Faculty Bibliography

BACKGROUND:Bariatric surgery has long been established as an effective treatment option for obesity and diabetes [Kalainov et al. in J Am Acad Orthop Surg [32(10):427-438, 2025] and Ogden et al. in JAMA 311(8):806-806, 2025. 10.1001/jama.2014.732]. Recently, GLP-1 Receptor Agonists' (GLP-1RAs) use has expanded as an alternative therapy for weight loss and diabetes management. While GLP1RAs are known to be safe and effective, few have compared long term outcomes of GLP-1RAs versus the "gold standard" of bariatric surgery among Medicare/Medicaid patients, who make up the largest payer group in the U.S. [Kalainov et al. in J Am Acad Orthop Surg [32(10):427-438, 2025]. METHODS:This was a retrospective, multicenter study of obese, type-2 diabetic patients (T2D) ≥ 18 years old, who initiated weekly injectable semaglutide or tirzepatide or underwent bariatric surgery between January 1st, 2018 to July 31st, 2024. Patients with a baseline BMI ≤ 35, those with prior GLP1-RA use, or any prior bariatric procedure were excluded from analysis. The primary outcome of interest was % total body weight loss 3 months to 3 years post intervention among bariatrics surgery patients vs. GLP1-RA patients (any GLP1-RA prescription and 12 months continuous GLP1-RA prescription). RESULTS:7667 patients were included for analysis (7200 GLP1-RA, 467 bariatric surgery). Bariatric surgery patients were younger (median (IQR): 43 (34, 53) vs. 65 (54, 72); p < 0.001) and more likely to be female (67.5% vs. 60.8%; p < 0.01) and Hispanic (58.7% vs. 19.4%; p < 0.001) while GLP1-RA users were more likely to be white (58.5% vs. 10.7%; p < 0.001). In models adjusting for demographic and clinical characteristics, bariatric surgery was associated with a 22.9% total weight loss 3 years following surgery compared to 2.3% for patients with any GLP1-RA use, and 15.9% vs 2.4% for patients with 12 months consecutive GLP1-RA use (22.9 [21.0-24.8] vs 2.3 [0.5-4.1], 15.9 [6.9-24.9] vs. 2.4 [6.7-11.5]. CONCLUSIONS:Among obese, T2D, publicly insured patients, bariatric surgery was associated with greater weight loss than GLP1-RAs at all measured periods from 3 months to 3 years post op.

OBJECTIVE:To evaluate out-of-pocket (OOP) costs and surprise billing (unexpected charges from out-of-network providers) in otolaryngology. STUDY DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:National commercial claims database. METHODS:Merative MarketScan database was queried for commercially insured patients aged 18 to 64 who underwent any of six otolaryngology procedures (thyroidectomy, parotidectomy, hypoglossal nerve stimulator implantation, drug-induced sleep endoscopy, septoplasty, or tonsillectomy) from 2014 to 2022. OOP costs were defined as the sum of deductibles, copays, and coinsurance for each 30-day surgical episode. A potential surprise bill was defined as an out-of-network claim within an episode where both the primary surgeon and facility were in-network. Relationships between OOP costs, potential surprise bills, and patient- and system-level exposures were analyzed. RESULTS:Of 58,772 procedures meeting inclusion criteria, 52,131 (89%) procedures were outpatient and 6641 (11%) were inpatient. Median (interquartile range [IQR]) total OOP costs were $1207 ($183-$2594), and coinsurance accounted for 66% of OOP costs. OOP costs were higher for patients with insurance plans that were fee-for-service-based (2.9 times; P < .001) or high-deductible (4.7 times; P < .001) versus managed care plans. A potential surprise bill accompanied 4.8% of surgical encounters, which was associated with significantly higher OOP costs (median $1739 vs $1269; P < .001). The odds of having a potential surprise bill were lower in 2022 versus 2014 to 2021 (odds ratio [OR] 0.29, 95% CI 0.21-0.40; P < .001). CONCLUSION/CONCLUSIONS:Common elective otolaryngology procedures were associated with high OOP expenditures, potentially exceeding the reserve funds of many patients. Potential surprise bills decreased after the passage of the No Surprises Act but were not eliminated.

OBJECTIVE:Given frailty and comorbidities that occur with both aging and end-stage kidney disease (ESKD), it is unclear if older patients with ESKD derive the improved survival and kidney transplant (KT) access associated with Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). METHODS:Using 2006-2021 USRDS data, we identified 876 patients with RYGB and 1508 patients with SG and compared 5-year mortality by age-group (18-29/30-39/40-49/50-59/60-69/≥ 70 years) to nonsurgical matched controls using 1:3 Mahalanobis distance matching, Kaplan-Meier, and Cox regression. We also compared age-stratified KT incidence between waitlisted patients and controls. RESULTS:) for patients with SG versus controls. CONCLUSIONS:RYGB in older patients with ESKD is associated with increased mortality and lower KT likelihood, whereas SG is associated with decreased mortality and higher KT likelihood compared to nonsurgical matched controls. Choice of bariatric surgery type may play a role in improving survival for older patients with ESKD.

BACKGROUND:Early postoperative small bowel obstruction (ESBO) following roux-en-Y gastric bypass (RYGB) is a feared complication, generally estimated to occur in 1-2% of cases. Most surgeons advocate for prompt surgical exploration for ESBO after RYGB. There is currently a paucity of literature regarding conservative management approaches to ESBO after RYGB. OBJECTIVES/OBJECTIVE:To determine the safety and efficacy of non-operative management of early small bowel obstruction following RYGB. SETTING/METHODS:Academic-affiliated municipal hospital. METHODS:We performed a retrospective review of all patients at a single institution who underwent RYGB between July 1, 2020 and April 30, 2024 and were readmitted within 30 days of the procedure due to a small bowel obstruction. Mesenteric defects were closed with permanent suture in 100% of cases. RESULTS:2430 RYGBs were performed, 54 patients (2.2%) developed ESBO. The average interval from time of surgery to diagnosis of ESBO was 7.3 days [range 2-26 days]. The vast majority of patients (n = 43; 80%) were successfully managed conservatively including nasogastric decompression (n = 20; 47%). Most (73%) of the patients requiring reoperation were found to have kinking at the anastomosis or dense adhesions from the cut end of the staple line. CONCLUSIONS:This study demonstrates that non-operative management may be a safe and effective treatment option for the majority of RYGB patients who develop ESBO. Clinical judgement is required to identify those who would benefit from early exploration.

INTRODUCTION/BACKGROUND:GLP-1 receptor agonists (GLP1-RAs) are increasingly prescribed as an alternative to bariatric surgery for weight loss, and may pose as an alternative to conversion Roux-En-Y Gastric Bypass (cRYGB) in patients with insufficient weight loss or weight recurrence after sleeve gastrectomy [A C, N C, A I. Postoperative morbidity and weight loss after revisional bariatric surgery for primary failed restrictive procedure: a systematic review and network meta-analysis. International Journal of Surgery; 2022;Jensen et al. in Obes Surg 33:1017-1025, 2023; Jamal et al. in Obes Surg 34:1324-1332, 2024; Lautenbach A, Wernecke M, Stoll FD, Meyhöfer SM, Meyhöfer S, Aberel J. 1422-P: The potential of semaglutide once-weekly in patients without Type 2 Diabetes with weight regain or insufficient weight loss after bariatric surgery. Diabetes 2022; 71(Supplement_1);]. METHODS AND PROCEDURES/METHODS:Adult patients ≥ 18 years old, who previously underwent a sleeve gastrectomy and were subsequently treated with weekly injectable Semaglutide or Tirzepatide, or treated with conversion from sleeve gastrectomy were included for analysis. Patients converted for GERD, GLP1-RA use with BMI ≤ 35, or pre operative GLP1-RA use were excluded. Post operative weights and Hgb A1C were assessed from 3 months to 3 years post intervention (start of GLP1-RA or surgery). T-test, ANOVA, and chi-squared analysis were used to compare groups, while multivariable linear regression analysis was used to evaluate the effect of bariatric surgery on %TBWL at 3 years post intervention when adjusting for baseline characteristics. RESULTS:4901 patients were included for analysis (3004 cRYGB, 1897 GLP1-RA). There was no difference in pre-intervention weight (242.8 ± 44.4 GLP1-RA vs 242.3 ± 57.8 cRYGB, p = .993). cRYGB patients had a higher baseline Hgba1c (6.19 ± 1.4 vs 5.85 ± 1.2, p < 0.001). cRYGB was associated with significantly greater weight loss at all post operative time points up to 3 years post intervention, (26.1 vs 13.7%, p < 0.001). There was no significant difference in Hgba1c control between treatments at all post intervention time points (all p > 0.05). In the multivariate linear regression analysis, when adjusting for sex, baseline BMI, baseline age, and non-white race, cRYGB was associated with an 11% greater %TBWL compared to those who were treated with a GLP1-RA. CONCLUSIONS:For patients who have had insufficient weight loss or weight recurrence following sleeve gastrectomy, conversion to RYGB offers greater, long-term weight loss compared to GLP1-RAs.

OBJECTIVE:To examine the associations between patient out-of-pocket (OOP) costs and nonadherence to glucagon-like peptide 1 receptor agonists (GLP-1a), and the consequent impact on adverse outcomes, including hospitalizations and emergency department (ED) visits. RESEARCH DESIGN AND METHODS/METHODS:This retrospective cohort study used MarketScan Commercial data (2016-2021). The cohort included nonpregnant adults aged 18-64 years with type 2 diabetes who initiated GLP-1a therapy. Participants were continuously enrolled in the same private insurance plan for 6 months before the prescription date and 1 year thereafter. Exposures included average first 30-day OOP costs for GLP-1a, categorized into quartiles (lowest [Q1] to highest [Q4]). Primary outcomes were the annual proportion of days covered (PDC) for GLP-1a and nonadherence, defined as PDC <0.8. Secondary outcomes included diabetes-related and all-cause hospitalizations and ED visits 1 year post-GLP-1a initiation. RESULTS:Among 61,907 adults who initiated GLP-1a, higher 30-day OOP costs were associated with decreased adherence. Patients in the highest OOP cost quartile (Q4: $80-$3,375) had significantly higher odds of nonadherence (odds ratio [OR]1.25; 95% CI 1.19-1.31) compared with those in Q1 ($0-$21). Nonadherence was linked to increased incidence rates of diabetes-related hospitalizations or ED visits (incidence rate ratio [IRR] 1.86; 95% CI 1.43-2.42), cumulative length of hospitalization (IRR 1.56; 95% CI 1.41-1.72), all-cause ED visits (IRR 1.38; 95% CI 1.32-1.45), and increased ED-related costs ($69.81, 95% CI $53.54-$86.08). CONCLUSIONS:Higher OOP costs for GLP-1a were associated with reduced adherence and increased rates of adverse outcomes among type 2 diabetes patients.

OBJECTIVE:To characterize the extent of private equity (PE) investment affecting surgical care. BACKGROUND:Over the last decade, investor-backed, for-profit PE groups have invested in health care at an unprecedented rate, but the breadth of these investments affecting surgical practice remains largely unknown. METHODS:Four nationally representative databases were used to identify all merger/acquisitions involving surgical practices between 2015 and 2019, determine PE investment in those transactions, and link the acquisitions with a physician data set. RESULTS:A total of 1542 unique transactions were identified, of which 539 were financed by PE. Fifty-eight transactions were then classified into their respective categories within surgical care: digestive disease, orthopedics, urology, vascular surgery, and plastic/cosmetic surgery. These transactions accounted for 199 practice sites and 1405 physicians, averaging 24.2 physicians per transaction. Acquisition activity peaked in 2017, with a total of 63 practices involved. Digestive disease, urology, and orthopedic surgery accounted for the most activity. General surgeons were involved in a small share of the digestive disease practice acquisitions. Three "surgery-adjacent" categories were also identified: anesthesiology, ambulatory surgery centers, and surgical staffing firms. Among these, anesthesia was the largest category in terms of practices (194) and physicians (2660) involved in transactions across the study period. Medical Service Organizations were a key mechanism through which PE firms invested in surgical care. CONCLUSIONS:PE has engaged in substantial investment within surgical specialties, creating increased practice consolidation. These investments affect all levels of medical care and have notable implications for patients, practitioners, and policymakers.

INTRODUCTION/UNASSIGNED:Tracheostomy involves complex, resource-intensive care. Yet, few data about the procedure-related cost burden for patients and their families are available. Passage of the No Surprises Act has been associated with changes in patient billing for certain healthcare services, but data on tracheostomy have not been investigated. METHODS/UNASSIGNED:We conducted a retrospective cohort study using the Merative MarketScan database for commercially insured patients aged 18-64 who underwent tracheostomy from 2014-2022 in the United States. We estimated out-of-pocket (OOP) costs (sum of deductibles, copay, and coinsurance) and potential surprise bills (an out-of-network claim where both the primary surgeon and facility were in-network) within 30 days of surgery. Relationships between OOP costs, potential surprise bills, and patient- and system-level exposures were analyzed. RESULTS/UNASSIGNED:Among 8,950 patients who underwent tracheostomy, the mean (SD) age was 49.3 (12.7) years; most patients were male (61.8%) and had fee-for-service based insurance (79.8%). The mean (SD) total OOP cost attributable to tracheostomy was $1,423 (2,029), and coinsurance accounted for 62.8% of these costs. Potential surprise bills were present in 9.1% of surgical episodes overall and were associated with higher OOP costs (mean (SD) $1909 (2433) vs. $1444 (2021); p<0.001)). High-deductible health plans and fee-for-service based plans were the largest predictors for overall OOP costs (cost ratio 2.66 and 1.84, respectively; p<0.001 for both) and potential surprise bills (odds ratio 2.07 and 2.78, respectively; p<0.001 for both). The incidence of potential surprise bills diminished over the course of the study period. CONCLUSIONS/UNASSIGNED:Patients undergoing tracheostomy have significant exposure to OOP costs, predominantly attributable to coinsurance, with potential surprise bills representing an additional source of cost exposure. These findings highlight the need for financial counseling and policy reform to reduce patient cost burdens.

INTRODUCTION/BACKGROUND:In response to intense market pressures, many hospitals have consolidated into systems. However, evidence suggests that consolidation has not led to the improvements in clinical quality promised by proponents of mergers. The challenges to delivering care within expanding health systems and the opportunities posed to surgical leaders remains largely unexplored. METHODS:Semistructured interviews with 30 surgical leaders at teaching hospitals affiliated with health systems from August-December 2019. Interviews were transcribed verbatim and coded in an iterative process using MaxQDA software. Attitudes and strategies toward redesigning health care delivery across expanding systems were analyzed using thematic analysis. RESULTS:Leaders reported challenges to redesigning care delivery across the system ranging from resource constraints (e.g. hospital beds and operating rooms) to evolving market demands (e.g., patient preferences to receive care close to home). However, participants also highlighted that system expansion provided multiple opportunities to increase access (e.g. decant low-complexity care to affiliated centers) and improve quality of care (e.g. standardize best practices) for diverse populations including the potential to leverage their health system to expand access and improve quality. CONCLUSIONS:Though evidence suggests that hospital consolidation has not led to redesigned care delivery or improved clinical quality at a national level, leaders are pursuing varying sets of strategies aimed at leveraging system expansion in order to improve access and quality of care.