Increasing the Value of Healthcare: Improving Mortality While Reducing Cost in Bariatric Surgery



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.


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.


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.


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.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3


  1. 1.

    May AL, Freedman D, Sherry B, et al. Centers for disease control and prevention (CDC). Obesity—United States, 1999–2010. MMWR Surveill Summ. 2013;62(3):120–8.

    PubMed  Google Scholar 

  2. 2.

    Nguyen DM, El-Serag HB. The epidemiology of obesity. Gastroenterol Clin N Am. 2010;39(1):1–7. doi:10.1016/j.gtc.2009.12.014.

    CAS  Article  Google Scholar 

  3. 3.

    Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends in obesity among US adults, 1999–2008. JAMA. 2010;303(3):235–41. doi:10.1001/jama.2009.2014.

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Peterli R, Borbély Y, Kern B, et al. Early results of the Swiss multicentre bypass or sleeve study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. Ann Surg. 2013;258(5):690–4.

    PubMed Central  Article  PubMed  Google Scholar 

  5. 5.

    Buchwald H. Consensus conference panel. Consensus conference statement bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers. Surg Obes Relat Dis. 2005;1(3):371–81.

    Article  PubMed  Google Scholar 

  6. 6.

    “United States—National Expenditure on Health.” World Health Organization, Mar. 2014. Last accessed: 5 Mar 2014.

  7. 7.

    “Inflation Calculator: Bureau of Labor Statistics.” U.S. Bureau of Labor Statistics. U.S. Bureau of Labor Statistics, Available at: Last accessed: 03 Mar 2014.

  8. 8.

    Agency for Healthcare Research and Quality (2007–2009) HCUP Nationwide Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality, Rockville, MD. Available at: Accessed 24 Jul 2014.

  9. 9.

    Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45:613–9.

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    HCUP cost-to-charge ratio files (CCR). Healthcare Cost and Utilization Project (HCUP). 2001–2009. U.S. Agency for Healthcare Research and Quality, Rockville, MD. Available at: Accessed 20 Jul 2014.

  11. 11.

    Pfuntner, A (Truven Health Analytics), Wier LM (Truven Health Analytics), Steiner C (AHRQ). Costs for hospital stays in the United States, 2010. HCUP Statistical Brief #146. January 2013. Agency for Healthcare Research and Quality, Rockville, MD. Available at Accessed 24 Jul 2014.

  12. 12.

    Stranges E (Thomson Reuters), Russo CA (Thomson Reuters), Friedman B (AHRQ). Procedures with the most rapidly increasing hospital costs, 2004–2007. HCUP Statistical Brief #82: procedures with the most rapidly increasing hospital costs 2004–2007. December 2009. Agency for Healthcare Research and Quality, Rockville, MD. Available at: Accessed 20 Jul 2014.

  13. 13.

    Torio CM (AHRQ), Andrews RM (AHRQ). National inpatient hospital costs: the most expensive conditions by payer, 2011. HCUP Statistical Brief #160. August 2013. Agency for Healthcare Research and Quality, Rockville, MD. Available at: Accessed: 20 Jul 2014.

  14. 14.

    Pfuntner A (Thomson Reuters), Levit K (Thomson Reuters), Elixhauser A (Agency for Healthcare Research and Quality). Components of cost increases for inpatient hospital procedures, 1997–2009. HCUP Statistical Brief #133. May 2012. Agency for Healthcare Research and Quality, Rockville, MD. Available at: Accessed 20 Jul 2014.

  15. 15.

    Porter ME. What is value in health care? N Engl J Med. 2010;363:2477–81.

    CAS  Article  PubMed  Google Scholar 

  16. 16.

    Morton JM, Winegar D, Blackstone R, et al. Is ambulatory laparoscopic Roux-en-Y gastric bypass associated with higher adverse events? Ann Surg. 2014;259(2):286–92.

    Article  PubMed  Google Scholar 

  17. 17.

    Zhao Y (Social and Scientific Systems, Inc.), Encinosa W (AHRQ). Bariatric surgery utilization and outcomes in 1998 and 2004. Statistical Brief #23. January 2007. Agency for Healthcare Research and Quality, Rockville, Md. Accessed 24 Jul 2014.

  18. 18.

    Trus TL, Pope GD, Finlayson SR. National trends in utilization and outcomes of bariatric surgery. Surg Endosc. 2005;19(5):616–20.

    CAS  Article  PubMed  Google Scholar 

  19. 19.

    Estimate of bariatric surgery numbers [ASMBS web site]. March 2014. Available at: Accessed: 24 Jul 2014.

  20. 20.

    Klabunde CN, Warren JL, Legler JM. Assessing comorbidity using claims data: an overview. Med Care. 2002;40(8):IV-26–35.

    Google Scholar 

  21. 21.

    Lüchtenborg M, Riaz SP, Coupland VH, et al. High procedure volume is strongly associated with improved survival after lung cancer surgery. J Clin Oncol. 2013;31(25):3141–6.

    Article  PubMed  Google Scholar 

  22. 22.

    Patel VI, Mukhopadhyay S, Ergul E, et al. Impact of hospital volume and type on outcomes of open and endovascular repair of descending thoracic aneurysms in the United States medicare population. J Vasc Surg. 2013;58(2):346–54.

    Article  PubMed  Google Scholar 

  23. 23.

    Long DM, Gordon T, Bowman H, et al. Outcome and cost of craniotomy performed to treat tumors in regional academic referral centers. Neurosurgery. 2003;52(5):1056–63. discussion 1063–5.

  24. 24.

    Rosenthal E. Medicine’s top earners are not the MD’s [New York Times web site]. May 17, 2014. Available at: Accessed 24 Jul 2014.

  25. 25.

    Creswell J, Fink S, Cohen S. Hospital charges surge for common ailments, data shows [NY Times web site.] June 2, 2014. Available at: Accessed: 24 Jul 2014.

  26. 26.

    Lin KH, Leung WS, Wang CP, et al. Cost analysis of management in acute appendicitis with CT scanning under a hospital global budgeting scheme. Emerg Med J. 2008;25(3):149–52. doi:10.1136/emj.2007.050963.

    Article  PubMed  Google Scholar 

  27. 27.

    Pritchett CV, Levinsky NC, Ha YP, et al. Management of acute appendicitis: the impact of CT scanning on the bottom line. J Am Coll Surg. 2010;210(5):699–705. doi:10.1016/j.jamcollsurg.2009.12.043.

    Article  PubMed  Google Scholar 

  28. 28.

    Shaligram A, Pallati P, Simorov A, et al. Do you need a computed tomography scan to evaluate suspected appendicitis in young men: an administrative database review. Am J Surg. 2012;204(6):1025–30. doi:10.1016/j.amjsurg.2012.05.024. discussion 1030.

  29. 29.

    Beinfeld MT, Gazelle GS. Diagnostic imaging costs: are they driving up the costs of hospital care? Radiology. 2005;235(3):934–9.

    Article  PubMed  Google Scholar 

  30. 30.

    Etzioni DA, Wasif N, Dueck AC, et al. Association of hospital participation in a surgical outcomes monitoring program with inpatient complications and mortality. JAMA. 2015;313(5):505–11.

    CAS  Article  PubMed  Google Scholar 

  31. 31.

    Telem DA, Talamini M, Laurie Shroyer A, et al. Long-term mortality rates (>8-year) improve as compared to the general and obese population following bariatric surgery. Surg Endosc. 2015;29(3):529–36.

    Article  PubMed  Google Scholar 

Download references

Conflict of Interest

Drs. Ryan C. Broderick, Hans F. Fuchs, Cristina R. Harnsberger, David C. Chang, Garth R. Jacobsen, Bryan J. Sandler, and Santiago Horgan have no conflicts of interest or financial ties to declare.

Author information



Corresponding author

Correspondence to Ryan C. Broderick.

Additional information

Ryan C. Broderick and Hans F. Fuchs contributed equally to this work.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Broderick, R.C., Fuchs, H.F., Harnsberger, C.R. et al. Increasing the Value of Healthcare: Improving Mortality While Reducing Cost in Bariatric Surgery. OBES SURG 25, 2231–2238 (2015).

Download citation


  • Bariatric surgery
  • Outcomes
  • Value
  • Population database