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NEW YORK (Reuters Health) – A Medicare policy limiting where people can undergo weight-loss surgery to so-called “centers of excellence” was not responsible for reducing complications from the procedures, according to a new study.
In 2006, the Centers for Medicare & Medicaid Services (CMS) said it would only pay for bariatric surgery done at hospitals that had certain equipment and medical teams in place and were certified by the American College of Surgeons or the American Society for Metabolic and Bariatric Surgery (ASMBS).
“About a decade ago, there were very real concerns that there were safety problems with bariatric surgery,” said Dr. Justin Dimick, who led the new study at the University of Michigan in Ann Arbor.
At some hospitals, he said, as many as nine percent of patients died during or after surgery.
But that started changing before CMS stepped in with new restrictions, according to Dimick, in part due to less-invasive surgical techniques and better surgeon training.
He and his colleagues used billing codes to track bariatric surgery complications, such as leaks and bleeding, during about 300,000 procedures done between 2004 and 2009 both at centers of excellence and at other hospitals.
They found the proportion of patients on Medicare who had any procedure-related complication dropped from 12 percent before the policy change to eight percent afterward, according to findings published Tuesday in the Journal of the American Medical Association.
In non-Medicare patients – who had no restrictions on where they received surgery – complication rates also dropped, from between six and seven percent to below five percent.
More complications are to be expected among Medicare patients, the researchers said, due to their age.
“Bariatric surgery got a lot safer over this time period… but it happened in both Medicare and non-Medicare patients,” Dimick told Reuters Health.
“The policy was implemented in 2006, and outcomes were getting better well before that,” he added. “The evidence shows that the policy itself had no benefit.”
Dr. Jaime Ponce, president of ASMBS, disagreed with that assessment and said the new study was limited by its use of billing data instead of more detailed patient records.
“It’s very difficult to say that accreditation has not helped hospitals or bariatric surgery programs,” said Ponce, who was not involved in the new research.
Previous studies showed the CMS policy was linked to a reduction in procedure costs and in deaths after surgery, he noted.
Ponce said the policy may have encouraged both hospitals that did and didn’t end up being considered centers of excellence to improve their patient care.
“What (the study) showed is that all of the hospitals improved over time,” he told Reuters Health.
According to ASMBS, about 200,000 people have weight loss surgery every year. Surgery is typically recommended for people with a body mass index – a measure of weight in relation to height – of at least 40, or at least 35 if they also have co-occurring health problems such as diabetes or severe sleep apnea.
Dimick and his colleagues are pushing for a move away from the current certification system, toward one that provides more feedback for all hospitals that perform bariatric surgery. Ponce, however, said the Medicare policy is helping patients and should remain in place.
A representative from CMS said the agency is examining its bariatric surgery coverage, including the certification requirement, “and can’t comment on it until we issue a final decision.” That report is expected later this year.
One drawback of the current policy, Dimick said, is that some people on Medicare can’t be treated at nearby hospitals that perform bariatric surgery but aren’t certified.
“The harms here are that Medicare patients who needed surgery might not have been able to have it, because it required travel somewhere else,” he said.
SOURCE: http://bit.ly/MvXYT6 Journal of the American Medical Association, online February 26, 2013.
Copyright (2013) Thomson Reuters. Click for restrictions
CHICAGO (Reuters) – There will be good and bad news next year for seniors using Medicare’s prescription drug program.
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NEW YORK (Reuters Health) – A measure used by Medicare to penalize hospitals for poor performance is not linked to how many patients die after being admitted, suggests a new study.
The study, published in the Journal of the American Medical Association on Tuesday, suggests that hospitals can keep the number of patients who come back for more treatment low without having more of them die.
“The concern was that their performance in one area is going to compromise their performance in another,” said Dr. Harlan Krumholz, the study’s lead author from the Yale University School of Medicine in New Haven, Connecticut.
Currently, the U.S. Centers for Medicare and Medicaid Services (CMS), which oversees the federal government’s insurance programs for the elderly, disabled and poor, uses those measures to judge a hospital’s quality.
CMS also punishes hospitals with high readmission rates by reducing their payments. In 2013, CMS estimates hospitals will lose – on average – 0.3 percent of their funding, about $270 million overall (see Reuters Health story of January 22, 2013 here: http://reut.rs/Xwm984).
For the new study, Krumholz and his colleagues looked at whether there was a link between the number of people who died within 30 days of being admitted to hospitals and the number of people who came back for more treatment within 30 days after they were discharged.
They analyzed data on older Americans on Medicare who were admitted to U.S. hospitals between July 2005 and June 2008 with a heart attack, heart failure and pneumonia – the conditions CMS tracks.
They found about 20 percent of heart attack patients, 24 percent of heart failure patients and 18 percent of pneumonia patients came back to the hospital for more care. That compared to about 17 percent of heart attack patients and 11 percent of heart failure and pneumonia patients who died.
Overall, they found no relationship between the number of heart attack and pneumonia patients who were readmitted and those who died.
The researchers also found that between 5 percent and 9 percent of hospitals were able to have both low readmission and death rates, which Krumholz said should calm concerns that doing well in one area means doing poorly in the other.
“I think our goal should be to learn from the hospitals excelling in both areas and spread those ideas,” said Krumholz, whose team created the measures CMS uses to judge hospital quality.
He added that the findings also suggest that readmission and death rates measure two different events, and one is not dependant on the other.
‘NO EASY PATH’
But Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association, said the new study does not close the door on questions about readmission and death rates.
“This question that has been raised around the link between readmission and mortality is beginning to be investigated. There is no easy path to know what the relationship is because it’s a very complicated problem,” said Foster, who was not involved with the new study.
Foster told Reuters Health that she believes the new study has flaws, including that the researchers adjusted the rates for smaller hospitals, which led to the findings. She added that there could be other reasons why hospitals performed well on both measures.
“I’d love to say that it’s only to the hospitals’ credit that they’ve done so well (to) have low levels of mortality and readmission. But in all fairness, we recognize that community and other factors have an important role,” she said.
SOURCE: http://bit.ly/WddS8K Journal of the American Medical Association, online February 12, 2013.
Copyright (2013) Thomson Reuters. Click for restrictions