close-up Weight Loss Surgery in California: A Close-Up of Geographic Variation

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1 in California: A Close-Up of Geographic Variation C A LIFORNIA HEALTHCARE FOUNDATION Geographic Variation Series. This Close-Up is part of a comprehensive set of reports that examine the rates at which 13 elective procedures are delivered in different communities across the state. They include cardiac procedures, carotid endarterectomy, hip and knee replacement, mastectomy, hysterectomy, childbirth procedures, gallbladder surgery, and weight loss surgery. A research summary, All Over the Map: Elective Procedure Rates in California Vary Widely, provides additional background information on the topic of regional variation and a complete methodology for the study. 1 The data are from 2005 through 2009 and are based on patients place of residence. Rates can vary widely, even in contiguous communities. The data account for age, sex, income, education, insurance status, and race. Peo p l e w h o a r e severely o b e s e a r e at increased risk for developing serious medical conditions, such as diabetes, high blood pressure, heart disease, and osteoarthritis. Treatment options for obese patients include: Nonsurgical options Gastric banding Gastric bypass surgery Some patients try nonsurgical ways to lose weight such as cutting down on calories, eating healthier food, becoming more active, and setting realistic weight goals. Gastric banding is a treatment whereby a band is placed around the upper part of the stomach to separate it from the lower part. After surgery, the stomach pouch can hold only about ¼ cup of food, making the patient feel full after eating only a small amount. Patients who undergo gastric banding tend to have a faster recovery than those who choose gastric bypass surgery. Gastric banding is a reversible procedure. Gastric bypass surgery is a procedure that makes the stomach smaller using surgical staples or a plastic band. The surgery also involves connecting part of the stomach to a new part of the small intestine, causing food to bypass some of the lower part of the stomach and the first part of the small intestine. Gastric bypass surgery both lowers the amount of food the patient can eat in one sitting, and makes people feel full with less food by affecting stomach hormones. Both gastric banding and gastric bypass surgery can lead to significant weight loss and reduce or eliminate some of the conditions caused by obesity. For example, symptoms of diabetes disappear in more than three-quarters of people who undergo weight loss surgery. More than 60% of people no longer have high blood pressure after weight loss surgery. People who have gastric bypass surgery often lose more weight than those with gastric banding. Up to 33% of patients who have weight loss surgery develop gallstones. 2 Some will not have any symptoms, while others may have such symptoms as nausea, vomiting, and pain. Other complications of both gastric banding and gastric bypass surgery include vomiting, diarrhea, and wound infections, which usually get better on their own or with treatment. Patients who undergo gastric bypass can develop nutritional deficiencies. close-up Sep t e m b e r 2011

2 For the average patient undergoing bypass today, the mortality risk is probably less than 0.5 percent and could be as low as 0.25 percent in high-volume academic medical centers, while, for some patient groups, at 30 days the mortality risk can be substantially higher, between 1% and 2%. 3 Risk of such complications as blood clots and digestive system blockage is also higher for gastric bypass surgery, with as many as 20% experiencing one or more complications. For gastric banding surgery, the risk of complications is 13% Both procedures carry other serious risks. Five percent of gastric bypass surgery patients experience blockage in the digestive system, which may require surgery. Less than Figure 1. Geographic Variation in, California, Note: This is a static representation of a portion of the data that can be seen on an interactive map at: data variation analyses Residents of Ukiah HSA (Napa HRR) are at least six times as likely to undergo weight loss surgery as residents of Livermore HSA (Alameda HRR). Residents of Los Banos HSA (Modesto HRR) are at least four and a half times as likely to undergo weight loss surgery as residents of Walnut Creek HSA (Contra Costa HRR). Residents of Fortuna HSA (Redding HRR) are at least four and a half times as likely to undergo weight loss surgery as residents of Vallejo HSA (San Francisco HRR). Residents of Bakersfield HSA (Bakersfield HRR) are at least three times as likely to undergo weight loss surgery as residents of Davis HSA (Sacramento HRR). Residents of Orange HSA (Orange HRR) are at least two and a half times as likely to undergo weight loss surgery as residents of San Diego HSA (San Diego HRR). DEFINITIONS: Hospital service areas (HSAs) represent a local health care market for community-based inpatient care. HSAs can include more than one community. Hospital referral regions (HRRs) represent a health care market for tertiary medical care. (A tertiary designation is based on where patients receive major cardiovascular surgical procedures and neurosurgery.) Each HRR includes at least one HSA that has a hospital or hospitals that perform major cardiovascular procedures or neurosurgery. 2 California HealthCare Foundation

3 1% of gastric banding patients have this complication. Eight percent of gastric banding patients will need an operation to correct the procedure in the future, whereas less than 2% of gastric bypass patients will need corrective surgery. Additional serious complications of both procedures include blood clots and leaks at the staple lines in the stomach. Antibiotics are the first line of treatment for treating digestive leaks, but further surgery may also be needed. Regardless of treatment choice, patients aiming to lose weight will be advised to eat healthier food, eat less, and be more active. Surgery does not guarantee weight loss, and, in order to keep the weight off, patients will have to adhere to a strict diet. 4 Patients in several California communities (hospital service areas or HSAs) undergo weight loss surgery at rates notably higher or lower than the state rate. 5 See Figure 1 on the previous page. Residents of three of six Modesto HSAs undergo weight loss surgery at more than one and a half times the state rate. In one of those three HSAs, Los Banos HSA, residents undergo the procedure at more than twice the state rate. See Figure 2. Note regarding Figures 2 and 3: The narrow vertical line at the top of each bar displays the range of the confidence intervals. Figure 2., Modesto HSAs Compared to State Rate, Patients Under Age 65, COMPARED TO STATE RATE Los Banos Merced Modesto Oakdale Sonora Turlock in California: A Close-Up of Geographic Variation 3

4 Residents of three of eight Contra Costa HSAs Antioch HSA, Fairfield HSA, and Walnut Creek HSA undergo weight loss surgery at less than half the state rate. See Figure 3. Figure 3., Contra Costa HSAs Compared to State Rate, Patients Under Age 65, COMPARED TO STATE RATE Clearlake Deer Park Fort Bragg Garberville Lakeport Napa Ukiah Willits Figure 4., by HSA, Note: Each dot represents the rate for a procedure in a single California HSA. Dots at the top and bottom of the graphs represent the extremes in rates. The narrower the graph, the greater the variation in rates across HSAs. Highest Rates Rate per 100,000 Ukiah (Napa HRR) 53 Los Banos (Modesto HRR) 50 Fortuna (Redding HRR) 49 Barstow (San Bernardino HRR) 38 Oakdale (Modesto HRR) 37 Hollister (San Jose HRR) 36 Orange (Orange HRR) 36 Tulare (Bakersfield HRR) 34 Bakersfield (Bakersfield HRR) 34 Sonora (Modesto HRR) 34 State Rate 17 Lowest Rate Livermore (Alameda HRR) 4 Castro Valley (Alameda HRR) Oroville California HealthCare Foundation

5 Table 1. Rates of in California Hospital Service Areas (HSAs), HOW TO USE THIS TABLE: In the Bakersfield HSA, residents undergo weight loss surgery at a rate of Legend at least 183% of the state rate (and at most 220%). That means they are at least one and a half times as At least twice the state rate likely as the average Californian to undergo the procedure. The table also shows that residents of Antioch At least one and a half times the state rate HSA undergo weight loss surgery at a rate of at most 45% of the state rate. That means they are less than Less than half of the state rate half as likely as the average Californian to undergo the procedure. Notes: An HSA includes both the city for which it is named as well as surrounding areas. Confidence intervals describe a range and are listed in parentheses. For example, 57% 70% indicates that, with 95% confidence, the range of possible values spans from California 100% Alameda 51% (32% 82%) Anaheim 116% (102% 132%) Antioch 34% (26% 45%) Apple Valley 80% (61% 105%) Arcadia 51% (39% 68%) Arcata 108% (70% 168%) Arroyo Grande 85% (59% 121%) Auburn 61% (46% 82%) Avalon Bakersfield 201% (183% 220%) Banning 70% (50% 99%) Barstow 226% (167% 306%) Bellflower 115% (90% 148%) Berkeley 38% (25% 57%) Big Bear Lake Brawley 149% (92% 243%) Burbank 101% (87% 117%) Burlingame 79% (61% 104%) Camarillo 182% (145% 227%) Canoga Park 159% (137% 184%) Carmichael 63% (53% 74%) Castro Valley 28% (18% 43%) Chester Chico 86% (66% 113%) Chino 92% (75% 113%) Chula Vista 80% (66% 97%) Clearlake Coalinga Colusa Concord 40% (29% 54%) Corcoran Corona 110% (93% 129%) Coronado Covina 48% (34% 67%) Culver City 110% (75% 162%) Daly City 47% (35% 65%) Davis 40% (27% 60%) Deer Park Delano 163% (113% 236%) Dinuba Downey 92% (73% 114%) Duarte El Centro 104% (73% 148%) Encinitas 43% (32% 58%) Encino 189% (118% 304%) Escondido 57% (45% 73%) Eureka 162% (118% 221%) Fairfield 36% (26% 49%) Fall River Mills Fallbrook 102% (68% 151%) Folsom 97% (73% 129%) Fontana 65% (50% 84%) Fort Bragg Fortuna 289% (209% 398%) Fountain Valley 117% (96% 142%) Fremont 42% (33% 55%) Fresno 74% (65% 84%) Fullerton 117% (103% 134%) Garberville Garden Grove 126% (96% 164%) Gardena 101% (63% 162%) in California: A Close-Up of Geographic Variation 5

6 Gilroy 120% (88% 165%) Glendale 102% (88% 119%) Glendora 68% (51% 91%) Granada Hills 128% (94% 173%) Grass Valley 102% (73% 144%) Greenbrae 44% (33% 59%) Greenville Gridley Hanford 155% (122% 198%) Harbor City 90% (72% 114%) Hawthorne 92% (67% 127%) Hayward 41% (28% 58%) Healdsburg 99% (59% 165%) Hemet 69% (55% 87%) Hollister 211% (159% 281%) Huntington Beach 86% (70% 106%) Indio 63% (44% 92%) Inglewood 107% (88% 129%) Irvine 91% (71% 118%) Jackson 97% (65% 144%) Joshua Tree 90% (61% 134%) King City La Jolla 88% (70% 111%) La Mesa 59% (51% 68%) Laguna Hills 68% (55% 83%) Lake Isabella Lakeport 164% (112% 239%) Lakewood 86% (59% 125%) Lancaster 74% (64% 86%) Lindsay Livermore 23% (14% 37%) Lodi 106% (87% 130%) Loma Linda 48% (33% 70%) Lompoc 68% (46% 101%) Long Beach 106% (94% 119%) Los Alamitos 88% (68% 112%) Los Angeles 106% (95% 118%) Los Banos 296% (213% 410%) Lynwood 64% (49% 84%) Madera 176% (124% 248%) Manteca 157% (126% 197%) Martinez 52% (35% 78%) Marysville 118% (80% 173%) Merced 131% (104% 165%) Mission Hills 139% (107% 180%) Mission Viejo 64% (53% 76%) Modesto 164% (148% 183%) Montebello 104% (77% 140%) Monterey 100% (79% 127%) Monterey Park Morgan Hill 61% (39% 97%) Mount Shasta Mountain View 66% (51% 84%) Napa 52% (37% 73%) National City Newport Beach 78% (67% 92%) Northridge 136% (111% 167%) Norwalk 117% (88% 157%) Novato 55% (36% 85%) Oakdale 220% (165% 293%) Oakland 55% (44% 69%) Oceanside 47% (39% 57%) Ojai 141% (93% 215%) Orange 210% (178% 249%) Oroville 148% (99% 219%) Oxnard 182% (147% 224%) Palm Springs 72% (54% 97%) Panorama City 133% (101% 174%) Paradise 115% (75% 176%) Paramount 107% (68% 167%) Pasadena 77% (61% 97%) Petaluma 67% (48% 93%) Pinole 76% (55% 104%) Pittsburg 46% (31% 70%) 6 California HealthCare Foundation

7 Placerville 97% (76% 125%) Pleasanton 39% (28% 54%) Pomona 83% (69% 101%) Porterville 115% (86% 155%) Poway 70% (57% 87%) Rancho Mirage 66% (52% 83%) Red Bluff Redding 51% (38% 67%) Redlands 51% (39% 66%) Redwood City 68% (55% 85%) Ridgecrest 154% (100% 238%) Riverside 83% (73% 94%) Roseville 86% (72% 101%) Sacramento 86% (77% 96%) Salinas 96% (76% 120%) San Andreas 136% (95% 194%) San Bernardino 64% (54% 76%) San Clemente 72% (53% 97%) San Diego 59% (52% 66%) San Dimas 55% (33% 90%) San Francisco 76% (63% 91%) San Gabriel 73% (53% 101%) San Jose 90% (80% 100%) San Leandro 51% (35% 74%) San Luis Obispo 46% (31% 67%) San Mateo 76% (60% 97%) San Pablo 57% (41% 79%) San Pedro 103% (79% 135%) San Ramon Santa Ana 143% (122% 169%) Santa Barbara 59% (47% 74%) Santa Cruz 64% (51% 81%) Santa Maria 88% (67% 115%) Santa Monica 73% (60% 88%) Santa Paula 184% (126% 269%) Santa Rosa 80% (67% 95%) Sebastopol Selma 139% (98% 197%) Simi Valley 126% (103% 153%) Solvang Sonoma 99% (64% 153%) Sonora 199% (153% 260%) South El Monte South Laguna 68% (54% 85%) South San Francisco 114% (84% 156%) Stanford 49% (35% 69%) Stockton 125% (107% 145%) Sun City 108% (84% 139%) Tarzana 126% (94% 169%) Templeton 60% (43% 84%) Thousand Oaks 163% (131% 204%) Torrance 62% (53% 72%) Tracy 62% (44% 88%) Tulare 203% (159% 258%) Turlock 158% (125% 199%) Ukiah 312% (235% 413%) Upland 81% (70% 93%) Vacaville 63% (49% 82%) Valencia 55% (45% 67%) Vallejo 34% (25% 46%) Van Nuys 131% (108% 159%) Ventura 133% (109% 163%) Victorville 80% (66% 97%) Visalia 112% (92% 137%) Walnut Creek 35% (27% 45%) Watsonville 40% (26% 61%) Weaverville West Covina 69% (54% 88%) Whittier 86% (72% 103%) Wildomar/Murrieta 78% (65% 93%) Willits Woodland 105% (77% 144%) Yuba City 96% (68% 136%) in California: A Close-Up of Geographic Variation 7

8 P r o c e d u r e s Ch o s e n f o r t h e St u d y Procedures studied were based upon patient discharge data for weight loss surgery. This analysis controlled for age, sex, race, education, income, and insurance status. A u t h o r s Vanessa Hurley, MPH, policy analyst, and Shannon Brownlee, MS, acting director, New America Foundation Health Policy Program A b o u t t h e Fo u n d a t i o n The California HealthCare Foundation works as a catalyst to fulfill the promise of better health care for all Californians. We support ideas and innovations that improve quality, increase efficiency, and lower the costs of care. For more information, visit us online at E n d n o t e s 1. The research for this report was developed by Laurence Baker, PhD, of Stanford University, in collaboration with Maryann O Sullivan, JD, and the staff and leadership of the Campaign for Effective Patient Care. Analysis and interpretation of the estimates were performed by Frances Tompkins, former project assistant, and O Sullivan, former executive director, of the Campaign for Effective Patient Care, in consultation with Shannon Brownlee, MS, acting director of the New America Foundation Health Policy Program. Lance Lang, MD, chaired an advisory committee of clinicians in various specialties, which was also consulted in the production of this report to review the analysis and to ensure the accuracy of medical content. For a complete list of advisory committee members, see the research summary All Over the Map: Elective Procedure Rates in California Vary Widely, Data were obtained from the Office of Statewide Health Planning and Development. 2. A multicenter, placebo-controlled, randomized, doubleblind, prospective trial of prophylactic ursodiol for the prevention of gallstone formation following gastricbypass-induced rapid weight loss, The American Journal of Surgery 1995 January; 169(1):91 6; discussion correspondence from David Arterburn, MD, medical editor, Foundation for Informed Medical Decision Making, August 5, This section was written using the following sources: : Is It Right for You? (Boston: Health Dialog). Obesity: Should I Have Weight-Loss Surgery?, Kaiser Permanente, accessed February 7, 2011, members. kaiserpermanente.org. Gastric Bypass Surgery: Risks, Mayo Clinic, 5. State averages should not be taken as the correct or right rate for elective procedures; they are used only as the comparator for analysis, not as a benchmark. There is no recommended baseline for elective procedures. 8 California HealthCare Foundation