title: Increasing the Value of Healthcare: Improving Mortality While Reducing Cost in Bariatric Surgery.
abstract: BACKGROUND
  Healthcare costs in the United States (U.S.) are rising. As outcomes improve, such as decreased length of stay and decreased mortality, it is expected that costs should go down. The aim of this study is to analyze hospital charges, cost of care, and mortality in bariatric surgery over time.
  
  
  METHODS
  A retrospective analysis of the Nationwide Inpatient Sample (NIS) database was performed. Adults with morbid obesity who underwent gastric bypass or sleeve gastrectomy were identified by ICD-9 codes. Multivariate analyses identified independent predictors of changes in hospital charges and in-hospital mortality. Results were adjusted for age, race, gender, Charlson comorbidity index, surgical approach (open versus laparoscopic), hospital volume, and insurance status. In order to estimate baseline surgical inflation, changes in hospital charges over time were also calculated for appendectomy.
  
  
  RESULTS
  From 1998 to 2011, 209,106 patients were identified who underwent bariatric surgery. Adjusted in-hospital mortality for bariatric surgery decreased significantly by 2003 compared to 1998 (p < 0.001, OR 0.47, 95 % CI 0.22-0.92) and remained significantly decreased for the remainder of the study period. As such, a 60-80 % decrease in mortality was maintained from 2003 to 2010 compared to 1998. After adjusting for inflation, the cumulative increase in hospital charges per day of a bariatric surgery admission was 130 % from 1998 to 2011. Charges per stay increased by 2.1 % annually for bariatric surgery compared to 5.5 % for appendectomy.
  
  
  CONCLUSIONS
  In-hospital mortality rate following bariatric surgery underwent a ninefold decrease since 1998 while maintaining surgical inflation costs less than appendectomy. Innovation in bariatric surgical technique and technology has resulted in improvement of outcomes while providing overall cost savings.
authors.affiliation: Department of Surgery, Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Ave, MC 0740, San Diego, CA, 92093, USA. rbroderick@ucsd.edu.
authors.forename: Ryan C
authors.initials: RC
authors.lastname: Broderick
authors.affiliation: Department of Surgery, Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Ave, MC 0740, San Diego, CA, 92093, USA. hfuchs@ucsd.edu.|Department of Surgery, University of Cologne, Cologne, Germany. hfuchs@ucsd.edu.
authors.forename: Hans F
authors.initials: HF
authors.lastname: Fuchs
authors.affiliation: Department of Surgery, Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Ave, MC 0740, San Diego, CA, 92093, USA. charnsberger@ucsd.edu.
authors.forename: Cristina R
authors.initials: CR
authors.lastname: Harnsberger
authors.affiliation: Department of Surgery, Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Ave, MC 0740, San Diego, CA, 92093, USA. dchang8@mgh.harvard.edu.|Department of Surgery, Harvard Medical School-Codman Center, Massachusetts General Hospital, Boston, MA, USA. dchang8@mgh.harvard.edu.
authors.forename: David C
authors.initials: DC
authors.lastname: Chang
authors.affiliation: Department of Surgery, Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Ave, MC 0740, San Diego, CA, 92093, USA. bsandler@ucsd.edu.
authors.forename: Bryan J
authors.initials: BJ
authors.lastname: Sandler
authors.affiliation: Department of Surgery, Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Ave, MC 0740, San Diego, CA, 92093, USA. gjacobsen@ucsd.edu.
authors.forename: Garth R
authors.initials: GR
authors.lastname: Jacobsen
authors.affiliation: Department of Surgery, Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California, San Diego, 9500 Gilman Ave, MC 0740, San Diego, CA, 92093, USA. shorgan@ucsd.edu.
authors.forename: Santiago
authors.initials: S
authors.lastname: Horgan
mesh_terms: D000328:Adult; D000368:Aged; D050110:Bariatric Surgery / Q000191:economics* / Q000379:methods / Q000401:mortality*; D016208:Databases, Factual; D005260:Female; D005743:Gastrectomy / Q000191:economics / Q000379:methods / Q000401:mortality; D015390:Gastric Bypass / Q000191:economics / Q000379:methods / Q000401:mortality; D017048:Health Care Costs; D017052:Hospital Mortality; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D007902:Length of Stay / Q000191:economics / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000401:mortality* / Q000601:surgery*; D058996:Quality Improvement; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology
keywords: Bariatric surgery; Outcomes; Population database; Value