Abstract
Objective.
We sought to determine improvements in mental and physical health-related quality of life (HRQOL) following bariatric surgery in Medicaid and commercially insured patients.
Methods.
Using data from the Longitudinal Assessment of Bariatric Surgery, an observational cohort study of adults undergoing bariatric surgery (2006-2009), we examined changes in Short Form (SF)-36 mental (MCS) and physical component summary (PCS) scores in 1,529 patients who underwent Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Adjustable Band (LAGB), or Sleeve Gastrectomy (SG) and were followed for 5 years. Piecewise linear mixed-effects models estimated MCS and PCS scores as a function of insurance group (Medicaid, N=177; commercial, N=1,352) in 0-1 and 1-5 years post-surgery, with interactions between insurance group and surgery type.
Results.
Medicaid patients had lower PCS and MCS scores at baseline. At 1-year post-surgery, commercial and Medicaid patients experienced similar improvement in PCS scores (Commercial-Medicaid difference in PCS change [95% CI]: RYGB: 1.5 [−0.2, 3.3]; LAGB: 1.9 [−2.2, 6.0]; SG: 6.4 [0.0, 12.8]). 1-year MCS score improvement was minimal and similar between insurance groups. In years 1-5, PCS and MCS scores were stable in all groups.
Conclusions.
Both insurance groups experience improvements in physical HRQOL and minimal changes in mental HRQOL.
Keywords: Epidemiology, obesity treatment, bariatric surgery, outcomes, Medicaid
Introduction
Severe obesity is associated with impairment to health-related quality of life (HRQOL), a multi-dimensional concept that includes domains related to physical, mental, emotional and social functioning (1-5). Increasing HRQOL is a Healthy People 2020 central public health goal (1) and HRQOL measures are considered important indicators of intervention outcomes and are powerful predictors of mortality and morbidity (6, 7). Among the general patient population with severe obesity, bariatric surgery has demonstrated effectiveness in improving long-term HRQOL (8-10). However, while current evidence suggests bariatric surgery is effective in improving HRQOL among the general population, bariatric surgery effectiveness is known to vary by individual-level characteristics and less is known about HRQOL among patient subgroups.
Importantly, the Medicaid patient population has a disproportionately high burden of obesity, a greater number of comorbidities, and lower HRQOL as compared to commercially insured patients (11-13). Despite this poorer overall health profile, recent evidence suggests Medicaid patients have similar post-operative improvements in weight (14) and comorbidity remission outcomes (15, 16), and that these improvements are sustained over time. Yet, no studies to date have focused on post-surgical changes to HRQOL among patients with Medicaid, a critical but understudied potential health benefit of bariatric surgery.
The goal of this investigation was to quantify the changes in physical and mental HRQOL following bariatric surgery in Medicaid and commercially insured patients. We utilize data from the Longitudinal Assessment of Bariatric Surgery (LABS) (17), a multi-site, diverse, observational cohort with high levels of follow-up over 5-years post-operatively. We hypothesized that Medicaid patients have lower baseline levels of physical and mental HRQOL, but experience similar improvements following surgery and over time as compared to commercially insured patients.
Methods
Analytic Sample
Of the 2458 LABS participants, we first excluded participants who were missing baseline health insurance information or reported self-paying for surgery (N=389). Next, participants reporting Medicare only (N=210), Tricare only (N=67) or “Other” insurance (N=86) were excluded. Participants undergoing Biliary Pancreatic Diversion with Duodenal Switch (N=16) and Banded Bypass (N=26) were uncommon in this cohort and thus excluded. Finally, participants who contributed fewer than two HRQOL scores over the six time points were excluded from analyses (N=135), leaving 1,529 participants in the final analytic cohort (Figure 1).
Figure 1. Flow diagram, creation of analytic cohort.
Data collection
LABS-certified trained personnel collected study data using standard protocols (18, 19). Data collection consisted of blood and urine samples, physical measurements, self-assessment forms, surgeon and medical staff forms, and chart review procedures. Baseline data were collected within 30 days before surgery. Annual follow-up assessments were conducted within 6 months of surgery anniversary date for five consecutive years. Data were entered twice using a web-based data entry system developed, distributed, and maintained by the University of Pittsburgh LABS Data Coordinating Center.
Study Variables
Short-Form 36 Physical & Mental Component Summary Scores (Outcome)
The SF-36 is a widely used and validated 36-item questionnaire which measures functional health and well-being from the patient’s point of view (20). The SF-36 includes two psychometrically-based sub-scores, the physical component summary (PCS) and the mental component summary (MCS). MCS and PCS scores are calibrated such that 50 is the average or U.S. population norm score; scores below 50 suggest lower self-rated health (20). In this study, MCS and PCS scores were analyzed as a continuous score at each study time point (range 0-100), where a five point increase in score represents a clinically meaningful improvement (21, 22).
Insurance Type
Self-reported insurance type was collected using a self-assessment form at the baseline study visit. Participants with available baseline insurance information were classified into two categories: 1) Medicaid with or without Medicare; and 2) Commercial insurance with or without Medicare. Participants reporting other insurance types were excluded from this analysis as they were heterogeneous with regard to their sociodemographic and clinical profile. Insurance classification at baseline was analyzed as a time constant variable; potential changes to insurance status over time were not incorporated given the desire to understand how the differences in baseline health status between groups influenced long-term outcomes.
Surgery type
Three primary weight-loss procedures were ascertained from surgeon reports at baseline: 1) Roux-en-Y Gastric Bypass (RYGB); 2) Laparoscopic Adjustable Gastric Band (LAGB); and 3) Sleeve Gastrectomy (SG). Participants whose initial bariatric surgery was subsequently revised or reversed remain classified with the baseline surgery type. Additionally, the decision to proceed with a specific type of operation is determined by the patient and surgeon as a component of clinical care, LABS did not participate in surgery type selection.
Covariates
Covariates included self-reported age at surgery, sex (male, female), and baseline BMI (kg/m2). Comorbidities (diabetes, hypertension, dyslipidemia, sleep apnea, ischemic heart disease, congestive heart failure, history of stroke, pulmonary hypertension, asthma, history of deep vein thrombosis or pulmonary embolism, and venous edema with ulcerations) were determined using a combination of self-report, clinical assessment, and medical chart review and are defined elsewhere (17). An index of comorbidities was created as the number of comorbidities at baseline (range: 0-11) to provide a rough estimate of disease burden.
Statistical Analysis
Descriptive statistics summarize baseline characteristics for each insurance category. Pearson’s chi-square test for categorical variables and t-tests for continuous variables were used to assess statistical significance of differences in baseline characteristics between the payer groups. Data management was conducted using SAS version 9.4; descriptive analyses and mixed models were conducted using Stata version 15.
Piecewise linear mixed-effects models were used to compare changes in continuous PCS and MCS scores over the 5-year post-operative period. Mixed-effects models account for the correlation among repeated measurements taken on the same individual over time and uses all available data at each time point. The piecewise approach allowed us to model non-linear changes in MCS and PCS scores over time by fitting two linear slopes corresponding to the two distinct post-operative periods of change, 0-1 and 1-5 years post-operatively. Further, interactions between insurance group, surgery type, and the two time terms enable direct comparison of 1) baseline MCS and PCS scores, and 2) the magnitude of change in MCS and PCS scores within and between the groups in the two post-operative periods. We included the spline functions as fixed and random effects, to estimate overall mean trajectories at the population level, and individual trajectories at the subject-specific level. Covariates were included as fixed effects.
Results
Description of the sample
At baseline, Medicaid patients were slightly younger (mean age: 43.6 vs 45.6 years), heavier (mean BMI: 51.7 vs 47.9 kg/m2), and had a higher comorbidity index (mean comorbidities: 2.9 vs 2.5) as compared to commercially insured patients (Table 1). Follow-up over at five years was high, ranging from 71-83% of the original sample, and varied across surgery type and by the Medicaid (Medicaid: RYGB: 71%; LAGB: 74%; SG: 83%) and Commercial patient groups (RYGB: 73%; LAGB: 71%; SG: 76%) (data not shown).
Table 1.
Baseline characteristics of 1,529 patients undergoing bariatric surgery
| Characteristic | Overall (n=1,529) | Commercial (n=1,352) | Medicaid (n=177) |
|---|---|---|---|
| Age [Mean (SD)] | 45.3 (10.8) | 45.6 (10.7) | 43.6 (11.1) |
| Sex -n(%) | |||
| Male | 293 (19.2) | 267 (19.8) | 26 (14.7) |
| Female | 1,236 (80.8) | 1,085 (80.3) | 151 (85.3) |
| BMI (kg/m2) [Mean (SD)] | 48.3 (7.6) | 47.9 (7.2) | 51.7 (9.5) |
| Comorbidity Index [Mean (SD)] | 2.5 (1.5) | 2.5 (1.5) | 2.9 (1.6) |
| Procedure Type -n(%) | |||
| RYGB | 1,105 (72.3) | 963 (71.2) | 142 (80.2) |
| LAGB | 383 (25.1) | 360 (26.6) | 23 (13.0) |
| SG | 41 (2.7) | 29 (2.1) | 12 (6.8) |
Abbreviations: RYGB: Roux-en-Y Gastric Bypass; LAGB: Laparoscopic Adjustable Gastric Band; SG: Sleeve gastrectomy; SD: standard deviation; kg: kilogram
Note: boldface indicates statistical significance (p<0.05) for Commercial versus Medicaid, per t-test or chi-square test for continuous or categorical variables, respectively.
Five-year adjusted physical HRQOL changes in patients undergoing bariatric surgery
Adjusted baseline PCS scores for all three surgery types were low in both insurance groups (below the population norm of 50), more so among Medicaid patients (adjusted mean baseline PCS: 34.2 [RYBG], 36.3 [LAGB], 36.2 [SG]) than commercially insured patients (adjusted mean baseline PCS: 39.0 [RYGB], 41.5 [LAGB], 40.2 [SG]) (Table 2; Figure 2). At 1-year post-surgery, both patient groups had experienced increases in their PCS scores. The increase in insurer group-specific mean score was similar between the two insurance groups undergoing RYGB [PCS change (95% CI): Commercial: 13.5 (12.8, 14.1) and Medicaid: 11.9 (10.3, 13.6); Commercial-Medicaid difference (95% CI): 1.5 (−0.2, 3.3)] and LAGB [PCS increase (95% CI): Commercial: 8.7 (7.6, 9.7) and Medicaid 6.7 (2.8, 10.7); Commercial-Medicaid difference (95% CI): 1.9 (−2.2, 6.0)]. Whereas among patients who underwent SG, commercial patients experienced a 6.4 points (95% CI: 0.0, 12.8) greater increase in PCS score [13.7 (95% CI: 10.2, 17.2)] compared to Medicaid patients [7.3 (95% CI: 1.9, 12.7)]. In the 1-5 year period, scores among both patients groups and following all surgery types were relatively stable maintaining the initial improvements in mean score, with a slight downward trend over time.
Table 2.
Adjusted physical component summary score at baseline and change over time, between insurance groups and by surgery type
| Estimated meana | Commercial | Medicaid | Difference (Comm - Med) |
|---|---|---|---|
| Roux-en-Y Gastric Bypass | |||
| Baseline PCS Score | 39.0 (38.4, 39.6) | 34.2 (32.6, 35.7) | 4.8 (3.2, 6.5) |
| PCS Score Δ 0-1y | 13.5 (12.8, 14.1) | 11.9 (10.3, 13.6) | 1.5 (−0.2, 3.3) |
| PCS Score Δ 1-5y | −1.0 (−1.1, −0.8) | −1.1 (−1.5, −0.6) | 0.1 (−0.4, 0.6) |
| Laparoscopic Adjustable Gastric Band | |||
| Baseline PCS Score | 41.5 (40.6, 42.5) | 36.3 (32.5, 40.0) | 5.3 (1.4, 9.2) |
| PCS Score Δ 0-1y | 8.7 (7.6, 9.7) | 6.7 (2.8, 10.7) | 1.9 (−2.2, 6.0) |
| PCS Score Δ 1-5y | −0.8 (−1.1, −0.5) | −0.6 (−1.6, 0.4) | −0.2 (−1.2, 0.8) |
| Sleeve Gastrectomy | |||
| Baseline PCS Score | 40.2 (36.8, 43.6) | 36.2 (30.9, 41.5) | 4.0 (−2.2, 10.2) |
| PCS Score Δ 0-1y | 13.7 (10.2, 17.2) | 7.3 (1.9, 12.7) | 6.4 (0.0, 12.8) |
| PCS Score Δ 1-5y | −0.3 (−1.2, 0.6) | −1.1 (−2.4, 0.3) | 0.8 (−0.8, 2.5) |
Abbreviations: Δ: change; y: year; comm: commercial; Med: Medicaid; PCS: medical component summary score
Piecewise linear mixed-effects model with a knot placed at 1-year post-operatively used to estimate change in PCS score, interaction term with insurance and surgery type estimate group-specific means for Medicaid (N=177) and commercial groups (N=1,352) by surgery type. Model adjusted for age at surgery, sex, baseline body mass index, comorbidity index.
Note: boldface indicates a statistically significant difference (p<0.05)
Figure 2. Adjusteda physical component summary (PCS) score between insurance groups and by surgery type.
aPiecewise linear mixed-effects model with a knot placed at 1-year post-operatively used to estimate change in PCS score, interaction term with insurance and surgery type estimate group-specific means for Medicaid (N=177) and commercial groups (N=1,352) by surgery type. Model adjusted for age at surgery, sex, baseline body mass index, comorbidity index.
Five-year adjusted mental HRQOL changes in patients undergoing bariatric surgery
Adjusted baseline MCS scores were high at baseline and near the population norm of 50 in both insurance groups; however, Medicaid patients (adjusted mean baseline MCS: 47.1 [RYGB], 48.0 [LAGB], 42.9 [SG]) across all three surgery types had slightly lower scores than Commercial patients (adjusted mean baseline MCS: 49.5 [RYGB], 49.5 [LAGB], 46.4 [SG]) (Table 3; Figure 3). In the 0-1 year period, Medicaid patients undergoing RYGB experienced a minimal increase in MCS scores [MCS increase (95% CI): 1.4 (−0.4, 3.2)] and those undergoing LAGB and SG experienced slight decreases [MCS decrease (95% CI), LAGB: −1.4 (−5.6, 2.9) and SG: −0.7 (−6.4, 5.0)]. Commercial patients across all three surgery types experienced minimal increases in MCS scores (MCS increase (95% CI), RYGB: 2.2 (1.6, 2.9) and LAGB: 1.5 (0.4, 2.6) and SG: 3.2 (−0.5, 7.0)]. None of the differences between insurer groups in MCS score change were statistically significant. Similar to the PCS score, the scores for both patient groups were stable in the 1-5 year period.
Table 3.
Adjusted mental component summary score at baseline and change over time, between insurance groups and by surgery type
| Estimated meana | Commercial | Medicaid | Difference (Comm - Med) |
|---|---|---|---|
| Roux-en-Y Gastric Bypass | |||
| Baseline MCS Score | 49.5 (48.8, 50.2) | 47.1 (45.3, 48.8) | 2.4 (0.6, 4.3) |
| MCS Score Δ 0-1y | 2.2 (1.6, 2.9) | 1.4 (−0.4, 3.2) | 0.8 (−1.1, 2.8) |
| MCS Score Δ 1-5y | −1.0 (−1.2, −0.8) | −0.8 (−1.3, −0.3) | −0.2 (−0.7, 0.4) |
| Laparoscopic Adjustable Gastric Band | |||
| Baseline MCS Score | 49.5 (48.4, 50.6) | 48.0 (43.8, 52.3) | 1.5 (−2.9, 5.9) |
| MCS Score Δ 0-1y | 1.5 (0.4, 2.6) | −1.4 (−5.6, 2.9) | 2.9 (−1.5, 7.3) |
| MCS Score Δ 1-5y | −0.3 (−0.6, −0.0) | −0.7 (−1.9, 0.4) | 0.4 (−0.8, 1.6) |
| Sleeve Gastrectomy | |||
| Baseline MCS Score | 46.4 (42.6, 50.2) | 42.9 (37.0, 48.9) | 3.5 (−3.5, 10.4) |
| MCS Score Δ 0-1y | 3.2 (−0.5, 7.0) | −0.7 (−6.4, 5.0) | 3.9 (−2.9, 10.8) |
| MCS Score Δ 1-5y | −1.0 (−2.1, 0.0) | 0.1 (−1.4, 1.7) | −1.1 (−3.0, 0.7) |
Abbreviations: Δ: change; y: year; comm: commercial; Med: Medicaid; MCS: medical component summary score
Piecewise linear mixed-effects model with a knot placed at 1-year post-operatively used to estimate change in MCS score, interaction term with insurance and surgery type estimate group-specific means for Medicaid (N=177) and commercial groups (N=1,352) by surgery type. Model adjusted for age at surgery, sex, baseline body mass index, comorbidity index.
Note: boldface indicates a statistically significant difference (p<0.05)
Figure 3. Adjusteda mental component summary (MCS) score between insurance groups and by surgery type.
aPiecewise linear mixed-effects model with a knot placed at 1-year post-operatively used to estimate change in PCS score, interaction term with insurance and surgery type estimate group-specific means for Medicaid (N=177) and commercial groups (N=1,352) by surgery type. Model adjusted for age at surgery, sex, baseline body mass index, comorbidity index.
Discussion
In this study, we provide new information on long-term improvements to mental and physical HRQOL among Medicaid and commercially insured patients following bariatric surgery. All patient groups had levels of mental HRQOL similar to that of the U.S. population score at pre-operative time points and experienced only minor changes in the post-operative period. Conversely, both insurer groups report low baseline levels of physical HRQOL as compared to the U.S. population norm, experience clinically meaningful increases following surgery, and sustain these improvements over five years post-operatively. Importantly, we observed that Medicaid patients reported lower levels of physical-HRQOL at baseline across all surgery types compared to commercially insured patients. And despite a similar magnitude of improvement in the first post-operative year between groups, scores among Medicaid patients remained lower over time.
To our knowledge, no other studies have reported insurer group-specific changes to HRQOL following bariatric surgery. Findings among the general patient population align with the current study’s findings; a recent meta-analysis reported that bariatric surgery had a greater positive influence on physical HRQOL compared to mental HRQOL across 72 studies (10). Similarly, a second meta-analysis found no effect of surgery on mental HRQOL following bariatric among 11 randomized clinical trials, findings which also align with the current study’s report (9). Our findings support reporting group-specific changes following bariatric surgery, as reporting overall findings may mask important policy- and clinically-relevant differences.
Differences in Mental HRQOL
Notably, prior to undergoing bariatric surgery, the MCS scores among the both Medicaid and commercially insured patient groups were at or near the U.S. population norm. These findings generally align with other research on mental HRQOL among patients undergoing bariatric surgery, that obesity has little impact on mental HRQOL (9, 10).
In both post-operative time periods, the MCS scores did not clinically meaningfully change among the insurer- and surgery-type groups. Some evidence suggests there may be an inverse association between bariatric surgery and mental HRQOL, where the psychological impacts of the surgery may actually worsen mental HRQOL over time or the incidence of post-operative mental health conditions increases (9). Our findings do not support this hypothesis and suggest bariatric surgery has little impact on mental HRQOL post-operatively regardless of the insurer group or surgery type. Our findings suggest future research should focus on other measures of mental health, such as depression, which might vary by patient population, especially historically underserved patient groups. Also, the SF-36 can be further broken down into more specific mental HRQOL sub-domains (e.g., emotional role functioning), and while the overall score is not changed in the post-operative period, certain domains could be more associated with bariatric surgery than others. By focusing on the overall score, changes among specific sub-domains may be masked; as such, future studies should explore these sub-domains.
Differences in Physical HRQOL
Across all surgery types, Medicaid patients had lower PCS scores as compared to commercial patients and we observed substantial improvements in PCS score in the first year following bariatric surgery among both patient groups. For commercially insured patients, improvements to PCS score aligned this group with the U.S. population normed score of 50. For Medicaid patients undergoing RYGB and LAGB, the magnitude of score improvement in the first post-operative year was similar to commercially insured patients, but Medicaid patients remained below the population average at all follow-up time points. Medicaid patients undergoing SG experienced less improvement in PCS score, but this result should be interpreted with caution given the small number of Medicaid patients undergoing SG. A similar pattern emerged in our recent investigations of weight loss (14) and comorbidity remission patterns (16), where we observe the disease disparity among Medicaid present at baseline patients persist into the post-operative periods despite a similar response to surgery. Finally, despite any difference in PCS score improvement between the insurer groups, improvements across all insurer- and surgery-type groups were greater than 5-points, indicating clinically meaningful improvements (21).
The finding that Medicaid patients experience consistently lower HRQOL aligns with the existing body of evidence that reports Medicaid patients have a greater severity of obesity and a greater number of comorbid conditions, which could directly lead to the lower physical HRQOL (11-13, 23). However, it is unclear if the presence of more severe obesity and comorbidities is the only explanation for the lower physical HRQOL. Prior evidence suggests Medicaid patients have obesity at younger ages and have a longer waiting period prior to surgery (12, 24), it’s possible a greater the length of time with obesity could explain the differential levels of physical HRQOL observed in this study. Similarly, Medicaid patients also may have limited or delayed access to health care (12, 24), making it more difficult to achieve adequate control of obesity-related comorbidities, like diabetes, over time. A greater burden of poorly controlled comorbid disease is another potential explanation for why physical HRQOL is consistently observed to be lower among Medicaid patients (25-27).
Clinical and Public Health Implications
Our findings suggest that despite the effectiveness of bariatric surgery in improving a vast array of post-operative outcomes, lower overall baseline health of Medicaid patients is a key contributor to the persistence of a lower post-operative health profile. Our findings highlight the need to increase the availability of effective obesity treatments and provide access to surgical treatment earlier in the clinical progression of disease which may increase the likelihood of overcoming comorbidity-associated clinical deterioration. Also, implementing upstream interventions to prevent the development of obesity and related conditions among underserved populations remains an ongoing area of critical public health importance.
Strengths and Limitations
Study limitations are noted. The primary outcome of interest is a self-reported measure and may be subject to bias. However, the SF-36 is a validated and widely used instrument for capturing health related quality of life. The number of Medicaid patients captured in LABS is only modest, although larger than most other studies of bariatric surgery. A small number of patients underwent SG, one of the most commonly conducted surgeries today. Inference on the effects of SG on HRQOL are limited in this observational study, although the observed associations were similar to the other patient groups. The primary strength of the study is five years of follow-up with a high rate of retention on a large and highly generalizable sample.
Conclusions
In this study, we found that Medicaid patients experienced important and sustained improvements in physical HRQOL following bariatric surgery. We also observed that, despite a high degree of obesity and heavy burden of comorbid disease, mental HRQOL was similar to that of the general U.S. population and surgery had no impact on changes over time. Importantly, despite similar improvement in physical HRQOL, levels remained below commercially insured patients and below the U.S. average over time. These differences highlight the importance of the overall disease burden among Medicaid patients and the need for improved primary prevention and treatment to lessen the burden of disease on quality of life.
What is already known about this subject?
Among the general patient population with severe obesity, bariatric surgery has demonstrated effectiveness in improving long-term health-related quality of life (HRQOL)
The Medicaid patient population has a disproportionately high burden of obesity, a greater number of comorbidities, and lower HRQOL as compared to commercially insured patients
The effectiveness of bariatric surgery at improving HRQOL in this population is unknown.
What does your study add?
We found that Medicaid patients experienced important and sustained improvements in physical HRQOL following bariatric surgery.
We also observed that, despite a high degree of obesity and heavy burden of comorbid disease, mental HRQOL was similar to that of the general U.S. population and surgery had no impact on changes over time. I
Despite similar improvement in physical HRQOL, levels remained below commercially insured patients and below the U.S. average over time.
Acknowledgments
Funding: LABS-2 was funded by a cooperative agreement by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Grant numbers: Data Coordinating Center, U01 DK066557; Columbia-Presbyterian, U01- DK66667 (in collaboration with Cornell University Medical Center CTSC, grant UL1-RR024996); University of Washington, U01-DK66568 (in collaboration with CTRC, grant M01 RR-00037); Neuropsychiatric Research Institute, U01- DK66471; East Carolina University, U01-DK66526; University of Pittsburgh Medical Center, U01-DK66585 (in collaboration with CTRC, grant UL1-RR024153); and Oregon Health & Science University, U01-DK66555.
Footnotes
Disclosures: None.
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