Rebecca O'Brien, MD; Eric Johnson, MS; Sebastien Haneuse, PhD; Karen J. Coleman, PhD; Patrick J. O'Connor, MD, MA, MPH; David P. Fisher, MD; Stephen Sidney, MD, MPH; Andy Bogart, MS; Mary Kay Theis, MA, MS; Jane Anau, BS; Emily B. Schroeder, MD, PhD; David Arterburn, MD, MPH
Disclaimer: Drs. O'Brien and Arterburn take full responsibility for the contents of the article.
Acknowledgment: The authors thank Mike Sorel, Terese Defor, and Jessica Liu for their efforts in creating the study database.
Financial Support: By award 5R01DK092317-04 from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Dr. Schroeder was supported by award 1K23DK099237-01 from the National Institutes of Health, and Dr. O'Connor was supported in part by award P30DK092928 from the National Institutes of Health.
Disclosures: Dr. O' Brien reports grants from the NIDDK during the conduct of the study. Mr. Johnson reports grants from the National Institutes of Health during the conduct of the study. Dr. Sidney reports grants from the NIDDK during the conduct of the study and grants from the National Heart, Lung, and Blood Institute; National Institute of Neurological Disorders and Stroke; and National Institute on Aging outside the submitted work. Mr. Bogart reports grants from the National Institutes of Health during the conduct of the study. Ms. Anau reports grants from the NIDDK during the conduct of the study. Dr. Schroeder reports grants from the NIDDK during the conduct of the study. Dr. Arterburn reports grants from Patient-Centered Outcomes Research Institute during the conduct of the study, grants from the National Institutes of Health outside the submitted work, and personal fees and nonfinancial support from the Michigan Bariatric Surgery Collaborative outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-2383.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: See the Appendix. Statistical code: Available from Dr. Arterburn (e-mail, email@example.com). Data set: Our data access committee will review any requests for access to data and make a determination. Please contact Dr. Arterburn for details on making a request (e-mail, firstname.lastname@example.org).
Corresponding Author: David Arterburn, MD, MPH, Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101; e-mail, email@example.com.
Current Author Addresses: Dr. O'Brien: Kaiser Permanente Medical Center, 39400 Paseo Padre Parkway, Fremont, CA 94538.
Mr. Johnson, Ms. Theis, Ms. Anau, and Dr. Arterburn: Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101.
Dr. Haneuse: Harvard School of Public Health, Department of Biostatistics, 655 Huntington Avenue, Building II, Boston, MA 02115.
Dr. Coleman: Kaiser Permanente Southern California, 100 South Los Robles Avenue, Pasadena, CA 91101.
Dr. O'Connor: HealthPartners Research Foundation, 8170 33rd Avenue South, MS23301A, Minneapolis, MN 55425.
Dr. Fisher: The Permanente Medical Group, 1950 Franklin Avenue, Oakland, CA 94612.
Dr. Sidney: Kaiser Permanente Division of Research, 2000 Broadway, Oakland, PA 94612.
Mr. Bogart: RAND Corporation, 1776 Main Street, Santa Monica, CA 90407.
Dr. Schroeder: Kaiser Permanente Colorado, 2550 South Parker Road, Suite 200, Aurora, CO 80014.
Author Contributions: Conception and design: S. Haneuse, K.J. Coleman, P.J. O'Connor, E.B. Schroeder, D. Arterburn.
Analysis and interpretation of the data: R. O'Brien, E. Johnson, S. Haneuse, P.J. O'Connor, D.P. Fisher, S. Sidney, A. Bogart, J. Anau, E.B. Schroeder, D. Arterburn.
Drafting of the article: R. O'Brien, S. Haneuse, K.J. Coleman, A. Bogart, E.B. Schroeder, D. Arterburn.
Critical revision of the article for important intellectual content: R. O'Brien, E. Johnson, S. Haneuse, K.J. Coleman, P.J. O'Connor, D.P. Fisher, S. Sidney, E.B. Schroeder, D. Arterburn.
Final approval of the article: R. O'Brien, E. Johnson, S. Haneuse, K.J. Coleman, P.J. O'Connor, D.P. Fisher, S. Sidney, A. Bogart, M.K. Theis, J. Anau, E.B. Schroeder, D. Arterburn.
Provision of study materials or patients: P.J. O'Connor, S. Sidney.
Statistical expertise: E. Johnson, S. Haneuse, A. Bogart.
Obtaining of funding: S. Haneuse, K.J. Coleman, D. Arterburn.
Administrative, technical, or logistic support: S. Sidney, J. Anau, D. Arterburn.
Collection and assembly of data: K.J. Coleman, S. Sidney, M.K. Theis, J. Anau, D. Arterburn.
Bariatric surgery improves glycemic control in patients with type 2 diabetes mellitus (T2DM), but less is known about microvascular outcomes.
To investigate the relationship between bariatric surgery and incident microvascular complications of T2DM.
Retrospective matched cohort study from 2005 to 2011 with follow-up through September 2015.
4 integrated health systems in the United States.
Patients aged 19 to 79 years with T2DM who had bariatric surgery (n = 4024) were matched on age, sex, body mass index, hemoglobin A1c level, insulin use, diabetes duration, and intensity of health care use up to 3 nonsurgical participants (n = 11 059).
Bariatric procedures (76% gastric bypass, 17% sleeve gastrectomy, and 7% adjustable gastric banding) compared with usual care.
Adjusted Cox regression analysis investigated time to incident microvascular disease, defined as first occurrence of diabetic retinopathy, neuropathy, or nephropathy.
Median follow-up was 4.3 years for both surgical and nonsurgical patients. Bariatric surgery was associated with significantly lower risk for incident microvascular disease at 5 years (16.9% for surgical vs. 34.7% for nonsurgical patients; adjusted hazard ratio [HR], 0.41 [95% CI, 0.34 to 0.48]). Bariatric surgery was associated with lower cumulative incidence at 5 years of diabetic neuropathy (7.2% for surgical vs. 21.4% for nonsurgical patients; HR, 0.37 [CI, 0.30 to 0.47]), nephropathy (4.9% for surgical vs. 10.0% for nonsurgical patients; HR, 0.41 [CI, 0.29 to 0.58]), and retinopathy (7.2% for surgical vs. 11.2% for nonsurgical patients; HR, 0.55 [CI, 0.42 to 0.73]).
Electronic health record databases could misclassify microvascular disease status for some patients.
In this large, multicenter study of adults with T2DM, bariatric surgery was associated with lower overall incidence of microvascular disease (including lower risk for neuropathy, nephropathy, and retinopathy) than usual care.
National Institute of Diabetes and Digestive and Kidney Diseases.
O'Brien R, Johnson E, Haneuse S, et al. Microvascular Outcomes in Patients With Diabetes After Bariatric Surgery Versus Usual Care: A Matched Cohort Study. Ann Intern Med. [Epub ahead of print 7 August 2018]169:300–310. doi: 10.7326/M17-2383
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Published: Ann Intern Med. 2018;169(5):300-310.
Published at www.annals.org on 7 August 2018
Cardiology, Coronary Risk Factors, Diabetes, Diabetic Nephropathy, Endocrine and Metabolism.
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