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OBES SURG (2018) 28:1321–1328


Association Between the Publication of Clinical

Evidence and the Use of Bariatric Surgery
David D. Kim 1 & David E. Arterburn 2 & Sean D. Sullivan 3 & Anirban Basu 3,4

Published online: 30 October 2017

# Springer Science+Business Media, LLC 2017

Abstract were applied, 35 papers were selected. We selected the fourth

Purpose The purpose of this study was to assess whether quarter in 2004 as the exposure based on publication for the
publication of clinical evidence was associated with increased two studies with the largest number of citations. Compared to
utilization of bariatric surgery. the projected secular trend, the publication of those two major
Methods We systematically searched the literature (1994 to articles was associated with 50 additional cases of bariatric
2008) to identify studies on bariatric surgery. We sorted the surgery performed per 100,000 eligible individuals per quar-
evidence by publication date and citation frequency. We ter. In our secondary analyses, higher quality evidence (e.g.,
linked the published evidence to data from the Kaiser RCTs) and more highly cited evidence were each associated
Permanente Washington (KPWA) on 1421 bariatric surgery with a greater probability of receiving bariatric surgery.
cases and 45,665 medically managed patients with severe Conclusions For patient members of the KPWA with severe
obesity to assess the association between evidence and use obesity, publication of clinical evidence was associated with
of bariatric surgery. We used an interrupted time series analy- increased use of bariatric surgery. This finding suggests that
sis with a control group to estimate the association. In second- publication of higher quality positive clinical evidence may
ary analyses, we examined the association with accumulating influence utilization.
major clinical evidence, the type of evidence, and stratification
by influential tiers. Keywords Publication . Evidence . Uptake . Utilization .
Results A total of 9913 papers were identified and the top 100 Bariatric surgery
cited papers were initially selected. After inclusion criteria

Electronic supplementary material The online version of this article Introduction

( contains supplementary
material, which is available to authorized users.
Since David Eddy’s seminal contribution that advised setting
* David D. Kim national guidelines explicitly based on clinical evidence rather than subjective clinical judgment and consensus [1], the field
of evidence-based medicine (EBM) has burgeoned. However,
one of the most persistent challenges in EBM is how slowly
Center for the Evaluation of Value and Risk in Health, Institute for
Clinical Research and Health Policy Studies, Tufts Medical Center,
clinical evidence appears to translate into changes in practice
800 Washington St. Box 63, Boston, MA 02111, USA [2].
Kaiser Permanente Washington Health Research Institute,
Several studies have attempted to understand the impact of
Seattle, WA, USA clinical evidence on changes in practice. For example, Lamas
Pharmaceutical Outcomes Research and Policy Program,
et al. found a significant increase in the use of aspirin for
Department of Pharmacy, University of Washington, Seattle, WA, patients who experienced myocardial infarction after the pub-
USA lication of three clinical trials [3]. Also, clinical alerts dissem-
Department of Health Services and Economics, University of inated from a carotid endarterectomy trial were found to be
Washington, Seattle, WA, USA associated with prompt and substantial changes in practice [4].
1322 OBES SURG (2018) 28:1321–1328

Publication of a clinical trial on a new drug (ramipril) in pa- influence on utilization. To account for secular utilization
tients at high risk of cardiovascular events led to changes in trends, we used an interrupted time series (ITS) analysis to
prescribing patterns [5]. These findings suggest that clinical compare the actual observed utilization of bariatric surgery
evidence can influence practice patterns; however, these stud- to the projected utilization in the absence of publication of a
ies were simple pre-post analyses that compared outcomes at given study. For the secondary analyses, we extended the
only two specific time points (i.e., one before and one after) scope of this primary analysis by examining whether some
and were limited to a particular source of clinical evidence— characteristics of clinical evidence (e.g., an accumulation ef-
the randomized controlled trial. In this study, we examined not fect, type of evidence, and stratification by influential tiers)
only the association between clinical evidence and utilization were also associated with utilization of bariatric surgery.
over time but also how different types of clinical evidence
were associated with changes in clinical practice using the Data Source and Setting
example of bariatric surgery.
Bariatric surgery is one example of a rapidly advancing We analyzed an electronic health record (EHR) database pro-
medical technology where understanding how clinical evi- vided by the Kaiser Permanente Washington (KPWA) located
dence influences practice patterns is important. First of all, in Seattle, WA. The KPWA is an integrated health care system
clinical evidence on several types of bariatric surgery shows that provides the delivery of medical care as well as insurance
many overall benefits. Systematic reviews, RCTs, and obser- coverage for approximated 600,000 residents in Washington
vational studies have concluded that several types of bariatric state. The KPWA provided a de-identified longitudinal EHR
surgery are associated with a significant and sustained weight database from 1994 to 2008 that included information on pa-
loss [6–9], decreased long-term mortality [10–12], a signifi- tient demographic characteristics (e.g., age and gender), diag-
cant improvement in the obesity-related comorbidities, espe- nostic and procedure information, and health information, in-
cially type 2 diabetes [8, 9, 13–16], and improved quality of cluding measured height and weight, which is critical for de-
life [17, 18] among the recipients. Some adverse events, in- fining obesity and is often missing in large claim datasets and
cluding gastrointestinal complications, nutritional and meta- was available from 2003 to 2008. Self-reported height and
bolic abnormalities, reflux, and vomiting, were associated weight were also available on women age 40 years and older
with bariatric surgery, but were relatively uncommon who completed surveys related to breast cancer risk factors
[19–21]. Despite these clinical benefits, less than 1% of the from 1994 to 2002.
potentially eligible patients choose to undergo a bariatric pro- We identified a sample of the KPWA members that were
cedure [22, 23]. It is unclear whether the publication of addi- clinically eligible to receive bariatric surgery at any time be-
tional evidence could potentially lead to greater use of bariat- tween 1994 and 2008 based on the National Institute of Health
ric procedures in the eligible population. Bariatric Surgery guideline [24] (i.e., patients with body mass
Publication of clinical evidence is a potential gateway to index (BMI) 35–40 and at least one obesity-related disease
changes in clinical practice that are mediated through changes (ORD) or those who had a BMI ≥ 40). For the purpose of this
in insurance coverage, clinical practice guidelines, and orga- study, we defined ORDs as conditions as the following: hy-
nizational structures. The primary objective of this study was pertension, dyslipidemia, type 2 diabetes mellitus, osteoarthri-
to examine whether the publication of major clinical evidence tis, obstructive sleep apnea, depression, coronary heart dis-
is associated with increasing utilization of bariatric surgery. ease, and congestive heart failure.
We do not look at the potential channels through which such Using the International Classification of Diseases, Ninth
an association may be mediated, but rather examine the over- Revision, Clinical Modification (ICD-9-CM), we also identi-
all relationship between clinical evidence and practice in the fied a subset of the population with type 2 diabetes mellitus
context of bariatric surgery. (T2DM). As in prior studies, members who underwent bariat-
ric surgery during the study period were identified by ICD-9
and CPT-4 codes [25, 26]. This study was reviewed by
Methods the KPWA Human Subjects Review Committee and deemed
exempt because of the use of de-identified secondary data.
Study Design
We approached this scientific question with two sequential
analyses to examine changes in utilization of bariatric surgery Citation Analysis
after the publication of major clinical evidence. First, we con-
ducted a citation analysis as a proxy for major clinical evi- We conducted a systematic literature search to identify major
dence, to quantify each publication’s potential impact on the clinical evidence related to bariatric surgery. We conducted
field, and to use their date of publication to examine their our search on the Web of Science—a citation indexing service
OBES SURG (2018) 28:1321–1328 1323

provided by Thomson Reuters that provides a comprehensive no-diabetes cohort (i.e., the two top-ranked articles would
citation search—using the following keywords: (Bbariatric have no effect). Then, we estimated differences between ob-
surgery^ OR Bgastric bypass^ OR Bgastric banding^ OR served utilization and the projected utilization among the dia-
Bs l e e v e g a s t r e c t o m y ^ O R Bo b e s i t y s u rg e r y ^ O R betes cohort, attributing the difference to the impact of the
Bgastroplasty^ OR Bbiliopancreatic diversion^ OR clinical evidence on the additional utilization of bariatric sur-
Bjejunoileal bypass^). We limited our search to articles pub- gery. Using the post-period trends of the no-diabetes cohort as
lished up to 2008 to align with the available patient-level data. a counterfactual for the diabetes cohort produced conservative
To identify major clinical evidence in bariatric surgery, we estimates for the association of evidence exposure and bariat-
applied the following inclusion criteria: (1) must describe pre- ric surgery uptake.
viously unreported data on the clinical effectiveness or safety For statistical modeling, we initially modeled the primary
of bariatric surgery, (2) must be ranked among the top 100 outcome using a binary indicator at the patient level on wheth-
cited articles in terms of total number of citations from 1994 to er an eligible patient received bariatric surgery or not in a
2008, and (3) must involve human subjects only. Among the specific quarter, and then expressed the outcome as the num-
articles that met the inclusion criteria, we calculated the total ber of bariatric cases per 100,000 patients with severe obesity
number of citations per quarter since the article’s publication per quarter in the KPWA population. We implemented a linear
to rank the impact of each article on the field. To address our generalized estimating equation regression model to account
concern that identifying the top-cited articles based on the for the within-subject correlation. Also, we included quadratic
total number of citations might underestimate the influence time variables in the model to capture non-linear time trends.
for more recently published articles, we also explored the im- Considering uncertainty around the dissemination of clinical
pact of different metrics, such as total citations in the first evidence and the timing of clinical decision-making for bar-
5 years of the publication or citation per quarter since its iatric surgery (which is generally 3–6 months prior to the
publication. actual date of surgery), we excluded all data 6 months before
We found one particular time period (i.e., the fourth quarter and after the primary exposure period of interest (4Q 2004).
of 2004) during which the two most frequently cited articles We provide a detailed description of the model in the Online
were published. The two top-ranked articles were (1) a sys- Appendix.
tematic review and meta-analysis that examined weight loss
and changes in diabetes, hyperlipidemia, hypertension, and Secondary Analysis
obstructive sleep apnea [8] and (2) a prospective matched-
controlled cohort study (aka the Swedish Obese Subjects We conducted secondary analyses to examine whether some
Study) that reported the long-term improvement (> 10 years) specific characteristics of clinical evidence published between
in weight, hypertension, lipid control, and diabetes after un- 1994 and 2008 were associated with increasing utilization of
dergoing bariatric surgery [27]. Therefore, we selected the bariatric surgery among all eligible population in the KPWA.
fourth quarter in 2004 as the primary exposure period of in- Here instead of defining one specific exposure period, we
terest based on the timing of publication for these two studies. assumed that evidence accumulated over time in a continuous
manner using all of the highest cited articles identified from
Interrupted Time Series Analysis the citation analysis. Also, given uncertainty around the
timing of dissemination of clinical evidence and the timing
We examined how the utilization of bariatric surgery changed of decision-making for bariatric surgery described earlier, we
before and after the exposure period. To account for secular evaluated the impact of following characteristics on changes
utilization trends in bariatric surgery, we grouped the eligible in subsequent bariatric utilization at 6 months post publica-
cohort into a Bdiabetes cohort^ that would have likely benefit- tion: (1) one additional major article published conditional on
ed most from the publication of these studies because they the number of existing major articles at the time of publication
provided favorable evidence in this specific subgroup of pa- (i.e., an accumulation effect), (2) types of clinical evidence
tients with diabetes and a Bno-diabetes cohort^ (i.e., patients published: randomized-controlled trial (RCT), systematic re-
with no diabetes). A similar trend between both groups in the view and meta-analysis, comparative observational study
pre-exposure period (i.e., before the 4Q 2004) would suggest (e.g., prospective matched case-control study), or observation-
that the differential changes in the post-period in the diabetes al study without comparators (e.g., case study or cohort
cohort may be associated with the publication of the clinical study), and (3) stratification by three tiers, defined by the
evidence. citations per quarter, to examine whether more influential ar-
To estimate how much additional bariatric utilization in the ticles were associated with higher increase in utilization of
diabetes cohort was associated with the publication of clinical bariatric surgery. We defined articles with more than ten cita-
evidence, we first projected a utilization trend as if the utiliza- tions per quarter as Tier 1, five to ten citations per quarter as
tion in the diabetes cohort would have been similar to that of a Tier 2, and less than five citations per quarter as Tier 3.
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For statistical modeling, we implemented a fixed-effect females, people with any ORDs, and a higher proportion with
multivariate regression model, adjusting for seasonality, age, insurance coverage for bariatric surgery. The bariatric cohort
individual-level fixed effect, and the main predictor for each also had higher mean BMI than the non-bariatric cohort.
model. A fixed-effect multivariate regression model helps to
account for unobserved individual-level characteristics in the
databases (e.g., race and income level) and estimates changes Citation Analysis
in the probability of receiving bariatric surgery within an in-
dividual due to changes in characteristics of clinical evidence. Figure 1 provides a flow diagram that summarizes the results
We validated the use of the fixed-effect model through the of the literature search. We initially found 9913 articles from
Hausman test. The details on the secondary analysis are pro- 1994 to 2008 and eventually selected 35 publications for in-
vided in the Online Appendix. All of these analyses were clusion in our study based on our criteria above. Among those
conducted in STATA 12 (StataCorp. 2011, Stata Statistical 35 major articles, the average number of citations was 548. We
Software: Release 12. College Station, TX: StataCorp LP). also estimated citation per quarter since each article’s publica-
tion to account for the effect of time since its publication, and
the average number of citations per quarter was 12.3. Finally,
the sensitivity analysis using different citation count metrics
Results found that the results were consistent. A list of the 35 major
articles is provided in the Online Appendix.
Sample Characteristics Based on the citation analysis, we determined that the
fourth quarter of 2004 was a particularly important period
The KPWA database included a bariatric cohort of 1421 pa- for the publication of highly influential articles, including a
tients who received bariatric surgery from 1994 to 2008 and a systematic review that was ranked #1 in total citations (2760)
non-bariatric cohort that contained 45,665 records of patients and #1 in average citation per quarter (61), as well as the long-
with severe obesity who did not have surgery from 1994 to term evaluation of the SOS study that was ranked #2 in total
2008. Table 1 provides the sample characteristics among pa- citations (1802) and #3 in citation per quarter (40). In terms of
tients with severe obesity included in this study. Comparing content, both studies focused on not only weight loss but also
the bariatric cohort to the non-bariatric cohort at the KPWA, on improvement and/or remission of type 2 diabetes mellitus
the bariatric cohort had a significantly higher proportion of (T2DM) and other comorbid health conditions.

Table 1 Sample characteristics

among patients with severe Bariatric cohort† Eligible, non-bariatric cohort‡ BS cohort vs.
obesity in the Kaiser Permanente (N = 1421, 3.0%) (N = 45,665, 97.0%) non-BS cohort
Washington (KPWA)
Mean SE Interquartile Mean SE Interquartile P value
range range

Female (%) 82.0% – – 72.4% – – 0.000

ORDs§ (%) 96.8% – – 91.9% – – 0.000
BS insurance 74.7% – – 56.5% – – 0.001
coverage# (%)
Age 47.6 0.277 40–55 47.8 0.058 40–56 0.515
BMI 49.9 0.250 43.9–54.5 40.4 0.025 36.4–42.6 0.000
ORD_index§ 3.35 0.045 2–5 2.49 0.008 1–4 0.000

SE standard error, BS bariatric surgery, ORDs obesity-related diseases

Bariatric surgery cohort represents a group of patients who received bariatric surgery at the KPWA from 1994 to

Eligible population for bariatric surgery is determined by the National Institute of Health Bariatric Surgery
eligibility guideline—patients with BMI 35–40 and at least one obesity-related disease (ORD) or those who have
BMI ≥ 40; please note that, for the purpose of this study, we defined ORDs as hypertension, dyslipidemia, type 2
diabetes mellitus, osteoarthritis, obstructive sleep apnea, depression, coronary heart diseases, and congestive heart
‘ORDs’ is a binary variable representing whether a patient has any ORDs or not, whereas ‘ORD_index’ is a
continuous variable expressing the number of ORDs
A bariatric surgery insurance coverage variable indicates a patient who has ever had the coverage based
on KPWA enrollment contract or being a Medicare beneficiary
OBES SURG (2018) 28:1321–1328 1325

Fig. 1 Flow diagram of the literature search for influential articles on BNot specific or Relevant^ articles represent ones that did not provide
clinical effectiveness of bariatric surgery in humans. BS bariatric surgery, empirical evidence on clinical effectiveness of bariatric surgery or briefly
RCTs randomized controlled trials. Note: Under the BRecords excluded,^ overview bariatric surgery as one of treatment options for obesity

Interrupted Time Series Analysis with an increasing probability of receiving bariatric surgery in
the overall population (0.011% (95% confidence interval
The publication of major clinical evidence in the fourth quar- 0.009–0.013) per individual per publication). Also, RCTs
ter of 2004 was associated with an increase in utilization of and systematic reviews were associated with stronger influ-
bariatric surgery by 27.6% in the diabetes cohort with diabetes ence on the change in utilization than other types of clinical
(231 observed cases vs. 181 projected cases per 100,000 in- evidence. One additional RCT was associated with a 0.03%
dividuals). Figure 2 provides a graphical representation of (0.019–0.041) greater probability of receiving bariatric sur-
changes in the pre- and post-observed uptake among the dia- gery. Also, more influential articles—that is, those in higher
betes and the no-diabetes cohort and the predicted uptake impact tiers with greater number of citations per quarter—
among the diabetes cohort in the post-period. In the pre-peri- were associated with larger changes in the probability of re-
od, there was no statistically significant difference in uptake ceiving bariatric surgery. For example, one additional publi-
across groups, whereas the rate of uptake among the diabetes cation in Tier 1 was associated with an increase in the proba-
cohort was significantly higher than that of the no-diabetes bility of receiving bariatric surgery by 0.01% (0.004–0.016).
cohort after the exposure period (Appendix B-3 for regression A Tier 2 publication provided a similar impact (0.009%
results). (0.005–0.012)) while a Tier 3 publication was not significant-
Also, we found that it takes time for clinical evidence to ly associated with the probability of receiving bariatric surgery
translate into changes in practice. As shown in Table 2, the (Table 3).
differences between the observed uptake and the predicted
uptake over time increased as the time since the exposure
period increased. By 2008, the publication of this major evi-
dence was associated with a 64.1% increase (361 observed Discussion
cases vs. 220 predicted cases per 100,000 individuals per
quarter) in the uptake of bariatric surgery among the diabetes This study reported two major findings regarding how the
cohort. publication of clinical evidence was associated with changes
in utilization of bariatric surgery in a single health care system.
First, the primary analysis found that the concurrent publica-
Secondary Analysis tion of the two top-cited articles in the field of bariatric surgery
from 1994 to 2008 was associated with a dramatic increase in
From the secondary analysis, we found that the accumulation utilization of bariatric surgery, especially for the population
of each additional major clinical publication was associated with T2DM that could potentially benefit the most from
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Fig. 2 Observed and projected uptake of bariatric surgery before and much additional uptakes may be associated with the impact of the publi-
after 4Q 2004 in the KPWA population. Note: To account for secular cation of major clinical evidence. Then, we estimated differences in uti-
utilization trends, we used an interrupted time series (ITS) analysis to lization of bariatric surgery between the observed trend and the projected
compare the actual observed utilization of bariatric surgery to the trend among the diabetes cohort in the post-period, attributing the differ-
projected utilization among the diabetes cohort. We estimated the ence to the impact of major clinical evidence on the additional utilization
projected trend in a scenario that the utilization in the diabetes cohort of bariatric surgery. In the pre-period, the utilization trends between the
would be similar to that of a no-diabetes cohort, assuming that two most diabetes cohort and the no-diabetes cohort were not significantly different
influential articles would have not provided any additional clinical evi- (Online Appendix B)
dence for the diabetes cohort. This assumption helped us to estimate how

bariatric surgery based on the clinical evidence. Also, our utilization trends and a fixed-effect model to explain the rela-
secondary analysis demonstrated that higher quality clinical tionship between characteristics of clinical evidence and utili-
evidence (e.g., RCTs) and more highly cited evidence were zation within an individual).
each associated with a greater increase in the individual prob- Recently published data of the trend in bariatric surgery in
ability of receiving bariatric surgery. Michigan agrees with our main findings, where there were
To our knowledge, this is the first study to examine the faster increases in bariatric surgery among patients with
association between major clinical evidence and utilization T2DM, compared to non-T2DM patients between 2006–
of bariatric surgery. The strength of this study includes a cita- 2007 and 2008–2009 [28]. The increased rates of utilization
tion analysis that quantitatively identifies major clinical evi- in bariatric surgery (27.6% increase or 50 additional cases per
dence and the use of rigorous statistical models (e.g., ITS 100,000 individuals per quarter) among patients with T2DM
analysis with a no-diabetes cohort to control for secular can be considered as the upper bound of how additional

Table 2 Comparisons between

observed uptake vs. projected Observed uptake† (case Projected uptake (case Additional uptake associated with
uptake of bariatric surgery among per 100,000 per quarter) per 100,000 per quarter) clinical evidence (% change)
the diabetes cohort after fourth
quarter 2004 publication of two Year 1 (2005)‡ 183 146 + 17 (+ 25.3%)
most influential studies of Year 2 (2006) 154 158 − 4 (− 2.5%)
bariatric surgery Year 3 (2007) 203 182 + 21 (+ 11.5%)
Year 4 (2008) 361 220 + 141 (+ 64.1%)
Average§(2005–2008) 231 181 + 50 (+ 27.6%)

We estimated the projected uptake in a scenario that the utilization in the diabetes cohort would be similar to that
of the no-diabetes cohort, assuming that two most influential articles would have not provided any additional
clinical evidence for the diabetes cohort. This assumption helped us to estimate how much additional uptakes may
be associated with the impact of the publication of major clinical evidence

We only estimated the uptake in the post-4Q 2004 period after the publication of the two most influential studies
of bariatric surgery
Based on a quarterly average from 2005 to 2008
OBES SURG (2018) 28:1321–1328 1327

Table 3 Secondary analyses: the impact of the accumulation of influential articles, the type of evidence, or the influential tier of articles on the uptake
of bariatric surgery

Dependent variable Changes in probability of receiving bariatric surgery within an individual

Main predictor Model 1: accumulation effect [95% CI] Model 2: type of evidence [95% CI] Model 3: tier effect [95% CI]

Intercept (constant) 0.0034631 [0.0012871–0.005639] − 0.0039553 [− 0.006769– − 0.0011416] − 0.0010668 [− 0.0034836–0.00135]

Time (quarter-year) 0.0000765 [0.0000362–0.0001168] 0.0001042 [0.0000632–0.0001452] 0.0001109 [0.0000689–0.0001529]
Age − 0.0003461 [− 0.0005045– − 0.0001878] − 0.0002705 [− 0.0004292– − 0.0001118] − 0.0003414 [− 0.0004997– − 0.000183]
No. of major studies 0.0001148 [0.0000963–0.0001333] – –
RCT – 0.0003036 [0.0001947–0.0004125] –
Meta-analysis/review – 0.0001186 [0.0000625–0.0001747] –
Comp. Obs. Study – 0.0000707 [− 0.0000112–0.0001525] –
Obs. Study – − 0.0000349 [− 0.0000832–0.0000134] –
Tier 1 – – 0.0001070 [0.0000468–0.0001673]
Tier 2 – – 0.0000906 [0.0000531–0.000128]
Tier 3 − 0.0000428 [− 0.0001062–0.0000207]

Note: The unit of these analyses was an individual, and the time frame of the analyses was 1994–2008. Age represented the age of the individual at the
specific time period and each individual faced time-specific cumulative number of the major articles as a proxy for the characteristics of clinical evidence.
Because of the subject-specific indicators (fixed-effect model) included in the model, the impact of non-time varying individual-specific covariates (e.g.,
sex) was removed. More details were provided in the Appendix C. Coefficients (bold: significant at the 0.05 level; italics: significant at the 0.1 level)
CI confidence interval, RCT randomized control trial, Comp. Obs. Study comparative observational study (e.g., matched case-control study), Obs. Study
observational study (e.g., case study)

clinical evidence could change the utilization of bariatric sur- throughout the study period to eliminate the possibility
gery, because we evaluated the pre-post impact of the two of supply-driven uptake of bariatric surgery so that we
most influential articles in the field on the changes in could focus on how clinical evidence changes clinical
utilization. practice at the individual level. These surgeons almost
The secondary analysis suggested that the higher quality of exclusively performed Roux-en-Y gastric bypass during
clinical evidence [29], the stronger the potential impact on the study period. Also, insurance coverage at the KPWA
clinical practice. Also, even among all major articles, only for bariatric surgery remained stable during the study
those articles in the top tiers were significantly associated with period between 1994 and 2008. On February 12, 2009,
changing clinical practice in this population. This may be the Centers for Medicare & Medicaid Services changed
explained by that only a few leading articles (e.g., the first its national coverage determination that T2DM is a co-
meta-analysis or a first study to report the long-term effects) morbidity for purposes of bariatric surgery [33].
may change the trajectory of clinical practice, whereas other Because our study period is prior to this major change
articles, even though still highly cited, only serve as in coverage at the national level, our findings on the
supporting evidence rather than influencing clinical practice. overall relationship between clinical evidence and the
We acknowledge that other important factors, besides pub- use of bariatric surgery were not mediated through
lication of clinical evidence, are also likely to influence the changes in insurance coverage.
utilization of bariatric surgery, including increased prevalence Notwithstanding, one of the main limitations is a general-
of population with severe obesity [30, 31]; changes in insur- izability issue of these findings to other hospitals and health
ance coverage; emerging lower risk procedures (e.g., laparo- care systems that may have different supply-side characteris-
scopic Roux-en-Y gastric bypass, adjustable gastric banding, tics (e.g., number of surgeons or number of surgical facilities
and sleeve gastrectomy); and increased shared decision- available) as well as population characteristics.
making [32]. However, many of these contextual factors could
be driven by the publication of clinical evidence as an over-
arching source for inducing behavioral and systematic chang- Conclusions
es. Our study aimed to isolate the influence of clinical evi-
dence on utilization of bariatric procedures using common For the KPWA enrollees in Washington state, the publication
denominator (i.e., per 100,000 eligible individuals) and two of major clinical evidence was associated with increasing uti-
comparison groups (i.e., a diabetic cohort and a non-diabetic lization of bariatric surgery. Also, clinical evidence with a
cohort) in a single health care system. higher quality (e.g., RCTs) or from a more highly cited article
The study population (the KPWA population) served was associated with a greater increase in the individual prob-
well for the purpose of this study because there have ability of receiving bariatric surgery. Further studies are need-
been only two bariatric surgeons in the KPWA ed to replicate and confirm these findings in other settings.
1328 OBES SURG (2018) 28:1321–1328

Compliance with Ethical Standards 15. Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus
intensive medical therapy in obese patients with diabetes. N Engl J
Conflict of Interest The authors declare that they have no conflicts of Med. 2012;366(17):1567–76.
interest. NEJMoa1200225.
16. Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabe-
tes after bariatric surgery: systematic review and meta-analysis. Am
Informed Consent Not applicable.
J Med. 2009;122(3):248–256e5.
Ethical Approval For this type of study, formal consent is not required. 17. Livingston EH, Fink AS. Quality of life: cost and future of bariatric
surgery. Arch Surg. 2003;138(4):383–8.
18. Herpertz S, Kielmann R, Wolf AM, et al. Does obesity surgery
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