Quick Discharge After Gastric Bypass Linked to Higher Mortality

ORLANDO – Patients discharged within a day following laparoscopic Roux-en-Y gastric bypass surgery faced at least a twofold increased risk for 30-day mortality compared with patients discharged 2 days after surgery, in an analysis of more than 50,000 patients who underwent the operation at a U.S. or Canadian hospital during 2007-2010.

The finding raises safety concerns because many medical insurers routinely cover hospitalization for just 1 day following laparoscopic gastric bypass surgery.

"Short-stay laparoscopic gastric bypass should be approached with caution, and merits further investigation," Dr. John M. Morton said at the annual meeting of the American Society for Metabolic and Bariatric Surgery.

"We want to safeguard the [safety] results of bariatric surgery and not backtrack. The big question is whether [1-day discharge] is ready for prime time. I’d approach these patients with a degree of caution. Sending [most gastric bypass] patients home after 2 days is a remarkable achievement. I wouldn’t want that achievement smashed on the rocks of mortality by sending patients home too soon. Right now, I’m not willing to say that the goal length of stay is 1 day," said Dr. Morton, director of bariatric surgery at Stanford (Calif.) University.

Dr. Morton led the study of 51,788 patients who underwent laparoscopic Roux-en-Y gastric bypass surgery at U.S. or Canadian centers that participated in a national bariatric surgery registry during the period from June 2007 to October 2010. The investigators found that during this period, 59% of patients left the hospital after 2 days. However, the second most common discharge period was after 1 day, in 18% of patients, while another 1% were discharged after less than 1 day. The remaining 22% of patients left the hospital 3 or 4 days after surgery.

The 19% discharge rate after 1 day or less surprised Dr. Morton, and reflected the growing pressure from insurers to hasten the discharge of patients following gastric bypass surgery. "I would have expected 1 day discharge in less than 10% of patients," he said in an interview. "It’s been a big shift in our practice patterns to go to 2 days," he added. As recently as the mid-2000s, when laparoscopic gastric bypass began to surpass the number of bypasses performed using open surgery, most patients went home 4 or 5 days following surgery, he said.

The pressure to discharge patients within 1 day following surgery stems largely from a relatively recent policy adopted by Milliman Care Guidelines, a Seattle-based actuarial and consulting company that provides health-cost guidance to many health insurers as well as contractors that administer coverage for the Centers for Medicare and Medicaid Services. Last year, Milliman issued the 14th edition of its Care Guidelines, which began recommending that insurers cover hospitalization following laparoscopic gastric bypass for just 1 day.

Last October, Dr. Morton and other leaders of the American Society for Metabolic and Bariatric Surgery sent a letter to Milliman asking the company to reconsider its position. Dr. Morton, who chairs the society’s Access to Care Committee, launched the new study to collect better information on the medical consequences of faster discharge in this setting. He learned from Milliman that the company’s recommendation for 1-day discharge had been based on one published study reflecting a single center’s experience. That study found 1-day discharge following laparoscopic gastric bypass to be safe (Ann. Surg. 2005;242:494-501).

"I was shocked and dismayed that they advocated a day 1 discharge," said Dr. Morton. "The only motivation can be cost savings. It’s not patient safety. Gastric bypass patients can develop complications that include bleeding, myocardial infarctions, pulmonary embolism, and leaks at anastomoses. "These can be discovered in the first 2 days, and if they occur in the hospital there is an opportunity to rescue the patient."

To better document the impact of discharging patients less than 2 days after gastric bypass, Dr. Morton and his associates used data drawn from the Bariatric Outcomes Longitudinal Database (BOLD), a bariatric surgery database for programs in the United States and Canada begun in 2007 by the Surgical Review Corporation.

The 51,788 patients who underwent a laparoscopic Roux-en-Y gastric bypass operation during the nearly 3.5-year period reviewed had an average age of 46 years, and almost 80% were women. The researchers limited the study population to patients whose hospitalized length of stay was 4 days or less (94% of all laparoscopic gastric bypasses done during this time). During the 30 days following surgery, the overall mortality rate was 0.1%, the serious complication rate was 0.8%, and 3.8% of patients required readmission.

The analysis divided patients into those discharged the same day as their surgery (a 0-day length of stay), patients discharged the morning after their surgery and within 24 hours of their initial admission (1-day length of stay), and 2-, 3-, or 4-day length of stays.

In a multivariate analysis that controlled for baseline clinical and demographic factors, patients discharged on day 0 had a statistically significant, 13-fold increased risk of 30-day mortality compared with patients discharged on day 2. Patients discharged on day 1 had a twofold increased mortality rate that fell just short of significance (P = .055). Patients discharged on day 3 had a 30-day mortality rate that was virtually the same as that of day 2 patients, while those discharged on day 4 had a greater than fivefold increased mortality rate that was significant. Dr. Morton ascribed this higher mortality rate in patients with a 4-day hospitalization to the increased number of postoperative complications in these patients that likely led to their prolonged hospitalization.

"I think there is an opportunity for faster discharge, but with these data routine ambulatory discharge is not warranted, because 13-fold increased mortality is just not acceptable," commented Dr. Titus Duncan, director of minimally invasive and bariatric surgery at the Atlanta Medical Center.

Dr. Morton said that he has received an educational grant from Ethicon Endo-Surgery, and he has received honoraria from and served on the scientific advisory board of Vibrynt. Dr. Duncan said that he received a teaching grant from Ethicon Endo-Surgery.

ORLANDO – Patients discharged within a day following laparoscopic Roux-en-Y gastric bypass surgery faced at least a twofold increased risk for 30-day mortality compared with patients discharged 2 days after surgery, in an analysis of more than 50,000 patients who underwent the operation at a U.S. or Canadian hospital during 2007-2010.

The finding raises safety concerns because many medical insurers routinely cover hospitalization for just 1 day following laparoscopic gastric bypass surgery.

"Short-stay laparoscopic gastric bypass should be approached with caution, and merits further investigation," Dr. John M. Morton said at the annual meeting of the American Society for Metabolic and Bariatric Surgery.

"We want to safeguard the [safety] results of bariatric surgery and not backtrack. The big question is whether [1-day discharge] is ready for prime time. I’d approach these patients with a degree of caution. Sending [most gastric bypass] patients home after 2 days is a remarkable achievement. I wouldn’t want that achievement smashed on the rocks of mortality by sending patients home too soon. Right now, I’m not willing to say that the goal length of stay is 1 day," said Dr. Morton, director of bariatric surgery at Stanford (Calif.) University.

Dr. Morton led the study of 51,788 patients who underwent laparoscopic Roux-en-Y gastric bypass surgery at U.S. or Canadian centers that participated in a national bariatric surgery registry during the period from June 2007 to October 2010. The investigators found that during this period, 59% of patients left the hospital after 2 days. However, the second most common discharge period was after 1 day, in 18% of patients, while another 1% were discharged after less than 1 day. The remaining 22% of patients left the hospital 3 or 4 days after surgery.

The 19% discharge rate after 1 day or less surprised Dr. Morton, and reflected the growing pressure from insurers to hasten the discharge of patients following gastric bypass surgery. "I would have expected 1 day discharge in less than 10% of patients," he said in an interview. "It’s been a big shift in our practice patterns to go to 2 days," he added. As recently as the mid-2000s, when laparoscopic gastric bypass began to surpass the number of bypasses performed using open surgery, most patients went home 4 or 5 days following surgery, he said.

The pressure to discharge patients within 1 day following surgery stems largely from a relatively recent policy adopted by Milliman Care Guidelines, a Seattle-based actuarial and consulting company that provides health-cost guidance to many health insurers as well as contractors that administer coverage for the Centers for Medicare and Medicaid Services. Last year, Milliman issued the 14th edition of its Care Guidelines, which began recommending that insurers cover hospitalization following laparoscopic gastric bypass for just 1 day.

Last October, Dr. Morton and other leaders of the American Society for Metabolic and Bariatric Surgery sent a letter to Milliman asking the company to reconsider its position. Dr. Morton, who chairs the society’s Access to Care Committee, launched the new study to collect better information on the medical consequences of faster discharge in this setting. He learned from Milliman that the company’s recommendation for 1-day discharge had been based on one published study reflecting a single center’s experience. That study found 1-day discharge following laparoscopic gastric bypass to be safe (Ann. Surg. 2005;242:494-501).

"I was shocked and dismayed that they advocated a day 1 discharge," said Dr. Morton. "The only motivation can be cost savings. It’s not patient safety. Gastric bypass patients can develop complications that include bleeding, myocardial infarctions, pulmonary embolism, and leaks at anastomoses. "These can be discovered in the first 2 days, and if they occur in the hospital there is an opportunity to rescue the patient."

To better document the impact of discharging patients less than 2 days after gastric bypass, Dr. Morton and his associates used data drawn from the Bariatric Outcomes Longitudinal Database (BOLD), a bariatric surgery database for programs in the United States and Canada begun in 2007 by the Surgical Review Corporation.

The 51,788 patients who underwent a laparoscopic Roux-en-Y gastric bypass operation during the nearly 3.5-year period reviewed had an average age of 46 years, and almost 80% were women. The researchers limited the study population to patients whose hospitalized length of stay was 4 days or less (94% of all laparoscopic gastric bypasses done during this time). During the 30 days following surgery, the overall mortality rate was 0.1%, the serious complication rate was 0.8%, and 3.8% of patients required readmission.

The analysis divided patients into those discharged the same day as their surgery (a 0-day length of stay), patients discharged the morning after their surgery and within 24 hours of their initial admission (1-day length of stay), and 2-, 3-, or 4-day length of stays.

In a multivariate analysis that controlled for baseline clinical and demographic factors, patients discharged on day 0 had a statistically significant, 13-fold increased risk of 30-day mortality compared with patients discharged on day 2. Patients discharged on day 1 had a twofold increased mortality rate that fell just short of significance (P = .055). Patients discharged on day 3 had a 30-day mortality rate that was virtually the same as that of day 2 patients, while those discharged on day 4 had a greater than fivefold increased mortality rate that was significant. Dr. Morton ascribed this higher mortality rate in patients with a 4-day hospitalization to the increased number of postoperative complications in these patients that likely led to their prolonged hospitalization.

"I think there is an opportunity for faster discharge, but with these data routine ambulatory discharge is not warranted, because 13-fold increased mortality is just not acceptable," commented Dr. Titus Duncan, director of minimally invasive and bariatric surgery at the Atlanta Medical Center.

Dr. Morton said that he has received an educational grant from Ethicon Endo-Surgery, and he has received honoraria from and served on the scientific advisory board of Vibrynt. Dr. Duncan said that he received a teaching grant from Ethicon Endo-Surgery.

ORLANDO – Patients discharged within a day following laparoscopic Roux-en-Y gastric bypass surgery faced at least a twofold increased risk for 30-day mortality compared with patients discharged 2 days after surgery, in an analysis of more than 50,000 patients who underwent the operation at a U.S. or Canadian hospital during 2007-2010.

The finding raises safety concerns because many medical insurers routinely cover hospitalization for just 1 day following laparoscopic gastric bypass surgery.

"Short-stay laparoscopic gastric bypass should be approached with caution, and merits further investigation," Dr. John M. Morton said at the annual meeting of the American Society for Metabolic and Bariatric Surgery.

"We want to safeguard the [safety] results of bariatric surgery and not backtrack. The big question is whether [1-day discharge] is ready for prime time. I’d approach these patients with a degree of caution. Sending [most gastric bypass] patients home after 2 days is a remarkable achievement. I wouldn’t want that achievement smashed on the rocks of mortality by sending patients home too soon. Right now, I’m not willing to say that the goal length of stay is 1 day," said Dr. Morton, director of bariatric surgery at Stanford (Calif.) University.

Dr. Morton led the study of 51,788 patients who underwent laparoscopic Roux-en-Y gastric bypass surgery at U.S. or Canadian centers that participated in a national bariatric surgery registry during the period from June 2007 to October 2010. The investigators found that during this period, 59% of patients left the hospital after 2 days. However, the second most common discharge period was after 1 day, in 18% of patients, while another 1% were discharged after less than 1 day. The remaining 22% of patients left the hospital 3 or 4 days after surgery.

The 19% discharge rate after 1 day or less surprised Dr. Morton, and reflected the growing pressure from insurers to hasten the discharge of patients following gastric bypass surgery. "I would have expected 1 day discharge in less than 10% of patients," he said in an interview. "It’s been a big shift in our practice patterns to go to 2 days," he added. As recently as the mid-2000s, when laparoscopic gastric bypass began to surpass the number of bypasses performed using open surgery, most patients went home 4 or 5 days following surgery, he said.

The pressure to discharge patients within 1 day following surgery stems largely from a relatively recent policy adopted by Milliman Care Guidelines, a Seattle-based actuarial and consulting company that provides health-cost guidance to many health insurers as well as contractors that administer coverage for the Centers for Medicare and Medicaid Services. Last year, Milliman issued the 14th edition of its Care Guidelines, which began recommending that insurers cover hospitalization following laparoscopic gastric bypass for just 1 day.

Last October, Dr. Morton and other leaders of the American Society for Metabolic and Bariatric Surgery sent a letter to Milliman asking the company to reconsider its position. Dr. Morton, who chairs the society’s Access to Care Committee, launched the new study to collect better information on the medical consequences of faster discharge in this setting. He learned from Milliman that the company’s recommendation for 1-day discharge had been based on one published study reflecting a single center’s experience. That study found 1-day discharge following laparoscopic gastric bypass to be safe (Ann. Surg. 2005;242:494-501).

"I was shocked and dismayed that they advocated a day 1 discharge," said Dr. Morton. "The only motivation can be cost savings. It’s not patient safety. Gastric bypass patients can develop complications that include bleeding, myocardial infarctions, pulmonary embolism, and leaks at anastomoses. "These can be discovered in the first 2 days, and if they occur in the hospital there is an opportunity to rescue the patient."

To better document the impact of discharging patients less than 2 days after gastric bypass, Dr. Morton and his associates used data drawn from the Bariatric Outcomes Longitudinal Database (BOLD), a bariatric surgery database for programs in the United States and Canada begun in 2007 by the Surgical Review Corporation.

The 51,788 patients who underwent a laparoscopic Roux-en-Y gastric bypass operation during the nearly 3.5-year period reviewed had an average age of 46 years, and almost 80% were women. The researchers limited the study population to patients whose hospitalized length of stay was 4 days or less (94% of all laparoscopic gastric bypasses done during this time). During the 30 days following surgery, the overall mortality rate was 0.1%, the serious complication rate was 0.8%, and 3.8% of patients required readmission.

The analysis divided patients into those discharged the same day as their surgery (a 0-day length of stay), patients discharged the morning after their surgery and within 24 hours of their initial admission (1-day length of stay), and 2-, 3-, or 4-day length of stays.

In a multivariate analysis that controlled for baseline clinical and demographic factors, patients discharged on day 0 had a statistically significant, 13-fold increased risk of 30-day mortality compared with patients discharged on day 2. Patients discharged on day 1 had a twofold increased mortality rate that fell just short of significance (P = .055). Patients discharged on day 3 had a 30-day mortality rate that was virtually the same as that of day 2 patients, while those discharged on day 4 had a greater than fivefold increased mortality rate that was significant. Dr. Morton ascribed this higher mortality rate in patients with a 4-day hospitalization to the increased number of postoperative complications in these patients that likely led to their prolonged hospitalization.

"I think there is an opportunity for faster discharge, but with these data routine ambulatory discharge is not warranted, because 13-fold increased mortality is just not acceptable," commented Dr. Titus Duncan, director of minimally invasive and bariatric surgery at the Atlanta Medical Center.

Dr. Morton said that he has received an educational grant from Ethicon Endo-Surgery, and he has received honoraria from and served on the scientific advisory board of Vibrynt. Dr. Duncan said that he received a teaching grant from Ethicon Endo-Surgery.