OBES SURG (2018) 28:1321–1328
https://doi.org/10.1007/s11695-017-2990-1
ORIGINAL CONTRIBUTIONS
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
Purpose The purpose of this study was to assess whether
publication of clinical evidence was associated with increased
utilization of bariatric surgery.
Methods We systematically searched the literature (1994 to
2008) to identify studies on bariatric surgery. We sorted the
evidence by publication date and citation frequency. We
linked the published evidence to data from the Kaiser
Permanente Washington (KPWA) on 1421 bariatric surgery
cases and 45,665 medically managed patients with severe
obesity to assess the association between evidence and use
of bariatric surgery. We used an interrupted time series analy-
sis with a control group to estimate the association. In second-
ary analyses, we examined the association with accumulating
major clinical evidence, the type of evidence, and stratification
by influential tiers.
Results A total of 9913 papers were identified and the top 100
cited papers were initially selected. After inclusion criteria
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s11695-017-2990-1) contains supplementary
material, which is available to authorized users.
* David D. Kim
dkim3@tuftsmedicalcenter.org
1
Center for the Evaluation of Value and Risk in Health, Institute for
Clinical Research and Health Policy Studies, Tufts Medical Center,
800 Washington St. Box 63, Boston, MA 02111, USA
2
Kaiser Permanente Washington Health Research Institute,
Seattle, WA, USA
3
Pharmaceutical Outcomes Research and Policy Program,
Department of Pharmacy, University of Washington, Seattle, WA,
USA
4
Department of Health Services and Economics, University of
Washington, Seattle, WA, USA
were applied, 35 papers were selected. We selected the fourth
quarter in 2004 as the exposure based on publication for the
two studies with the largest number of citations. Compared to
the projected secular trend, the publication of those two major
articles was associated with 50 additional cases of bariatric
surgery performed per 100,000 eligible individuals per quar-
ter. In our secondary analyses, higher quality evidence (e.g.,
RCTs) and more highly cited evidence were each associated
with a greater probability of receiving bariatric surgery.
Conclusions For patient members of the KPWA with severe
obesity, publication of clinical evidence was associated with
increased use of bariatric surgery. This finding suggests that
publication of higher quality positive clinical evidence may
influence utilization.
Keywords Publication . Evidence . Uptake . Utilization .
Bariatric surgery
Introduction
Since David Eddy’s seminal contribution that advised setting
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
clinical evidence appears to translate into changes in practice
[2].
Several studies have attempted to understand the impact of
clinical evidence on changes in practice. For example, Lamas
et al. found a significant increase in the use of aspirin for
patients who experienced myocardial infarction after the pub-
lication of three clinical trials [3]. Also, clinical alerts dissem-
inated from a carotid endarterectomy trial were found to be
associated with prompt and substantial changes in practice [4].
1322
Publication of a clinical trial on a new drug (ramipril) in pa-
tients at high risk of cardiovascular events led to changes in
prescribing patterns [5]. These findings suggest that clinical
evidence can influence practice patterns; however, these stud-
ies were simple pre-post analyses that compared outcomes at
only two specific time points (i.e., one before and one after)
and were limited to a particular source of clinical evidence—
the randomized controlled trial. In this study, we examined not
only the association between clinical evidence and utilization
over time but also how different types of clinical evidence
were associated with changes in clinical practice using the
example of bariatric surgery.
Bariatric surgery is one example of a rapidly advancing
medical technology where understanding how clinical evi-
dence influences practice patterns is important. First of all,
clinical evidence on several types of bariatric surgery shows
many overall benefits. Systematic reviews, RCTs, and obser-
vational studies have concluded that several types of bariatric
surgery are associated with a significant and sustained weight
loss [6–9], decreased long-term mortality [10–12], a signifi-
cant improvement in the obesity-related comorbidities, espe-
cially type 2 diabetes [8, 9, 13–16], and improved quality of
life [17, 18] among the recipients. Some adverse events, in-
cluding gastrointestinal complications, nutritional and meta-
bolic abnormalities, reflux, and vomiting, were associated
with bariatric surgery, but were relatively uncommon
[19–21]. Despite these clinical benefits, less than 1% of the
potentially eligible patients choose to undergo a bariatric pro-
cedure [22, 23]. It is unclear whether the publication of addi-
tional evidence could potentially lead to greater use of bariat-
ric procedures in the eligible population.
Publication of clinical evidence is a potential gateway to
changes in clinical practice that are mediated through changes
in insurance coverage, clinical practice guidelines, and orga-
nizational structures. The primary objective of this study was
to examine whether the publication of major clinical evidence
is associated with increasing utilization of bariatric surgery.
We do not look at the potential channels through which such
an association may be mediated, but rather examine the over-
all relationship between clinical evidence and practice in the
context of bariatric surgery.
Methods
Study Design
We approached this scientific question with two sequential
analyses to examine changes in utilization of bariatric surgery
after the publication of major clinical evidence. First, we con-
ducted a citation analysis as a proxy for major clinical evi-
dence, to quantify each publication’s potential impact on the
field, and to use their date of publication to examine their
OBES SURG (2018) 28:1321–1328
influence on utilization. To account for secular utilization
trends, we used an interrupted time series (ITS) analysis to
compare the actual observed utilization of bariatric surgery
to the projected utilization in the absence of publication of a
given study. For the secondary analyses, we extended the
scope of this primary analysis by examining whether some
characteristics of clinical evidence (e.g., an accumulation ef-
fect, type of evidence, and stratification by influential tiers)
were also associated with utilization of bariatric surgery.
Data Source and Setting
We analyzed an electronic health record (EHR) database pro-
vided by the Kaiser Permanente Washington (KPWA) located
in Seattle, WA. The KPWA is an integrated health care system
that provides the delivery of medical care as well as insurance
coverage for approximated 600,000 residents in Washington
state. The KPWA provided a de-identified longitudinal EHR
database from 1994 to 2008 that included information on pa-
tient demographic characteristics (e.g., age and gender), diag-
nostic and procedure information, and health information, in-
cluding measured height and weight, which is critical for de-
fining obesity and is often missing in large claim datasets and
was available from 2003 to 2008. Self-reported height and
weight were also available on women age 40 years and older
who completed surveys related to breast cancer risk factors
from 1994 to 2002.
We identified a sample of the KPWA members that were
clinically eligible to receive bariatric surgery at any time be-
tween 1994 and 2008 based on the National Institute of Health
Bariatric Surgery guideline [24] (i.e., patients with body mass
index (BMI) 35–40 and at least one obesity-related disease
(ORD) or those who had a BMI ≥ 40). For the purpose of this
study, we defined ORDs as conditions as the following: hy-
pertension, dyslipidemia, type 2 diabetes mellitus, osteoarthri-
tis, obstructive sleep apnea, depression, coronary heart dis-
ease, and congestive heart failure.
Using the International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM), we also identi-
fied a subset of the population with type 2 diabetes mellitus
(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
the KPWA Human Subjects Review Committee and deemed
exempt because of the use of de-identified secondary data.
Analyses
Citation Analysis
We conducted a systematic literature search to identify major
clinical evidence related to bariatric surgery. We conducted
our search on the Web of Science—a citation indexing service
OBES SURG (2018) 28:1321–1328
provided by Thomson Reuters that provides a comprehensive
citation search—using the following keywords: (Bbariatric
surgery^ OR Bgastric bypass^ OR Bgastric banding^ OR
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
Bgastroplasty^ OR Bbiliopancreatic diversion^ OR
Bjejunoileal bypass^). We limited our search to articles pub-
lished up to 2008 to align with the available patient-level data.
To identify major clinical evidence in bariatric surgery, we
applied the following inclusion criteria: (1) must describe pre-
viously unreported data on the clinical effectiveness or safety
of bariatric surgery, (2) must be ranked among the top 100
cited articles in terms of total number of citations from 1994 to
2008, and (3) must involve human subjects only. Among the
articles that met the inclusion criteria, we calculated the total
number of citations per quarter since the article’s publication
to rank the impact of each article on the field. To address our
concern that identifying the top-cited articles based on the
total number of citations might underestimate the influence
for more recently published articles, we also explored the im-
pact of different metrics, such as total citations in the first
5 years of the publication or citation per quarter since its
publication.
We found one particular time period (i.e., the fourth quarter
of 2004) during which the two most frequently cited articles
were published. The two top-ranked articles were (1) a sys-
tematic review and meta-analysis that examined weight loss
and changes in diabetes, hyperlipidemia, hypertension, and
obstructive sleep apnea [8] and (2) a prospective matched-
controlled cohort study (aka the Swedish Obese Subjects
Study) that reported the long-term improvement (> 10 years)
in weight, hypertension, lipid control, and diabetes after un-
dergoing bariatric surgery [27]. Therefore, we selected the
fourth quarter in 2004 as the primary exposure period of in-
terest based on the timing of publication for these two studies.
Interrupted Time Series Analysis
We examined how the utilization of bariatric surgery changed
before and after the exposure period. To account for secular
utilization trends in bariatric surgery, we grouped the eligible
cohort into a Bdiabetes cohort^ that would have likely benefit-
ed most from the publication of these studies because they
provided favorable evidence in this specific subgroup of pa-
tients with diabetes and a Bno-diabetes cohort^ (i.e., patients
with no diabetes). A similar trend between both groups in the
pre-exposure period (i.e., before the 4Q 2004) would suggest
that the differential changes in the post-period in the diabetes
cohort may be associated with the publication of the clinical
evidence.
To estimate how much additional bariatric utilization in the
diabetes cohort was associated with the publication of clinical
evidence, we first projected a utilization trend as if the utiliza-
tion in the diabetes cohort would have been similar to that of a
1323
no-diabetes cohort (i.e., the two top-ranked articles would
have no effect). Then, we estimated differences between ob-
served utilization and the projected utilization among the dia-
betes cohort, attributing the difference to the impact of the
clinical evidence on the additional utilization of bariatric sur-
gery. Using the post-period trends of the no-diabetes cohort as
a counterfactual for the diabetes cohort produced conservative
estimates for the association of evidence exposure and bariat-
ric surgery uptake.
For statistical modeling, we initially modeled the primary
outcome using a binary indicator at the patient level on wheth-
er an eligible patient received bariatric surgery or not in a
specific quarter, and then expressed the outcome as the num-
ber of bariatric cases per 100,000 patients with severe obesity
per quarter in the KPWA population. We implemented a linear
generalized estimating equation regression model to account
for the within-subject correlation. Also, we included quadratic
time variables in the model to capture non-linear time trends.
Considering uncertainty around the dissemination of clinical
evidence and the timing of clinical decision-making for bar-
iatric surgery (which is generally 3–6 months prior to the
actual date of surgery), we excluded all data 6 months before
and after the primary exposure period of interest (4Q 2004).
We provide a detailed description of the model in the Online
Appendix.
Secondary Analysis
We conducted secondary analyses to examine whether some
specific characteristics of clinical evidence published between
1994 and 2008 were associated with increasing utilization of
bariatric surgery among all eligible population in the KPWA.
Here instead of defining one specific exposure period, we
assumed that evidence accumulated over time in a continuous
manner using all of the highest cited articles identified from
the citation analysis. Also, given uncertainty around the
timing of dissemination of clinical evidence and the timing
of decision-making for bariatric surgery described earlier, we
evaluated the impact of following characteristics on changes
in subsequent bariatric utilization at 6 months post publica-
tion: (1) one additional major article published conditional on
the number of existing major articles at the time of publication
(i.e., an accumulation effect), (2) types of clinical evidence
published: randomized-controlled trial (RCT), systematic re-
view and meta-analysis, comparative observational study
(e.g., prospective matched case-control study), or observation-
al study without comparators (e.g., case study or cohort
study), and (3) stratification by three tiers, defined by the
citations per quarter, to examine whether more influential ar-
ticles were associated with higher increase in utilization of
bariatric surgery. We defined articles with more than ten cita-
tions per quarter as Tier 1, five to ten citations per quarter as
Tier 2, and less than five citations per quarter as Tier 3.
1324 OBES SURG (2018) 28:1321–1328

For statistical modeling, we implemented a fixed-effect
multivariate regression model, adjusting for seasonality, age,
individual-level fixed effect, and the main predictor for each
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
in the probability of receiving bariatric surgery within an in-
dividual due to changes in characteristics of clinical evidence.
We validated the use of the fixed-effect model through the
Hausman test. The details on the secondary analysis are pro-
vided in the Online Appendix. All of these analyses were
conducted in STATA 12 (StataCorp. 2011, Stata Statistical
Software: Release 12. College Station, TX: StataCorp LP).
Results
Sample Characteristics
The KPWA database included a bariatric cohort of 1421 pa-
tients who received bariatric surgery from 1994 to 2008 and a
non-bariatric cohort that contained 45,665 records of patients
with severe obesity who did not have surgery from 1994 to
2008. Table 1 provides the sample characteristics among pa-
tients with severe obesity included in this study. Comparing
the bariatric cohort to the non-bariatric cohort at the KPWA,
the bariatric cohort had a significantly higher proportion of
females, people with any ORDs, and a higher proportion with
insurance coverage for bariatric surgery. The bariatric cohort
also had higher mean BMI than the non-bariatric cohort.
Citation Analysis
Figure 1 provides a flow diagram that summarizes the results
of the literature search. We initially found 9913 articles from
1994 to 2008 and eventually selected 35 publications for in-
clusion in our study based on our criteria above. Among those
35 major articles, the average number of citations was 548. We
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
found that the results were consistent. A list of the 35 major
articles is provided in the Online Appendix.
Based on the citation analysis, we determined that the
fourth quarter of 2004 was a particularly important period
for the publication of highly influential articles, including a
systematic review that was ranked #1 in total citations (2760)
and #1 in average citation per quarter (61), as well as the long-
term evaluation of the SOS study that was ranked #2 in total
citations (1802) and #3 in citation per quarter (40). In terms of
content, both studies focused on not only weight loss but also
on improvement and/or remission of type 2 diabetes mellitus
(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
2008
‡
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
failure
§
‘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
Fig. 1 Flow diagram of the literature search for influential articles on
clinical effectiveness of bariatric surgery in humans. BS bariatric surgery,
RCTs randomized controlled trials. Note: Under the BRecords excluded,^
Interrupted Time Series Analysis
The publication of major clinical evidence in the fourth quar-
ter of 2004 was associated with an increase in utilization of
bariatric surgery by 27.6% in the diabetes cohort with diabetes
(231 observed cases vs. 181 projected cases per 100,000 in-
dividuals). Figure 2 provides a graphical representation of
changes in the pre- and post-observed uptake among the dia-
betes and the no-diabetes cohort and the predicted uptake
among the diabetes cohort in the post-period. In the pre-peri-
od, there was no statistically significant difference in uptake
across groups, whereas the rate of uptake among the diabetes
cohort was significantly higher than that of the no-diabetes
cohort after the exposure period (Appendix B-3 for regression
results).
Also, we found that it takes time for clinical evidence to
translate into changes in practice. As shown in Table 2, the
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
cases vs. 220 predicted cases per 100,000 individuals per
quarter) in the uptake of bariatric surgery among the diabetes
cohort.
Secondary Analysis
From the secondary analysis, we found that the accumulation
of each additional major clinical publication was associated
1325
BNot specific or Relevant^ articles represent ones that did not provide
empirical evidence on clinical effectiveness of bariatric surgery or briefly
overview bariatric surgery as one of treatment options for obesity
with an increasing probability of receiving bariatric surgery in
the overall population (0.011% (95% confidence interval
0.009–0.013) per individual per publication). Also, RCTs
and systematic reviews were associated with stronger influ-
ence on the change in utilization than other types of clinical
evidence. One additional RCT was associated with a 0.03%
(0.019–0.041) greater probability of receiving bariatric sur-
gery. Also, more influential articles—that is, those in higher
impact tiers with greater number of citations per quarter—
were associated with larger changes in the probability of re-
ceiving bariatric surgery. For example, one additional publi-
cation in Tier 1 was associated with an increase in the proba-
bility of receiving bariatric surgery by 0.01% (0.004–0.016).
A Tier 2 publication provided a similar impact (0.009%
(0.005–0.012)) while a Tier 3 publication was not significant-
ly associated with the probability of receiving bariatric surgery
(Table 3).
Discussion
This study reported two major findings regarding how the
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-
tion of the two top-cited articles in the field of bariatric surgery
from 1994 to 2008 was associated with a dramatic increase in
utilization of bariatric surgery, especially for the population
with T2DM that could potentially benefit the most from
1326 OBES SURG (2018) 28:1321–1328

Fig. 2 Observed and projected uptake of bariatric surgery before and
after 4Q 2004 in the KPWA population. Note: To account for secular
utilization trends, we used an interrupted time series (ITS) analysis to
compare the actual observed utilization of bariatric surgery to the
projected utilization among the diabetes cohort. We estimated the
projected trend in a scenario that the utilization in the diabetes cohort
would be similar to that of a no-diabetes cohort, assuming that two most
influential articles would have not provided any additional clinical evi-
dence for the diabetes cohort. This assumption helped us to estimate how
much additional uptakes may be associated with the impact of the publi-
cation of major clinical evidence. Then, we estimated differences in uti-
lization of bariatric surgery between the observed trend and the projected
trend among the diabetes cohort in the post-period, attributing the differ-
ence to the impact of major clinical evidence on the additional utilization
of bariatric surgery. In the pre-period, the utilization trends between the
diabetes cohort and the no-diabetes cohort were not significantly different
(Online Appendix B)

bariatric surgery based on the clinical evidence. Also, our
secondary analysis demonstrated that higher quality clinical
evidence (e.g., RCTs) and more highly cited evidence were
each associated with a greater increase in the individual prob-
ability of receiving bariatric surgery.
To our knowledge, this is the first study to examine the
association between major clinical evidence and utilization
of bariatric surgery. The strength of this study includes a cita-
tion analysis that quantitatively identifies major clinical evi-
dence and the use of rigorous statistical models (e.g., ITS
analysis with a no-diabetes cohort to control for secular
utilization trends and a fixed-effect model to explain the rela-
tionship between characteristics of clinical evidence and utili-
zation within an individual).
Recently published data of the trend in bariatric surgery in
Michigan agrees with our main findings, where there were
faster increases in bariatric surgery among patients with
T2DM, compared to non-T2DM patients between 2006–
2007 and 2008–2009 [28]. The increased rates of utilization
in bariatric surgery (27.6% increase or 50 additional cases per
100,000 individuals per quarter) among patients with T2DM
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-
gery, because we evaluated the pre-post impact of the two
most influential articles in the field on the changes in
utilization.
The secondary analysis suggested that the higher quality of
clinical evidence [29], the stronger the potential impact on
clinical practice. Also, even among all major articles, only
those articles in the top tiers were significantly associated with
changing clinical practice in this population. This may be
explained by that only a few leading articles (e.g., the first
meta-analysis or a first study to report the long-term effects)
may change the trajectory of clinical practice, whereas other
articles, even though still highly cited, only serve as
supporting evidence rather than influencing clinical practice.
We acknowledge that other important factors, besides pub-
lication of clinical evidence, are also likely to influence the
utilization of bariatric surgery, including increased prevalence
of population with severe obesity [30, 31]; changes in insur-
ance coverage; emerging lower risk procedures (e.g., laparo-
scopic Roux-en-Y gastric bypass, adjustable gastric banding,
and sleeve gastrectomy); and increased shared decision-
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-
es. Our study aimed to isolate the influence of clinical evi-
dence on utilization of bariatric procedures using common
denominator (i.e., per 100,000 eligible individuals) and two
comparison groups (i.e., a diabetic cohort and a non-diabetic
cohort) in a single health care system.
The study population (the KPWA population) served
well for the purpose of this study because there have
been only two bariatric surgeons in the KPWA
throughout the study period to eliminate the possibility
of supply-driven uptake of bariatric surgery so that we
could focus on how clinical evidence changes clinical
practice at the individual level. These surgeons almost
exclusively performed Roux-en-Y gastric bypass during
the study period. Also, insurance coverage at the KPWA
for bariatric surgery remained stable during the study
period between 1994 and 2008. On February 12, 2009,
the Centers for Medicare & Medicaid Services changed
its national coverage determination that T2DM is a co-
morbidity for purposes of bariatric surgery [33].
Because our study period is prior to this major change
in coverage at the national level, our findings on the
overall relationship between clinical evidence and the
use of bariatric surgery were not mediated through
changes in insurance coverage.
Notwithstanding, one of the main limitations is a general-
izability issue of these findings to other hospitals and health
care systems that may have different supply-side characteris-
tics (e.g., number of surgeons or number of surgical facilities
available) as well as population characteristics.
Conclusions
For the KPWA enrollees in Washington state, the publication
of major clinical evidence was associated with increasing uti-
lization of bariatric surgery. Also, clinical evidence with a
higher quality (e.g., RCTs) or from a more highly cited article
was associated with a greater increase in the individual prob-
ability of receiving bariatric surgery. Further studies are need-
ed to replicate and confirm these findings in other settings.
1328
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflicts of
interest.
Informed Consent Not applicable.
Ethical Approval For this type of study, formal consent is not required.
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