an obesity diagnosis has increased substantially in the last decade, only 1.2 million discharges, or 3% of all discharges, had this diagnosis reported in 2003. In contrast, 30% of the U.S. population is estimated to be obese (1). The inability to identify obesity except through diagnosis limits the understanding of overall hospital care for obese patients. Conclusions This research presents national estimates of gastric bypass procedures performed in U.S. short-stay hospitals. It updates previously published estimates and provides a national perspective on the use of gastric bypass to treat obesity. Unlike previous research on bariatric procedures using the NHDS, this analysis included complex design information on the survey that permitted evaluation of the reliability of estimates and facilitated appropriate statistical testing. The findings of an increase in the rate of gastric bypass along with a decreasing length of stay need to be evaluated in conjunction with the finding that 1 of every 10 discharges with gastric bypass had a medical or surgical complication reported. This complication rate is not trivial and is comparable with all discharges that had surgical procedures during our study period. These complications do not include late complications that may present post-discharge, nor can we evaluate the nutritional effects such as iron, calcium, and vitamin deficiencies that could result from permanently restricting stomach volume. Gastric bypass requires a longterm change in eating habits. Most patients have to avoid concentrated carbohydrates at the beginning of any meal to avoid rapid gastric emptying (38). Anecdotal evidence exists of insurers dropping coverage of this procedure due to high costs associated with post-surgical complications (39). Medical treatment for obesity has become a complex issue. Although the effectiveness of diets and physical activity is proven, adherence to these programs is not high, resulting in large reversals of weight loss and potentially worsening health risks. Surgical treatment has become a growing option for the morbidly obese. The decrease in length of the hospital stay, possibly reflecting improved surgical technology, such as the use of laparoscopic procedures, may have added to the increased use of this procedure. A more complete analysis of gastric bypass should 2208


include changes in frequency and types of procedures, complications, and the success of the permanent change in anatomy and lifestyle that must accompany this procedure.

Acknowledgments We thank Irma Arispe, Katherine Flegal, Jennifer Maddens, and Robert Pokras for their thoughtful comments. There was no funding/outside support for this study. References 1. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999 –2000. JAMA. 2002;288:1723–7. 2. Centers for Disease Control and Prevention, National Center for Health Statistics. Healthy weight, overweight, and obesity among US adults. In: National Health and Nutrition Examination Survey. Hyattsville, MD: National Center for Health Statistics; 2003. 3. Sjo¨stro¨m L. Surgical intervention as a strategy for treatment of obesity. Endocrine. 2000;13:213–30. 4. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004; 292:1724 – 8. 5. Shen R, Dugay G, Rajaram K, et al. Impact of patient follow-up on weight loss after bariatric surgery. Obes Surg. 2004;14:514 –9. 6. Flum DR, Dellinger EP. Impact of gastric bypass operation on survival: a population-based analysis. J Am Coll Surg. 2004;199:543–51. 7. Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg. 2004;240:416 –24. 8. Agren G, Narbro K, Jonsson E, et al. Cost of in-patient care over 7 years among surgically and conventionally treated obese patients. Obes Res. 2002;10:1276 – 83. 9. Narbro K, Agren G, Jonsson E, et al. Pharmaceutical costs in obese individuals: comparison with a randomly selected population sample and long-term changes after conventional and surgical treatment: the SOS intervention study. Arch Intern Med. 2002;162:2061–9. 10. Craig BM, Tseng DS. Cost-effectiveness of gastric bypass for severe obesity. Am J Med. 2002;113:491– 8. 11. Sampalis JS, Liberman M, Auger S, Christou NV. The impact of weight reduction surgery on health-care costs in morbidly obese patients. Obes Surg. 2004;14:939 – 47. 12. Moore KA, Ouyang DW, Whang EE. Maternal and fetal deaths after gastric bypass surgery for morbid obesity. N Engl J Med. 2004;351:721–2. 13. Freudenheim M. Other perils of overweight. NY Times. 2005; May 27. 14. Maggard MA, Shugarman LR, Suttorp M, et al. Metaanalysis: surgical treatment of obesity. Ann Intern Med. 2005; 142:547–59. 15. Lehman Center Weight Loss Surgery Expert Panel. Commonwealth of Massachusetts Betsy Lehman Center for Patient Safety and Medical Error Reduction Expert Panel on Weight Loss Surgery: executive report. Obes Res. 2005;13:205–26.


16. Stein R, Connolly C. Medicare changes policy on obesity: some treatments may be covered. Washington Post. 2004; Jul 16:A01. 17. Steinbrook R. Surgery for severe obesity. N Engl J Med. 2004;350:1075–9. 18. Pope GD, Birkmeyer JD, Finlayson SR. National trends in utilization and in-hospital outcomes of bariatric surgery. J Gastrointest Surg. 2002;6:855– 60. 19. Livingston EH, Ko CY. Socioeconomic characteristics of the population eligible for obesity surgery. Surgery. 2004;135: 288 –96. 20. Livingston EH. Procedure incidence and in-hospital complication rates of bariatric surgery in the United States. Am J Surg. 2004;188:105–10. 21. Apovian CM, Backer C, Ludwig DS, et al. Best practice guidelines in pediatric/adolescent weight loss surgery. Obes Res. 2005;13:274 – 82. 22. Dennison C, Pokras R. Design and operation of the National Hospital Discharge Survey: 1988 redesign. Vital Health Stat. 2000;1:1– 42. 23. National Center for Health Statistics, Health Care Financing Administration. International Classification of Diseases, 9th Revision, Clinical Modification. 6th ed. Washington, DC: Public Health Service; 1998. 24. Shah BV, Barnwell BG, Bieler GS. SUDAAN User’s Manual: Release 7.0. Research Triangle Park, NC: Research Triangle Institute; 1996. 25. Gillum BS, Graves EJ, Kozak LJ. Trends in hospital utilization: United States, 1988 –92. Vital Health Stat. 1996;13:1– 71. 26. Polanczyk CA, Marcantonio E, Goldman L, et al. Impact of age on perioperative complications and length of stay in patients undergoing non-cardiac surgery. Ann Intern Med. 2001;134:637– 43. 27. Larkin H. Payment: insurance bypass. Hosp Health Netw. 2004;78:22.

28. Kozak LJ. Underreporting of race in the National Hospital Discharge Survey. Adv Data. 1995;265:1–11. 29. Mokdad AH, Serdula MK, Dietz WH, et al. The spread of the obesity epidemic in the United States, 1991–1998. JAMA. 1999;282:1519 –22. 30. Roberts RE, Deleger S, Strawbridge WJ, Kaplan GA. Prospective association between obesity and depression: evidence from the Alameda County Study. Int J Obes Relat Metab Disord. 2003;27:514 –21. 31. Clark MM, Balsiger BM, Sletten CD, et al. Psychosocial factors and 2-year outcome following bariatric surgery for weight loss. Obes Surg. 2003;13:739 – 45. 32. American Society for Bariatric Surgery. Rationale for Surgical Treatment of Morbid Obesity. Available at http:// www.asbs.org/html/rationale/rationale.html (Accessed July 8, 2005). 33. American Obesity Association. Obesity treatment. AOA Fact Sheets. Available at http://www.obesity.org/subs/fastfacts/ Obesity_Treatment.shtml (Accessed July 11, 2005). 34. DeFrances CJ, Hall MJ, Podgornik MN. 2003 National Hospital Discharge Survey. Adv Data. 2005;359:8 –9. 35. McCaig L. Ambulatory care visits for obesity: United States, 2001. Presented at the 18th National Conference on Chronic Disease Prevention and Control. Washington, DC, Feb 18, 2004. 36. Takeda Pharmaceuticals North America, Inc. Prescription Drug Benefit Cost and Plan Design Survey Report. 2003. 37. Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000;232:515–29. 38. Pratt JS, Cummings S, Vineberg DA, Graeme-Cook F, Kaplan LM. Case 25-2004: a 49-year-old woman with severe obesity, diabetes, and hypertension. N Engl J Med. 2004;351: 696 –705. 39. Some South Carolina residents may have harder time getting coverage for gastric bypass surgery to treat obesity. Managed Care Week. 2004.


2209