Bariatric Surgery can Lead to Net Cost Savings to Health Care Systems: Results from a Comprehensive European Decision Analytic Model

Cost-utility and budget impact analysis of laparoscopic bariatric surgery for obesity with Type II Diabetes Mellitus in Thailand

Bariatric surgery is another treatment options for patients with obesity, who cannot achieve weight controlled by conservative non-surgical therapy. Although bariatric surgery provides clinical benefits for these patients, it is costly. This study aims to evaluate the cost-effectiveness of bariatric surgery, as compared to nonbariatric surgery, in patients with body mass index (BMI) ≥32.5 kg/m2 and type 2 diabetes mellitus (T2DM), and to estimate the budget impact of bariatric surgery in Thailand.

METHODS

A Markov model was developed to estimate and compare total costs incurred and quality-adjusted life years (QALYs) gained between bariatric surgery and nonbariatric surgery over lifetime horizontal. Analysis was conducted under payer and societal perspectives. Costs and outcomes were discounted at an annual rate of 3%. The outcomes were presented as incremental cost- effectiveness ratio (ICER).

RESULTS

Under payer's perspective, bariatric surgery resulted in higher total lifetime cost (676,658.39 baht vs 574,683.38 baht) and QALYs gained (16.08 QALYs vs 14.78 QALYs), as compared to nonbariatric surgery, resulting in an ICER of 78,643.02 baht/QALY. Similarly, under the societal perspective, bariatric surgery resulted in higher total lifetime cost (1,451,923.83 baht vs 1,407,590.49 baht) and QALYs gained (16.08 QALYs vs 14.78 QALYs), as compared to nonbariatric surgery. Under societal perspective, ICER was estimated at 34,189.82 baht/QALY. A 5-year budget impact analysis indicated that bariatric surgery incurred the total budget of 223,821 million baht.

CONCLUSIONS

At the cost-effectiveness threshold of 160,000 baht/QALY, bariatric surgery was a cost-effective strategy and should continue to be included in the benefit package for patients with obesity and T2DM.

[Assessment of the Effect of Implementing an Obesity Center of Integrated Responsibility on Hospital Performance in Portugal]

The continuous increase in the prevalence of obesity has generated growing concern, having become an important challenge at a global level in economic and public health terms. In Portugal, the treatment of obesity presents significant problems in access to health services. In this context, there is a need to implement new management models that offer more effective responses. Centers of integrated responsibility, already implemented in this area, are a cutting-edge approach, and it is important to evaluate their performance and identify recommendations for improving the model. The main objective of this study is to assess the impact of implementing an obesity center of integrated responsibility on hospital performance. This study was conducted using a comprehensive multiple-case study approach, which was predominantly descriptive but also included explanatory elements. The methodological approach is a well-balanced mix of quantitative and qualitative analyses. The study evaluates various hospital performance indicators, encompassing the dimensions of access, production, efficiency, quality, and economic-financial, both before and after the implementation of the new model. The overall results indicate that the implementation of an obesity center of integrated responsibility led to improvements in hospital performance, particularly in the dimensions of access, production, and efficiency. While these findings are promising, the study also identifies areas for potential improvement in the model, such as organizational, functional, and legal aspects, including the method of granting incentives and the funding process. In the analyzed cases, this new organizational model proved to be a solution for improving hospital performance, particularly around obesity. These units can play a fundamental strategic role in the National Health System, contributing to access to specialized treatments, retention of professionals and financial sustainability.

Quality-adjusted life years and surgical waiting list: Systematic review of the literature

BACKGROUND

The quality-adjusted life year (QALY) is a metric that is increasingly used today in the field of health economics to evaluate the value of different medical treatments and procedures. Surgical waiting lists (SWLs) represent a pressing problem in public healthcare. The QALY measure has rarely been used in the context of surgery. It would be interesting to know how many QALYs are lost by patients on SWLs.

AIM

To investigate the relationship between QALYs and SWLs in a systematic review of the scientific literature.

METHODS

The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. An unlimited search was carried out in PubMed, updated on January 19, 2024. Data on the following variables were investigated and analyzed: Specialty, country of study, procedure under study, scale used to measure QALYs, the use of a theoretical or real-life model, objectives of the study and items measured, the economic value assigned to the QALY in the country in question, and the results and conclusions published.

RESULTS

Forty-eight articles were selected for the study. No data were found regarding QALYs lost on SWLs. The specialties in which QALYs were studied the most in relation to the waiting list were urology and general surgery, with 15 articles each. The country in which the most studies of QALYs were carried out was the United States (n = 21), followed by the United Kingdom (n = 9) and Canada (n = 7). The most studied procedure was organ transplantation (n = 39), including 15 kidney, 14 liver, 5 heart, 4 lung, and 1 intestinal. Arthroplasty (n = 4), cataract surgery (n = 2), bariatric surgery (n = 1), mosaicplasty (n = 1), and septoplasty (n = 1) completed the surgical interventions included. Thirty-nine of the models used were theoretical (the most frequently applied being the Markov model, n = 34), and nine were real-life. The survey used to measure quality of life in 11 articles was the European Quality of Life-5 dimensions, but in 32 articles the survey was not specified. The willingness-to-pay per QALY gained ranged from $100000 in the United States to €20000 in Spain.

CONCLUSION

The relationship between QALYs and SWLs has only rarely been studied in the literature. The rate of QALYs lost on SWLs has not been determined. Future research is warranted to address this issue.

Reducing greenhouse gas emissions in a bariatric surgical unit is a complex but feasible project

Obesity is a growing issue worldwide, whose causes and consequences are linked to the environment and which therefore has a high carbon footprint. On the other hand, obesity surgery, along with other procedures in surgical suites, entails environmental consequences and responsibilities. We conducted a prospective comparative study on two groups of bariatric interventions (N = 59 and 56, respectively) during two consecutive periods of time (Oct 2021-March 2022), first without and then with specific measures aimed at reducing greenhouse gas emissions related to bariatric procedures by approximately 18%. These measures included recycling of disposable surgical equipment, minimizing its use, and curbing anesthetic gas emissions. Further and continuous efforts/incentives are warranted, including reframing the surgical strategies. Instead of comparing measurements, which is difficult at the present time, we suggest defining an ECO-SCORE in operating rooms, among other healthcare facilities.

Bariatric Surgery for Adults With Class I Obesity and Difficult-to-Manage Type 2 Diabetes: A Health Technology Assessment

Background

Many individuals with type 2 diabetes are classified as either overweight or obese. A patient may be described as having difficult-to-manage type 2 diabetes if their HbA1c levels remain above recommended target levels, despite efforts to treat it with lifestyle changes and pharmacotherapy. Bariatric surgery refers to procedures that modify the gastrointestinal tract. In patients with class II or III obesity, bariatric surgery has resulted in substantial weight loss, improved quality of life, reduced mortality risk, and resolution of type 2 diabetes. There is some evidence suggesting these outcomes may also be possible for patients with class I obesity as well. We conducted a health technology assessment of bariatric surgery for adults with class I obesity and difficult-to-manage type 2 diabetes, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding bariatric surgery, and patient preferences and values.

Methods

We performed a systematic clinical literature review. We assessed the risk of bias of each included study, using the Cochrane Risk of Bias tool for randomized controlled trials, the Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tool for cohort studies, and the Risk of Bias in Systematic Reviews (ROBIS) tool for systematic reviews; we assessed the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature review and conducted a cost-utility analysis of bariatric surgery in comparison with nonsurgical usual care over a lifetime horizon from a public payer perspective. We also analyzed the budget impact of publicly funding bariatric surgery for adults with class I obesity and difficult-to-manage type 2 diabetes in Ontario. To contextualize the potential value of bariatric surgery, we spoke with people with obesity and type 2 diabetes who had undergone or were considering this procedure.

Results

We included 14 studies in the clinical evidence review. There were large increases in diabetes remission rates (GRADE: Low to Very low) and large reductions in body mass index (GRADE: Low to Very low) with bariatric surgery than with medical management. Bariatric surgery may also reduce the use of medications for type 2 diabetes (GRADE: Low) and may improve quality of life for people with class I obesity and difficult-to-manage type 2 diabetes compared with medical management. (GRADE: Low)Our economic evidence review included 5 cost-effectiveness studies; none were conducted in a Canadian setting, and 4 were considered partially applicable to our research question. Most studies found bariatric surgery to be cost-effective compared to standard care for patients with class I obesity and type 2 diabetes; however, the applicability of these results to the Ontario context is uncertain due to potential differences in clinical practice, resource utilization, and unit costs.Our primary economic evaluation found that over a lifetime horizon, bariatric surgery was more costly (incremental cost: $8,151 per person) but also more effective than current usual care (led to a 0.339 quality-adjusted life-year [QALY] gain per person). The cost increase was driven by costs associated with surgery (before, after, and during surgery), and the QALY gain was due to life-years gained. Results were sensitive to the bariatric surgery cost and assumptions regarding its long-term benefits with respect to weight loss and diabetes remission.Publicly funding 50 bariatric surgeries in year 1, and gradually increasing to 250 surgeries in year 5, for people with class I obesity and difficult-to-manage type 2 diabetes would lead to budget increases of $0.55 million in year 1 to $2.45 million in year 5, for a total of $7.63 million over 5 years.The people with obesity and type 2 diabetes with whom we spoke reported that bariatric surgery was generally seen as a positive treatment option, and those who had undergone the procedure reported positively on its value as a treatment to manage their weight and diabetes.

Conclusions

For adults with class I obesity and difficult-to-manage type 2 diabetes, bariatric surgery may be more clinically effective and cost-effective than medical management. Compared with medical management in people with class I obesity and difficult-to-manage type 2 diabetes, bariatric surgery may result in large increases in diabetes remission rates, large reductions in BMI, and reduced medication use for type 2 diabetes, improved quality of life. Over a lifetime horizon, bariatric surgery led to a cost increase and QALY gain. Bariatric surgery can result in postsurgical complications that are not faced by those receiving medical management. The cost-effectiveness of bariatric surgery depends on its long-term impacts on obesity-related and diabetes-related complications, which could be uncertain.Our budget impact analysis suggests that publicly funding bariatric surgery in Ontario for people with class I obesity and difficult-to-manage type 2 diabetes would lead to a budget increase of $7.63 million over 5 years.For people with obesity and type 2 diabetes, bariatric surgery was seen as a potential positive treatment option to manage their weight and diabetes.

Perioperative optimization and profitability (POP) in a high-volume bariatric surgery center

BACKGROUND

Currently, bariatric surgery is the most effective long-term treatment of obesity. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the primary types of bariatric surgery performed worldwide. To minimize the risks of surgical complications and optimize cost-effectiveness, it is essential to develop fast-track protocols and patient logistics. At Aleris Hospitals in Denmark, a fast-track methodology in bariatric surgery has been implemented and continuously optimized over the last 15 years. The main objective was to demonstrate timelines recorded during one consecutive year in a fast-track, high-volume bariatric surgery setting after logistic optimization.

METHODS

This study included 949 consecutive patients who had undergone primary bariatric surgery in 2021. The primary outcomes were length of hospital stay and perioperative timeline recordings that were prospectively collected. The secondary outcomes were mortality, complication rates, and weight loss data.

RESULTS

The vast majority of our patients (99.1%) were discharged from the hospital within the day after surgery. The median total surgery time was 30 min, after 12 min of patient preparation and with a turnover time between patients of seven min. The median knife-to-knife time in one operating room was 56 min. Mortality was zero, 30-day reoperation rate was 1.2%, and 30-day readmission rate was 0.8%. SG and RYGB patients had an excess weight loss after four months of 45.6% and 57.9%, respectively.

CONCLUSION

Implementation of fast-track principles in the clinical practice of bariatric surgery allows for an optimized, cost-effective surgical organization supporting the quality of procedures and patient safety.

Cost-effectiveness of metabolic surgery for the treatment of type 2 diabetes and obesity: a systematic review of economic evaluations

AIM

To systematically identify and appraise the international literature on the cost-effectiveness of metabolic surgery for the treatment of comorbid type 2 diabetes (T2D) and obesity.

METHODS

A systematic search was conducted in electronic databases and grey literature sources up to 20 January 2021. Economic evaluations in a T2D population or a subpopulation with T2D were eligible for inclusion. Screening, data extraction, critical appraisal of methodological quality (Consensus Health Economic Criteria list) and assessment of transferability (International Society for Pharmacoeconomics and Outcomes Research questionnaire) were undertaken in duplicate. The incremental cost-effectiveness ratio (ICER) was the main outcome. Costs were reported in 2020 Irish Euro. Cost-effectiveness was interpreted using willingness-to-pay (WTP) thresholds of €20,000 and €45,000/quality-adjusted life year (QALY). Due to heterogeneity arising from various sources, a narrative synthesis was undertaken.

RESULTS

Thirty studies across seventeen jurisdictions met the inclusion criteria; 16 specifically in a T2D population and 14 in a subpopulation with T2D. Overall, metabolic surgery was found to be cost-effective or cost-saving. Where undertaken, the results were robust to sensitivity and scenario analyses. Of the 30 studies included, 15 were considered high quality. Identified limitations included limited long-term follow-up data and uncertainty regarding the utility associated with T2D remission.

CONCLUSION

Published high-quality studies suggest metabolic surgery is a cost-effective or cost-saving intervention. As the prevalence of obesity and obesity-related diseases increases worldwide, significant investment and careful consideration of the resource requirements needed for metabolic surgery programmes will be necessary to ensure that service provision is adequate to meet demand.

Cost-effectiveness analysis of five anti-obesity medications from a US payer's perspective

BACKGROUND AND AIMS

To determine the cost-effectiveness of anti-obesity medications (AOM): tirzepatide, semaglutide, liraglutide, phentermine plus topiramate (PpT), and naltrexone plus bupropion (NpB).

METHODS AND RESULTS

From a U.S. perspective we developed a Markov model to simulate weight change over a 40-year time horizon using results from clinical studies. According to the body mass index (BMI), cardiovascular diseases, diabetes and mortality risk were the health states considered in the model, being mutually exclusive. Costs of AOM, adverse events, cardiovascular events, and diabetes were included. We applied a 3% per-year discount rate and calculated the incremental cost-effectiveness ratios (ICERs) of cost per quality-adjusted life-year (QALY) gained. Probabilistic sensitivity analyses incorporated uncertainty in input parameters. A deterministic analysis was conducted to determine the robustness of the model. The model included a cohort of 78.2% females with a mean age of 45 years and BMI of 37.1 (SD 4.9) for females and 36.8 (SD 4.9) for males. NpB and PpT were the least costly medications and, all medications differed no more than 0.5 QALYs. Tirzepatide ICER was $355,616 per QALY. Liraglutide and semaglutide options were dominated by PpT.

CONCLUSION

Compared to other AOM, PpT was lowest cost treatment with nearly identical QALYs with other agents.

Value of Surgical and Nonsurgical Treatment for Sleep Apnea: A Closer Look at Healthcare Utilization

OBJECTIVE

To determine how surgery, continuous positive airway pressure (CPAP), and no treatment impact healthcare utilization in patients who have obstructive sleep apnea (OSA).

STUDY DESIGN

This is a retrospective cohort study of patients between the ages of 18 and 65 that were diagnosed with OSA (9th International Classification of Diseases) from January 2007 to December 2015. Data were collected over 2 years, and prediction models were generated to evaluate trends over time.

SETTING

A population-based study using real-world data and insurance databases.

METHODS

A total of 4,978,649 participants were identified, all with at least 25 months of continuous enrollment. Patients with previous soft tissue procedures not approved for OSA (nasal surgery), or without continuous insurance coverage were excluded. A total of 18,050 patients underwent surgery, 1,054,578 were untreated, and 799,370 received CPAP. IBM Marketscan Research database was utilized to describe patient-specific clinical utilization, and expenditures, across outpatient, and inpatient services, and medication prescriptions.

RESULTS

When the cost of the intervention was eliminated in the 2-year follow-up, the monthly payments of group 1 (surgery) were significantly less than group 3 (CPAP) in overall, inpatient, outpatient, and pharmaceutical payments (p < .001). The surgery group was associated with less cumulative payments compared to the other 2 groups when the cost of the intervention (CPAP or surgery) was eliminated in all comorbidities and age groups.

CONCLUSION

Treating OSA with surgery can lessen overall healthcare utilization compared to no treatment and CPAP.

Gastric Bypass Versus Sleeve Gastrectomy: Comparison of Patient Outcomes, Satisfaction, and Quality of Life in a Single-Center Experience

Background: Laparoscopic sleeve gastrectomy (LSG) is the most common primary bariatric operation performed in the United States. Its relative technical ease, combined with a decreased risk for anatomic and malabsorptive complications make LSG an attractive option compared to laparoscopic gastric bypass (LGB) for many patients and surgeons. However, emerging evidence for progressive gastroesophageal reflux disease (GERD) after LSG, and the inferior weight loss in many studies, suggests that the enthusiasm for LSG requires reassessment. We hypothesized that patient satisfaction and quality of life (QoL) may be lower after LSG compared to LGB because of these differences. Methods: We distributed a survey querying weight-loss outcomes, complications, foregut symptoms, QoL, and overall satisfaction to patients who underwent bariatric operations at our institution between 2000 and 2020 and who had electronic mail contact information available. Mean follow-up was 2.75 ± 2.41 years for LGB patients and 3.37 ± 2.18 (P = .021) years for LSG patients. We compared these groups for weight-loss outcomes, changes in foregut symptoms, gastrointestinal QoL, postbariatric QoL, and overall satisfaction using appropriate statistical tests. Results: Among 323 respondents, 126 underwent LGB and 197 underwent LSG. LGB patients had larger body mass index (BMI) reduction than LSG patients (-17.16 ± 9.07 kg/m² versus -14.87 ± 7.4 kg/m², P = .023). LGB patients reported less reflux (P = .003), with decreased heartburn (P < .0001) and regurgitation (P = .0027). However, a greater proportion of LGB patients reported at least one complication (P = .025). Despite this, more LGB patients reported satisfaction (92.86%) than LSG patients (73.6%). Conclusion: LGB patients are significantly more likely to be satisfied than LSG patients. Factors contributing to the higher level of satisfaction include less GERD and better BMI decrease.

Cost-Effectiveness of Bariatric Surgery in Tunisia

PURPOSE

Obesity is a growing global issue with evidence linking it to an increase in loss of disease-free years, reduced quality of life, increased mortality, and additional economic burden. This study sought to establish the cost-effectiveness of gastric bypass and sleeve gastrectomy, compared to conventional therapy in patients with obesity, from a Tunisian healthcare payor perspective.

PATIENTS AND METHODS

A Markov model compared lifetime costs and outcomes of bariatric surgery with conventional treatment among patients with body mass index (BMI) ≥ 40 kg/m², BMI ≥ 35 kg/m² with obesity-related co-morbidities (Group 1), or BMI ≥ 35 kg/m² with type 2 diabetes mellitus (T2DM) (Group 2). Inputs were sourced from the Tunisian Health Examination Survey, local clinician data and literature sources. Health states were associated with different cost and utility decrements. Changes in body mass index, systolic blood pressure, lipid ratio and diabetes remission rates were modelled on a yearly basis. The incremental cost-effectiveness ratio (ICER), quality-adjusted life years (QALYs) and net monetary benefit (NMB) were key outcomes. Sensitivity and scenario analyses were performed to test the model's robustness.

RESULTS

The model showed that the benefits of bariatric surgery were favorable compared to conventional treatment, with an ICER of 1844 TND/QALY in Group 1 patients and 2413 TND/QALY in Group 2 patients. Bariatric surgery resulted in a QALY gain of 3.26 per patient in Group 1 and a gain of 1.77 per patient in Group 2. At a willingness to pay threshold of 31,379 TND/QALY, the incremental NMB was 96,251 TND and 51,123 TND for Group 1 and Group 2, respectively.

CONCLUSION

From the Tunisian healthcare payor perspective, bariatric surgery is cost-effective for patients with obesity and those with T2DM and obesity-related comorbidities. These findings may have impact on future decision-making on funding and reimbursement of bariatric surgery in Tunisia.

Impacts of bariatric surgery in health outcomes and health care costs in Brazil: Interrupted time series analysis of multi-panel data

Background

The increasing burden of obesity generates significant socioeconomic impacts for individuals, populations, and national health systems worldwide. The literature on impacts and cost-effectiveness of obesity-related interventions for prevention and treatment of moderate to severe obesity indicate that bariatric surgery presents high costs associated with high effectiveness in improving health status referring to certain outcomes; however, there is a lack of robust evidence at an individual-level estimation of its impacts on multiple health outcomes related to obesity comorbidities.

Methods

The study encompasses a single-centre retrospective longitudinal analysis of patient-level data using micro-costing technique to estimate direct health care costs with cost-effectiveness for multiple health outcomes pre-and post-bariatric surgery. Data from 114 patients who had bariatric surgery at the Hospital of Clinics of the University of Sao Paulo during 2018 were investigated through interrupted time-series analysis with generalised estimating equations and marginal effects, including information on patients' characteristics, lifestyle, anthropometric measures, hemodynamic measures, biochemical exams, and utilisation of health care resources during screening (180 days before) and follow-up (180 days after) of bariatric surgery.

Results

The preliminary statistical analysis showed that health outcomes presented improvement, except cholesterol and VLDL, and overall direct health care costs increased after the intervention. However, interrupted time series analysis showed that the rise in health care costs is attributable to the high cost of bariatric surgery, followed by a statistically significant decrease in post-intervention health care costs. Changes in health outcomes were also statistically significant in general, except in cholesterol and LDL, leading to significant improvements in patients' health status after the intervention.

Conclusions

Trends multiple health outcomes showed statistically significant improvements in patients' health status post-intervention compared to trends pre-intervention, resulting in reduced direct health care costs and the burden of obesity.

Clinical cost evaluation and health benefits of post-bariatric intervention for patients with type 2 diabetes living in the UK

To assess associated healthcare costs and risk of developing obesity-related comorbidities among patients with type 2 diabetes with severe obesity and receiving insulin treatment, following bariatric surgery (BS). A retrospective cohort study was conducted from a UK electronic primary care database. Propensity score matching (1:1) was performed for BS with non-BS cohort. Follow-up was over 5 years (694 person-years), comparing drug utilization with clinical cost differences, such as visits to General practitioners (GPs), hospitalization, and laboratory use. Cox proportional regression was used to compute differences in the risk of obesity-related comorbidities and chi-square analysis to explore differences in insulin independency and diabetes remission proportions during follow-up. Eighty patients who received BS were matched to 80 non-BS (N = 160). The baseline mean age was 48.3 years (SD: 12.9) (61% female), and body mass index was 39.3 kg/m² (SD: 9.3). During follow-up, antidiabetic drug cost was significantly lower in the BS group than in the non-BS (median cost/person [£]: 527.77 [interquartile range (IQR): 1196.11] vs. 1564.13 [IQR: 1576.01]; p < 0.001). Overall, aggregate cost analysis showed a significant total healthcare cost reduction in the BS group (median cost/person [£]: 1597.96 [IQR: 2631.84] vs. 2440.12 [IQR: 2242.95]; p = 0.050). BS significantly protected against obesity-related comorbidities compared with the non-BS (adjusted hazard ratio: 0.56; 95% confidence interval: 0.32-0.96; p = 0.036) and increased insulin independency throughout all follow-up points: at year 5: 48.1% versus 28.9%; p = 0.044, respectively. While BS shows evidence of cost efficiency, cost saving was not identified. The efficiency is evident by the protective effect against crude obesity-related comorbidities associated with increased insulin independency.

A Scoping Review of Artificial Intelligence and Machine Learning in Bariatric and Metabolic Surgery: Current Status and Future Perspectives

Artificial intelligence (AI) is a revolution in data analysis with emerging roles in various specialties and with various applications. The objective of this scoping review was to retrieve current literature on the fields of AI that have been applied to metabolic bariatric surgery (MBS) and to investigate potential applications of AI as a decision-making tool of the bariatric surgeon. Initial search yielded 3260 studies published from January 2000 until March 2021. After screening, 49 unique articles were included in the final analysis. Studies were grouped into categories, and the frequency of appearing algorithms, dataset types, and metrics were documented. The heterogeneity of current studies showed that meticulous validation, strict reporting systems, and reliable benchmarking are mandatory for ensuring the clinical validity of future research.

Cost-effectiveness of bariatric and metabolic surgery, and implications of COVID-19 in the United Kingdom

Background

People living with obesity have been among those most disproportionately impacted by the COVID-19 pandemic, highlighting the urgent need for increased provision of bariatric and metabolic surgery (BMS).

Objectives

To evaluate the possible clinical and economic benefits of BMS compared with nonsurgical treatment options in the UK, considering the broader impact that COVID-19 has on people living with obesity.

Setting

Single-payer healthcare system (National Health Service, England).

Methods

A Markov model compared lifetime costs and outcomes of BMS and conventional treatment among patients with body mass index (BMI) ≥ 40 kg/m², BMI ≥ 35 kg/m² with obesity-related co-morbidities (Group A), or BMI ≥ 35 kg/m² with type 2 diabetes (T2D; Group B). Inputs were sourced from clinical audit data and literature sources; direct and indirect costs were considered. Model outputs included costs and quality-adjusted life years (QALYs). Scenario analyses whereby patients experienced COVID-19 infection, BMS was delayed by five years, and BMS patients underwent endoscopy were conducted.

Results

In both groups, BMS was dominant versus conventional treatment, at a willingness-to-pay threshold of £25,000/QALY. When COVID-19 infections were considered, BMS remained dominant and, across 1000 patients, prevented 117 deaths, 124 hospitalizations, and 161 intensive care unit admissions in Group A, and 64 deaths, 65 hospitalizations, and 90 intensive care unit admissions in Group B. Delaying BMS by 5 years resulted in higher costs and lower QALYs in both groups compared with not delaying treatment.

Conclusion

Increased provision of BMS would be expected to reduce COVID-19-related morbidity and mortality, as well as obesity-related co-morbidities, ultimately reducing the clinical and economic burden of obesity.

Incremental Net Monetary Benefit of Bariatric Surgery: Systematic Review and Meta-Analysis of Cost-Effectiveness Evidences

This systematic review aimed to comprehensively synthesize cost-effectiveness evidences of bariatric surgery by pooling incremental net monetary benefits (INB). Twenty-eight full economic evaluation studies comparing bariatric surgery with usual care were identified from five databases. In high-income countries (HICs), bariatric surgery was cost-effective among mixed obesity group (i.e., obesity with/without diabetes) over a 10-year time horizon (pooled INB = $53,063.69; 95% CI $42,647.96, $63,479.43) and lifetime horizon (pooled INB = $101,897.96; 95% CI $79,390.93, $124,404.99). All studies conducted among obese with diabetes reported that bariatric surgery was cost-effective. Also, the pooled INB for obesity with diabetes group over lifetime horizon in HICs was $80,826.28 (95% CI $32,500.75, $129,151.81). Nevertheless, no evidence is available in low- and middle-income countries.

The real-world cost-effectiveness of bariatric surgery for the treatment of severe obesity: a cost-utility analysis

BACKGROUND

Severe obesity is associated with adverse health outcomes and increased risk of death. This study evaluates the real-world cost-utility of therapy for severe obesity, from the publicly funded health care system and societal perspectives.

METHODS

We conducted a cost-utility analysis using primary data from a prospective observational cohort of adults living with severe obesity (BMI ≥ 35 kg/m² and a major medical comorbidity or BMI ≥ 40 kg/m²) who were enrolled in a regional obesity program over 2 years. We extrapolated 10-year and lifetime Markov models, validated and supplemented with literature sources, to compare medical, surgical and standard care therapies. We performed deterministic and probabilistic sensitivity analyses.

RESULTS

The cohort included 500 adults living with severe obesity, 150 of whom received laparoscopic surgical therapy. From a publicly funded health system perspective, at 2 years, surgical therapy had an incremental cost-effectiveness ratio (ICER) of $54 456 per quality-adjusted life-year (QALY) compared with standard care therapy. Over a lifetime, it had an ICER of $14 056 per QALY. From the societal perspective, at 2 years, surgical therapy had an ICER of $340 per QALY; over a lifetime, it was the dominant option. The results were robust to sensitivity analysis.

INTERPRETATION

From a public health care perspective, surgery for severe obesity is cost effective, and when approached from a societal perspective, it becomes cost saving. Real-world data support using surgical therapy for severe obesity, and our results contribute to the health economic and clinical literature with regard to a robust analysis from a societal perspective.

Diabetes Risk Reduction and Metabolic Surgery

Type 2 diabetes mellitus (T2D) and associated comorbid medical conditions are leading causes of strain on the American health care system. There has been a synchronous rise of obesity to epidemic proportions. If poorly treated, T2D is a scourge for patients, leading to end-organ damage and early mortality. Although T2D is considered best managed with lifestyle modification, medical management, and pharmacotherapy, recent studies have confirmed the superiority of metabolic surgery to conventional treatment algorithms as a path to remission. Increasing access to metabolic surgery will continue to yield benefits to patient health and improve the macroeconomic health of the world.

Survey of perceptions and educational needs of primary care providers regarding management of patients with class II and III obesity in Ontario, Canada

BACKGROUND

Primary care providers (PCPs) are typically the primary contact for patients with obesity seeking medical and surgical weight loss interventions; however, previous studies suggest that fewer than 7% of eligible adult patients are referred to publically funded medical and surgical weight loss interventions (MSWLI).

METHODS

We performed an anonymous survey study between October 2017 and June 2018 to explore the knowledge, experiences, perceptions, and educational needs of PCPs in Southeastern Ontario in managing patients with class II and III obesity.

RESULTS

Surveys were distributed to 591 PCPs (n = 538 family physicians; n = 53 nurse practitioners) identified as practicing in the Southeastern Ontario and 92 (15.6%) participated. PCPs serving a rural population estimated that 14.2 ± 10.9% of patients would qualify for MSWLI compared to 9.9 ± 8.5% of patients of PCPs serving an urban population (p = .049). Overall, 57.5% of respondents did not feel competent prescribing MSWLI to patients with class II/III obesity, while 69.8% stated they had 'good' knowledge of the referral criteria for MSWLI. 22.2% of respondents were hesitant to refer patients for bariatric surgery (BS) due to concerns about postoperative surgical complications and risks associated with surgery. Only 25% of respondents were comfortable providing long-term follow up after BS, and only 39.1% had participated in continuing education on management of patients with class II/III obesity in the past 5 years.

CONCLUSION

The majority of PCPs believe there is a need for additional education about MSWLI for patients with class II/III obesity. Future studies are needed to develop and compare the effectiveness of additional education and professional development around risks of contemporary BS, indications to consider referral for MSWLI, management and long-term follow-up of patients after BS.

Three-Year Outcomes of Bariatric Surgery in Patients With Obesity and Hypertension : A Randomized Clinical Trial

BACKGROUND

Midterm effects of bariatric surgery on patients with obesity and hypertension remain uncertain.

OBJECTIVE

To determine the 3-year effects of Roux-en-Y gastric bypass (RYGB) on blood pressure (BP) compared with medical therapy (MT) alone.

DESIGN

Randomized clinical trial. (ClinicalTrials.gov: NCT01784848).

SETTING

Investigator-initiated study at Heart Hospital (HCor), São Paulo, Brazil.

PARTICIPANTS

Patients with hypertension receiving at least 2 medications at maximum doses or more than 2 medications at moderate doses and with a body mass index (BMI) between 30.0 and 39.9 kg/m² were randomly assigned (1:1 ratio).

INTERVENTION

RYGB plus MT or MT alone.

MEASUREMENTS

The primary outcome was at least a 30% reduction in total number of antihypertensive medications while maintaining BP less than 140/90 mm Hg. Key secondary outcomes were number of antihypertensive medications, hypertension remission, and BP control according to current guidelines (<130/80 mm Hg).

RESULTS

Among 100 patients (76% female; mean BMI, 36.9 kg/m² [SD, 2.7]), 88% from the RYGB group and 80% from the MT group completed follow-up. At 3 years, the primary outcome occurred in 73% of patients from the RYGB group compared with 11% of patients from the MT group (relative risk, 6.52 [95% CI, 2.50 to 17.03]; P < 0.001). Of the randomly assigned participants, 35% and 31% from the RYGB group and 2% and 0% from the MT group achieved BP less than 140/90 mm Hg and less than 130/80 mm Hg without medications, respectively. Median (interquartile range) number of medications in the RYGB and MT groups at 3 years was 1 (0 to 2) and 3 (2.8 to 4), respectively (P < 0.001). Total weight loss was 27.8% and -0.1% in the RYGB and MT groups, respectively. In the RYGB group, 13 patients developed hypovitaminosis B₁₂ and 2 patients required reoperation.

LIMITATION

Single-center, nonblinded trial.

CONCLUSION

RYGB is an effective strategy for midterm BP control and hypertension remission, with fewer medications required in patients with hypertension and obesity.

PRIMARY FUNDING SOURCE

Ethicon, represented in Brazil by Johnson & Johnson do Brasil.

Health state utilities for economic evaluation of bariatric surgery: A comprehensive systematic review and meta-analysis

Health state utilities (HSUs) are health economic metrics that capture and assess health-related quality of life (HRQoL). They are essential in health-economic evaluations when calculating quality-adjusted life years. We investigated published studies reporting bariatric surgery-related HSUs elicited through direct or indirect (multiattribute utility instrument [MAUI]) patient-reported methods (PROSPERO registration number: CRD42019131725). Mean HSUs for different time points and HSU changes over time (where feasible) were meta-analysed using random-effects models. Of the 950 potentially relevant identified studies, n = 28 (2004-2018) qualified for data extraction, with n = 85 unique HSUs elicited mainly from the EQ-5D (88%). Most (75%) studies were published after 2013. The follow-up duration varied between studies and was often limited to 12 months. The pooled mean HSU was 0.72 (0.67-0.76) at baseline/presurgery (n = 18) and 0.84 (0.79-0.89) one-year postsurgery (n = 11), indicating a 0.11 (0.09-0.14) utility unit increment. EQ-5D showed the similar results. This positive difference can be partially explained by BMI and/or co-morbidities status improvement. This study provides a valuable summary of HSUs to future bariatric surgery-related cost-utility models. However, more well-designed higher-quality bariatric-related HSU studies are expected for future reviews to improve the available evidence. We suggest that researchers select an MAUI that is preferentially sensitive to the study population.

Cost-effectiveness of Interventions to Manage Diabetes: Has the Evidence Changed Since 2008?

OBJECTIVE

To synthesize updated evidence on the cost-effectiveness (CE) of interventions to manage diabetes, its complications, and comorbidities.

RESEARCH DESIGN AND METHODS

We conducted a systematic literature review of studies from high-income countries evaluating the CE of diabetes management interventions recommended by the American Diabetes Association (ADA) and published in English between June 2008 and July 2017. We also incorporated studies from a previous CE review from the period 1985-2008. We classified the interventions based on their strength of evidence (strong, supportive, or uncertain) and levels of CE: cost-saving (more health benefit at a lower cost), very cost-effective (≤$25,000 per life year gained [LYG] or quality-adjusted life year [QALY]), cost-effective ($25,001-$50,000 per LYG or QALY), marginally cost-effective ($50,001-$100,000 per LYG or QALY), or not cost-effective (>$100,000 per LYG or QALY). Costs were measured in 2017 U.S. dollars.

RESULTS

Seventy-three new studies met our inclusion criteria. These were combined with 49 studies from the previous review to yield 122 studies over the period 1985-2017. A large majority of the ADA-recommended interventions remain cost-effective. Specifically, we found strong evidence that the following ADA-recommended interventions are cost-saving or very cost-effective: In the cost-saving category are 1) ACE inhibitor (ACEI)/angiotensin receptor blocker (ARB) therapy for intensive hypertension management compared with standard hypertension management, 2) ACEI/ARB therapy to prevent chronic kidney disease and/or end-stage renal disease in people with albuminuria compared with no ACEI/ARB therapy, 3) comprehensive foot care and patient education to prevent and treat foot ulcers among those at moderate/high risk of developing foot ulcers, 4) telemedicine for diabetic retinopathy screening compared with office screening, and 5) bariatric surgery compared with no surgery for individuals with type 2 diabetes (T2D) and obesity (BMI ≥30 kg/m²). In the very cost-effective category are 1) intensive glycemic management (targeting A1C <7%) compared with conventional glycemic management (targeting an A1C level of 8-10%) for individuals with newly diagnosed T2D, 2) multicomponent interventions (involving behavior change/education and pharmacological therapy targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria, nephropathy/retinopathy, secondary prevention of cardiovascular disease with aspirin) compared with usual care, 3) statin therapy compared with no statin therapy for individuals with T2D and history of cardiovascular disease, 4) diabetes self-management education and support compared with usual care, 5) T2D screening every 3 years starting at age 45 years compared with no screening, 6) integrated, patient-centered care compared with usual care, 7) smoking cessation compared with no smoking cessation, 8) daily aspirin use as primary prevention for cardiovascular complications compared with usual care, 9) self-monitoring of blood glucose three times per day compared with once per day among those using insulin, 10) intensive glycemic management compared with conventional insulin therapy for T2D among adults aged ≥50 years, and 11) collaborative care for depression compared with usual care.

CONCLUSIONS

Complementing professional treatment recommendations, our systematic review provides an updated understanding of the potential value of interventions to manage diabetes and its complications and can assist clinicians and payers in prioritizing interventions and health care resources.

Prospective Analysis Regarding Health-Related Quality of Life (HR-QOL) between Morbid Obese Patients Following Bariatric Surgery Versus on a Waiting List

BACKGROUND

Major impairment of health-related quality of life (HRQoL) is one of the main reasons why obese patients request surgical treatment.

OBJECTIVE

To prospectively analyze the impact of HRQoL between obese patients who underwent surgery and those who were wait-listed.

METHODS

Between April 2017 and March 2018, 70 surgical and 69 wait-listed patients were interviewed twice, at baseline and at the 12-month follow-up. Quality of life was measured by the SF-12v2 and the Impact of Weight on Quality of Life-Lite (IWQoL-Lite) questionnaires. Sociodemographic-, clinical-, and surgical-related variables were collected.

RESULTS

One hundred thirty-nine patients were analyzed, showing similar baseline characteristics but differences in HRQoL. Performing more qualified work improved scores on some aspects of the SF-12 survey. In contrast, women scored worse on the self-esteem domain, and men scored worse on the mental health domain. By group, at the 12-month follow-up, statistically significant differences were found among all aspects of the questionnaires between both groups (P < 0.001) and between baseline and postoperative 12-month follow-up in the surgical group (P < 0.001). Furthermore, scores were lower in all domains in the evolution of wait-listed patients, with statistically significant differences among the Bodily Pain, Emotional Role, Mental Health, and Mental Component Summary Domains (P < 0.05).

CONCLUSION

HRQoL is a multimodal concept that allows the identification of factors impacting obese patients' quality of life. It promotes the benefit of surgery against waiting list delays, which can take up to 4 years in our hospital. Therefore, HRQoL is an important pillar to justify more resources for reducing unacceptable surgical delays.

Chronic abdominal pain and persistent opioid use after bariatric surgery

Background and aims Bariatric surgery remains a mainstay for treatment of morbid obesity. However, long-term adverse outcomes include chronic abdominal pain and persistent opioid use. The aim of this review was to assess the existing data on prevalence, possible mechanisms, risk factors, and outcomes regarding chronic abdominal pain and persistent opioid use after bariatric surgery. Methods PubMed was screened for relevant literature focusing on chronic abdominal pain, persistent opioid use and pharmacokinetic alterations of opioids after bariatric surgery. Relevant papers were cross-referenced to identify publications possibly not located during the ordinary screening. Results Evidence regarding general chronic pain status after bariatric surgery is sparse. However, our literature review revealed that abdominal pain was the most prevalent complication to bariatric surgery, presented in 3-61% of subjects with health care contacts or readmissions 1-5 years after surgery. This could be explained by behavioral, anatomical, and/or functional disorders. Persistent opioid use and doses increased after bariatric surgery, and 4-14% initiated a persistent opioid use 1-7 years after the surgery. Persistent opioid use was associated with severe pain symptoms and was most prevalent among subjects with a lower socioeconomic status. Alteration of absorption and distribution after bariatric surgery may impact opioid effects and increase the risk of adverse events and development of addiction. Changes in absorption have been briefly investigated, but the identified alterations could not be separated from alterations caused solely by excessive weight loss, and medication formulation could influence the findings. Subjects with persistent opioid use after bariatric surgery achieved lower weight loss and less metabolic benefits from the surgery. Thus, remission from comorbidities and cost effectiveness following bariatric surgery may be limited in these subjects. Conclusions Pain, especially chronic abdominal, and persistent opioid use were found to be prevalent after bariatric surgery. Physiological, anatomical, and pharmacokinetic changes are likely to play a role. However, the risk factors for occurrence of chronic abdominal pain and persistent opioid use have only been scarcely examined as have the possible impact of pain and persistent opioid use on clinical outcomes, and health-care costs. This makes it difficult to design targeted preventive interventions, which can identify subjects at risk and prevent persistent opioid use after bariatric surgery. Future studies could imply pharmacokinetic-, pharmacodynamics-, and physiological-based modelling of pain treatment. More attention to social, physiologic, and psychological factors may be warranted in order to identify specific risk profiles of subjects considered for bariatric surgery in order to tailor and optimize current treatment recommendations for this population.

Bariatric Surgery Offer in Brazil: a Macroeconomic Analysis of the Health system's Inequalities

BACKGROUND

Brazil currently holds the second place in the worldwide ranking of the largest number of bariatric surgical procedures performed. The offer of bariatric surgery in the public health system is not sufficient for its demand; it remains to be determined whether the recent economic downturn affected this offer.

OBJECTIVE

To analyze the proportion of bariatric surgeries performed by the public system in Brazil and assess the influence of macroeconomic variables over time.

METHODS

This is a nationwide analysis which correlated the estimated number of bariatric surgeries in Brazil in both public and private health-providing systems from 2003 through 2017 with the main macroeconomic variables of Brazil during the evaluated period (gross domestic product [GDP], inflation rate, and unemployment rate), and both overall and public healthcare expenditures.

RESULTS

The proportion of surgeries performed in the public system varied from 7.1% in 2014 to 10.4% in 2004. There was a significant positive correlation between the public proportion of surgeries with the unemployment rate (R = 0.55666; P = 0.03868). There were significant negative correlations between the proportion of public surgeries with the public health expenditure per capita (R = - 0.88811; P = 0.00011) and with the public percentage of healthcare expenditure per capita (R = - 0.67133; P = 0.01683).

CONCLUSION

There were direct correlations between the number of public bariatric procedures and the unemployment rate, as well as with the public healthcare expenditure per capita. Despite the increase in the number of public procedures, its proportion reveals an insufficiency of the current offer of bariatric surgery provided by the public system.

Bariatric surgery is a cost-saving treatment for obesity-A comprehensive meta-analysis and updated systematic review of health economic evaluations of bariatric surgery

Demand for bariatric surgery to treat severe and resistant obesity far outstrips supply. We aimed to comprehensively synthesise health economic evidence regarding bariatric surgery from 1995 to 2018 (PROSPERO registration number: CRD42018094189). Meta-analyses were conducted to calculate the annual cost changes "before" and "after" surgery, and cumulative cost differences between surgical and nonsurgical groups. An updated narrative review also summarized the full and partial health economic evaluations of surgery from September 2015. N = 101 studies were eligible for the qualitative analyses since 1995, with n = 24 studies after September 2015. Quality of reporting has increased, and the inclusion of complications/reoperations was predominantly contained in the full economic evaluations after September 2015. Technical improvements in surgery were also reflected across the studies. Sixty-one studies were eligible for the quantitative meta-analyses. Compared with no/conventional treatment, surgery was cost saving over a lifetime scenario. Additionally, consideration of indirect costs through sensitivity analyses increased cost savings. Medication cost savings were dominant in the before versus after meta-analysis. Overall, bariatric surgery is cost saving over the life course even without considering indirect costs. Health economists are hearing the call to present higher quality studies and include the costs of complications/reoperations; however, indirect costs and body contouring surgery are still not appropriately considered.

Effect of Roux-en-Y gastric bypass on pharmacologic dependence in obese patients with type 2 diabetes

Background

More than half the diabetes-related health care costs in Canada relate to drug costs. We aimed to determine the effect of Roux-en-Y gastric bypass (RYGB) on the use of insulin and orally administered hypoglycemic medications in patients with diabetes. We also looked to determine overall cost savings with the procedure.

Methods

We reviewed the bariatric clinic records of all patients with a confirmed diagnosis of type 2 diabetes mellitus who underwent RYGB between 2010/11 and 2014/15. Percentage estimated weight loss was recorded at 1 year, along with reductions in glycated hemoglobin (HbA1c) level and use of oral hypoglycemic therapy and insulin. We estimated medication costs using Manitoba-specific pricing data.

Results

Fifty-two patients with at least 12 months of complete follow-up data were identified. The mean percentage estimated weight loss was 50.2%. The mean HbA1c level decreased from 7.6% to 6.0%, the mean number of orally administered hypoglycemics declined from 1.6 to 0.2, and the number of patients receiving insulin decreased from 18 (35%) to 3 (6%) (all p < 0.001). The rate of resolution of type 2 diabetes was 71%. Estimated mean annual per-patient medication costs decreased from $508.56 to $79.17 (p < 0.001). Potential overall health care savings could total $3769 per patient in the first year, decreasing to $1734 at 10 years.

Conclusion

Roux-en-Y gastric bypass resulted in significant improvement in diabetic control, with a reduction in hypoglycemic medication use and associated costs in the early postoperative period. Potentially, large indirect and direct cost savings can be realized in the longer term.

Economics and Policy in Bariatric Surgery

PURPOSE OF REVIEW

The purpose of this review is to provide current synthesis of the evidence on the cost-effectiveness of bariatric surgery for persons with diabetes.

RECENT FINDINGS

Virtually, every study that has evaluated the cost-effectiveness of bariatric surgery for persons who are obese and have type 2 diabetes has concluded that surgery is cost-effective. A few studies outside the USA found that surgery is cost-saving. Currently, most but not all US insurers cover bariatric surgery in persons with type 2 diabetes and BMI ≥ 35 kg/m². Bariatric surgery is a cost-effective treatment for persons with type 2 diabetes and BMI ≥ 35 kg/m². There is interest in extending surgery to persons with diabetes and lower BMI; the cost-effectiveness of treating these individuals with bariatric surgery should be explored. Despite the potential benefits, not all obese or overweight persons with diabetes will choose surgery.

Rates and reasons for emergency department presentations of patients wait-listed for public bariatric surgery in Tasmania, Australia

BACKGROUND

Demand for bariatric surgery in the public hospital setting in Australia is high with prolonged wait-list times. Policy-makers need to consider the consequences of expanding public bariatric surgery including on emergency department (ED) presentations.

AIMS

To describe and evaluate public ED presentation rates and reasons for presenting in a cohort of patients wait-listed for public surgery.

METHODS

All Tasmanians placed on the public wait-list for primary bariatric surgery in 2008-2013 were identified using administrative datasets along with their ED presentations in 2000-2014. The presentations were assigned to one of three periods: before wait-list placement, whilst on the wait-list, and after wait-list removal for publicly-funded surgery or drop-out. A negative binomial mixed-effects regression model was used to derive ED presentation incidence rate ratios (IRR) to compare observation periods and patient groups.

RESULTS

652 wait-listed patients had 5149 public ED presentations. 178 patients had publicly-funded bariatric surgery - all as laparoscopically adjustable gastric banding (LAGB). Overall, ED presentation rates did not change significantly post-surgery compared with the waiting period (IRR 1.19, 95%CI 0.90-1.56). Presentation rates significantly increased for digestive system (IRR 2.02, 95%CI 1.19-3.45) and psychiatric diseases (IRR 4.85, 95%CI 1.06-22.26) after surgery. The likelihood of being admitted from the ED significantly increased after surgery (31.7%-38.9%, p<0.05).

CONCLUSION

ED presentations were common for patients wait-listed for public bariatric surgery and rates did not decrease over an average of three years post-LAGB. The likelihood of being admitted to the hospital from the ED increased after surgery.

Cost-Effectiveness of Bariatric Surgery versus Medication Therapy for Obese Patients with Type 2 Diabetes in China: A Markov Analysis

AIMS/INTRODUCTION

The present study estimated the cost-effectiveness of bariatric surgery versus medication therapy for the management of recently diagnosed type 2 diabetes mellitus (T2DM) in obese patients from a Chinese health insurance payer perspective.

MATERIALS AND METHODS

A Markov model was established to compare the 40-year time costs and quality-adjusted life-years (QALYs) between bariatric surgery and medication therapy. The health-care costs in the bariatric surgery group, proportion of patients in each group with remission of diabetes, and state transition probabilities were calculated based on observed resource utilization from the hospital information system (HIS). The corresponding costs in the medication therapy group were derived from the medical insurance database. QALYs were estimated from previous literature. Costs and outcomes were discounted 5% annually.

RESULTS

In the base case analysis, bariatric surgery was more effective and less costly than medication therapy. Over a 40-year time horizon, the mean discounted costs were 86,366.55 RMB per surgical therapy patient and 113,235.94 CNY per medication therapy patient. The surgical and medication therapy patients lived 13.46 and 10.95 discounted QALYs, respectively. Bariatric surgery was associated with a mean health-care savings of 26,869.39 CNY and 2.51 additional QALYs per patient compared to medication therapy. Uncertainty around the parameter values was tested comprehensively in sensitivity analyses, and the results were robust.

CONCLUSIONS

Bariatric surgery is a dominant intervention over a 40-year time horizon, which leads to significant cost savings to the health insurance payer and increases in health benefits for the management of recently diagnosed T2DM in obese patients in China.

An Exploratory Study: A Head-to-Head Comparison of the EQ-5D-5L and AQoL-8D for Long-Term Publicly Waitlisted Bariatric Surgery Patients Before and 3 Months After Bariatric Surgery

BACKGROUND

Choice of a multi-attribute utility instrument (MAUI) that appropriately assesses an intervention's health-related quality-of-life (HRQoL) impacts is a vital part of healthcare resource allocation and clinical assessment.

OBJECTIVE

Our exploratory study compared the EuroQol (EQ)-5D-5L and Assessment of Quality of Life (AQoL)-8D MAUIs, which were used to assess the effect of bariatric surgery for a cohort of long-term publicly waitlisted, severely obese patients.

METHODS

The study was conducted at the Hobart Private Hospital (Tasmania, Australia). To compare the sensitivity and instrument content of the two MAUIs, we used dimensional comparisons by investigating the distribution of patient-reported responses (number/percentage) across the MAUIs' levels and dimensions; summary health-state utility valuations (utilities); and individual/super-dimension scores (AQoL-8D) to investigate discriminatory power and HRQoL improvements preoperatively and 3 months postoperatively.

RESULTS

Participants' (n = 23) overall MAUI completion rate was 74%. Postoperative total weight loss was 9.9%. EQ-5D-5L utilities were relatively higher pre- and postoperatively than AQoL-8D utilities [mean standard deviation (SD) EQ-5D-5L 0.70 (0.25) to 0.80 (0.25); AQoL-8D 0.51 (0.24) to 0.61 (0.24)]. AQoL-8D Psychosocial super dimension was relatively low postoperatively [0.37 (0.25)], driving the instrument's lower utility. These results were supported by the dimensional comparisons that revealed an overall greater dispersion for the AQoL-8D. Nevertheless, there were clinical improvements in utilities for both instruments. AQoL-8D utilities were lower than population norms; not so the EQ-5D-5L utilities. The AQoL-8D dimensions of Happiness, Coping, and Self-worth improved the most.

CONCLUSIONS

AQoL-8D more fully captured the impact of obesity and bariatric surgery on HRQoL (particularly psychosocial impacts) for long-term waitlisted bariatric surgery patients, even 3 months postoperatively. AQoL-8D preoperative utility revealed our population's HRQoL was lower than people with cancer or heart disease.

Patient-Surgeon Relationship Influences Outcomes in Bariatric Patients

Bariatric surgery is an important therapy in weight loss. However, adherence to follow-up is critical and may be influenced by the patient-surgeon relationship. To test this hypothesis, bariatric surgical patients were surveyed from March 2013 to March 2015 via the National Association for Weight Loss Surgery webpage and social media outlets. Surgical outcomes and adherence to follow-up were collected, and aspects of the patient-surgeon relationship were assessed via the Likert scale. Correlations between survey item responses were calculated using Fisher's exact test, Student's t test, and Spearman's rho rank correlation. Three hundred twenty patients responded (n = 287 completed in entirety and n = 33 partially completed); 48 months was the median time to survey from operation (interquartile range, 22–84 months). Eighty-six per cent (n = 276) of patients rated their relationship with their operative surgeon as “average” to “very good.” Thirteen per cent (n = 43) rated their relationship as “poor” to “very poor.” Positive relationship with the operative surgeon and lack of complication were associated with adherence to follow-up ( P = 0.0001 and P = 0.002, respectively). The presence of complication did not affect the overall patient-surgeon relationship ( P = 0.5), although aspects of the patient-surgeon relationship were correlated to complications. There was no association between weight loss at one year and patient-surgeon relationship ( P = 0.6) or presence of complication ( P = 0.1). The findings of this study support the role of a positive patient-surgeon relationship in achieving long-term follow-up in post-bariatric surgical patients.

Bariatric surgery, lifestyle interventions and orlistat for severe obesity: the REBALANCE mixed-methods systematic review and economic evaluation

BACKGROUND

Adults with severe obesity [body mass index (BMI) of ≥ 35 kg/m2] have an increased risk of comorbidities and psychological, social and economic consequences.

OBJECTIVES

Systematically review bariatric surgery, weight-management programmes (WMPs) and orlistat pharmacotherapy for adults with severe obesity, and evaluate the feasibility, acceptability, clinical effectiveness and cost-effectiveness of treatment.

DATA SOURCES

Electronic databases including MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials and the NHS Economic Evaluation Database were searched (last searched in May 2017).

REVIEW METHODS

Four systematic reviews evaluated clinical effectiveness, cost-effectiveness and qualitative evidence for adults with a BMI of ≥ 35 kg/m2. Data from meta-analyses populated a microsimulation model predicting costs, outcomes and cost-effectiveness of Roux-en-Y gastric bypass (RYGB) surgery and the most effective lifestyle WMPs over a 30-year time horizon from a NHS perspective, compared with current UK population obesity trends. Interventions were cost-effective if the additional cost of achieving a quality-adjusted life-year is < £20,000-30,000.

RESULTS

A total of 131 randomised controlled trials (RCTs), 26 UK studies, 33 qualitative studies and 46 cost-effectiveness studies were included. From RCTs, RYGB produced the greatest long-term weight change [-20.23 kg, 95% confidence interval (CI) -23.75 to -16.71 kg, at 60 months]. WMPs with very low-calorie diets (VLCDs) produced the greatest weight loss at 12 months compared with no WMPs. Adding a VLCD to a WMP gave an additional mean weight change of -4.41 kg (95% CI -5.93 to -2.88 kg) at 12 months. The intensive Look AHEAD WMP produced mean long-term weight loss of 6% in people with type 2 diabetes mellitus (at a median of 9.6 years). The microsimulation model found that WMPs were generally cost-effective compared with population obesity trends. Long-term WMP weight regain was very uncertain, apart from Look AHEAD. The addition of a VLCD to a WMP was not cost-effective compared with a WMP alone. RYGB was cost-effective compared with no surgery and WMPs, but the model did not replicate long-term cost savings found in previous studies. Qualitative data suggested that participants could be attracted to take part in WMPs through endorsement by their health-care provider or through perceiving innovative activities, with WMPs being delivered to groups. Features improving long-term weight loss included having group support, additional behavioural support, a physical activity programme to attend, a prescribed calorie diet or a calorie deficit.

LIMITATIONS

Reviewed studies often lacked generalisability to UK settings in terms of participants and resources for implementation, and usually lacked long-term follow-up (particularly for complications for surgery), leading to unrealistic weight regain assumptions. The views of potential and actual users of services were rarely reported to contribute to service design. This study may have failed to identify unpublished UK evaluations. Dual, blinded numerical data extraction was not undertaken.

CONCLUSIONS

Roux-en-Y gastric bypass was costly to deliver, but it was the most cost-effective intervention. Adding a VLCD to a WMP was not cost-effective compared with a WMP alone. Most WMPs were cost-effective compared with current population obesity trends.

FUTURE WORK

Improved reporting of WMPs is needed to allow replication, translation and further research. Qualitative research is needed with adults who are potential users of, or who fail to engage with or drop out from, WMPs. RCTs and economic evaluations in UK settings (e.g. Tier 3, commercial programmes or primary care) should evaluate VLCDs with long-term follow-up (≥ 5 years). Decision models should incorporate relevant costs, disease states and evidence-based weight regain assumptions.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016040190.

FUNDING

The National Institute for Health Research Health Technology Assessment programme. The Health Services Research Unit and Health Economics Research Unit are core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorate.

Event simulation and external validation applied in published health economic models for obesity: a systematic review

INTRODUCTION

This study aims to determine methodological variations in the event simulation approaches of published health economic decision models, in the field of obesity, and to investigate whether their predictiveness and validity were investigated via external event validation techniques, which investigate how well the model reproduces reality.

AREAS COVERED

A systematic review identified a total of 87 relevant papers, of which 72 that simulated obesity-associated events were included. Most frequently simulated events were coronary heart disease (≈ 83%), type 2 diabetes (≈ 74%), and stroke (≈ 66%). Only for ten published model-based health economic assessments in obesity an external event validation was performed (14%; 10 of 72), and only for one the predictiveness and validity of the event simulation was investigated in a cohort of obese subjects.

EXPERT COMMENTARY

We identified a wide range of obesity related event simulation approaches. Published obesity models lack information on the predictive quality and validity of the applied event simulation approaches. Further work on comparing and validating these event simulation approaches is required to investigate their predictiveness and validity, which will offer guidance future modelling in the field of obesity.

A qualitative investigation of the health economic impacts of bariatric surgery for obesity and implications for improved practice in health economics

Obesity is an economic problem. Bariatric surgery is cost-effective for severe and resistant obesity. Most economic evaluations of bariatric surgery use administrative data and narrowly defined direct medical costs in their quantitative analyses. Demand far outstrips supply for bariatric surgery. Further allocation of health care resources to bariatric surgery (particularly public) could be stimulated by new health economic evidence that supports the provision of bariatric surgery. We postulated that qualitative research methods would elicit important health economic dimensions of bariatric surgery that would typically be omitted from the current economic evaluation framework, nor be reported and therefore not considered by policymakers with sufficient priority. We listened to patients: Focus group data were analysed thematically with software assistance. Key themes were identified inductively through a dialogue between the qualitative data and pre-existing economic theory (perspective, externalities, and emotional capital). We identified the concept of emotional capital where participants described life-changing desires to be productive and participate in their communities postoperatively. After self-funding bariatric surgery, some participants experienced financial distress. We recommend a mixed-methods approach to the economic evaluation of bariatric surgery. This could be operationalised in health economic model conceptualisation and construction, through to the separate reporting of qualitative results to supplement quantitative results.

Nationwide Macroeconomic Variables and the Growth Rate of Bariatric Surgeries in Brazil

BACKGROUND

The effect of nationwide economic issues on the necessary expansion in the number of bariatric procedures remains unclear.

OBJECTIVE

This study aims to determine whether there are correlations between the growth rate in the number of bariatric surgeries and the major macroeconomic variables over time in Brazil.

METHODS

It is a nationwide analysis regarding the number of bariatric surgeries in Brazil and the main national macroeconomic variables from 2003 through 2016: gross domestic product (GDP), inflation rate, and the unemployment rate, as well as the evolution in the number of registered bariatric surgeons.

RESULTS

There were significant positive correlations of the growth rate of surgeries with the early variations of the GDP (R = 0.5558; p = 0.04863) and of the overall health expenditure per capita (R = 0.78322; p = 0.00259). The growth rate of the number of bariatric surgeries was not correlated with the unemployment and inflation rates, as well as with the growth rate of available bariatric surgeons.

CONCLUSION

There were direct relationships between the growth rate of bariatric surgeries and the evolutions of the GDP and health care expenditure per capita. These variables appear to influence the nationwide offer of bariatric surgery.

Cost-utility analysis of bariatric surgery

BACKGROUND

The objective of the study was to evaluate the cost-utility of bariatric surgery in England.

METHODS

A state-transition Markov model was developed to compare the costs and outcomes of two treatment approaches for patients with morbid obesity: bariatric surgery, including gastric bypass, sleeve gastrectomy and adjustable gastric banding; and non-surgical usual care. Parameters of the effectiveness of surgery and complications were informed by data from the UK National Bariatric Surgery Registry, the Scandinavian Obesity Registry and the Swedish Obese Subjects study. Costs and utilities were informed by UK sources.

RESULTS

Bariatric surgery was associated with reduced mean costs to the health service by €2742 (£1944), and gain of 0·8 life-years and 4·0 quality-adjusted life-years (QALYs) over a lifetime compared with usual care. Bariatric surgery also had the potential to reduce the lifetime risks of obesity-related cardiovascular diseases and diabetes. Delaying surgery for up to 3 years resulted in a reduction of 0·7 QALYs and a minor decrease of €2058 (£1459) in associated healthcare costs.

CONCLUSION

Currently used surgical methods were found to be cost saving over the lifetime of individuals treated in England.

Cost-effectiveness analysis of bariatric surgery for morbid obesity in Belgium

AIMS

This study presents the cost-effectiveness analysis of bariatric surgery in Belgium from a third-party payer perspective for a lifetime and 10-year horizon.

MATERIALS AND METHODS

A decision analytic model incorporating Markov process was developed to compare the cost-effectiveness of gastric bypass, sleeve gastrectomy, and adjustable gastric banding against conventional medical management (CMM). In the model, patients could undergo surgery, or experience post-surgery complications, type 2 diabetes, cardiovascular diseases, or die. Transition probabilities, costs, and utilities were derived from the literature. The impact of different surgical methods on body mass index (BMI) level in the base-case analysis was informed by the Scandinavian Obesity Surgery Registry and the Swedish Obese Subject (SOS) study. Healthcare resource use and costs were obtained from Belgian sources. A base-case analysis was performed for the population, the characteristics of which were obtained from surgery candidates in Belgium.

RESULTS

In the base-case analysis over a 10-year time horizon, the increment in quality-adjusted life-years (QALYs) gained from bariatric surgery vs CMM was 1.4 per patient, whereas the incremental cost was €3,788, leading to an incremental cost-effectiveness ratio (ICER) of €2,809 per QALY. Over a lifetime, bariatric surgery produced savings of €9,332, an additional 1.1 life years and 5.0 QALYs. Bariatric surgery was cost-effective at 10 years post-surgery and dominant over conventional management over a lifetime horizon.

LIMITATIONS

The model did not include the whole scope of obesity-related complications, and also did not account for variation in surgery outcomes for different populations of diabetic patients. Also, the data about management of patients after surgery was based on assumptions and the opinion of a clinical expert.

CONCLUSIONS

It was demonstrated that a current mix of bariatric surgery methods was cost-effective at 10 years post-surgery and cost-saving over the lifetime of the Belgian patient cohort considered in this analysis.

Laparoscopic Sleeve Gastrectomy for Morbid Obesity at a Veterans Affairs Medical Center

BACKGROUND

Class III obesity is a global health emergency associated with an increase in the incidence of many other diseases such as type 2 diabetes mellitus, hypertension, hyperlipidemia, cancer, obstructive sleep apnea, nonalcoholic fatty liver disease, osteoarthritis, infertility, and mental health disorders. Minimal work has been published regarding the efficacy of laparoscopic sleeve gastrectomy (LSG) in the veteran population to surgically manage morbid obesity.

DESIGN

Retrospective analysis of LSG performed at a Veterans Affairs Medical Center (VAMC) between 2010 and 2017. Veterans were followed from their enrollment in the bariatric program until twelve months following LSG. The primary outcome of interest was excess and total weight loss with resolution of associated comorbidities.

RESULTS

Excess weight loss at nine and 12 months was 43.5% and 40.7% and total weight loss was 20.1% and 19.0%, respectively. LSG performed at a VAMC resulted in 86.9% improvement in type 2 diabetes mellitus and a 66.1% improvement in hypertension and 74.3% improvement in hyperlipidemia. Approximately 10.0% of diabetics obtained partial and 9.0% obtained complete resolution of their disease. Similarly, 22.0% of Veterans obtained partial and 13.0% obtained complete resolution from hypertension. Complete resolution from hyperlipidemia was achieved in 8.8% of Veterans. There were no postoperative complications or staple line leaks.

CONCLUSION

LSG is a safe and effective tool for morbid obesity with clinical and serological improvements for individuals who are unable to lose weight with medical management alone.

Prevalence and predictors of postoperative thiamine deficiency after vertical sleeve gastrectomy

BACKGROUND

As the vertical sleeve gastrectomy (VSG) becomes increasingly popular, its effect on postoperative micronutrient levels, such as thiamine, becomes more important. We previously found a 1.8% prevalence of thiamine deficiency in bariatric patients before surgery.

OBJECTIVE

The aims of this study were to determine the prevalence of thiamine deficiency at our center after VSG and to explore possible predictors of postoperative thiamine levels.

SETTING

University hospital, United States.

METHODS

A retrospective chart review was performed on 147 bariatric patients between 18- and 65-years old who underwent VSG between April 2011 and February 2015. Demographic characteristics, preoperative body mass index (BMI), obesity-associated co-morbidities, alcohol intake, smoking habits, insurance type, calendar year of the procedure, occurrence of postoperative complications, and compliance with postoperative nutrition and follow-up appointment guidelines were extracted from clinical charts. We defined thiamine deficiency as<78 nM on any lab draw within 1 year after the VSG. The χ², Fisher exact, and Mann-Whitney U tests, and multivariate logistic regression models were created to analyze the association of the above factors with thiamine deficiency after a VSG.

RESULTS

Of 147 patients, 105 met inclusion criteria and were analyzed, of whom 27 (25.7%) had thiamine deficiency. Overall median age was 42 years (interquartile ratio: 36, 49). The majority of patients were either African Americans or Caucasian (47.6% and 44.8%, respectively), female (77.1%), and compliant with vitamins (81.0%). The overall mean preoperative BMI was 46.4 kg/m². Patients with thiamine deficiency were more likely to be African American (66.7%, P = .024), have a larger preoperative BMI (P = .026), and to report repetitive episodes of nausea (59.3%, P = .002) and vomiting (44.4%, P = .001) at any of their postoperative appointments within 1 year after surgery. Compliance with vitamins did not differ between those with or without thiamine deficiency (70.4%, 84.6%, P = .10). After controlling for all factors, African American race (odds ratio [OR] 3.9, P = .019), higher preoperative BMI (OR 1.13, P = .001), nausea (OR 3.81, P = .02), and vomiting (OR 3.49, P = .032) were independent risk factors for the development of thiamine deficiency.

CONCLUSIONS

We found an alarmingly high prevalence of thiamine deficiency in postoperative SG patients. This disorder may have serious consequences including Wernicke encephalopathy; hence, it is important to identify predictive demographic, postoperative, and behavioral factors so that appropriate measures can be taken to prevent thiamine deficiency in VSG patients.

Diabetes Resolution and Work Absenteeism After Gastric Bypass: a 6-Year Study

Background

Obesity-related diseases cause costs to society. We studied the cost of work absenteeism before and after gastric bypass and the effects of postoperative diabetes resolution.

Patients and Methods

Data were obtained from the Scandinavian Obesity Surgery Registry (SOReg) (national coverage >98%) and cross-matched with data from the Social insurance Agency (coverage 100%) for the period ±3 years from operation. In 2010, a total of 7454 bariatric surgeries were performed; the study group is 4971 unique individuals with an annual income of >10,750 Euros and complete data sets. A sex-, age-, and income-matched reference population was identified for comparison.

Results

Patients with obesity had preoperatively a 3.5-fold higher absenteeism. During follow-up (FU), the ratio relative to the reference population remained constant. An increase of 12–14 net absenteeism days was observed in the first 3 months after surgery. Female sex (OR 1.5, CI 1.13–1.8), preoperative anti-depressant use (OR 1.5, CI 1.3–1.9), low income (OR 1.4, CI 1.2–1.8), and a history of sick leave (OR 1.004, CI 1.003–1.004) were associated with increased absenteeism during FU. Diabetes resolution did not decrease absenteeism from preoperative values.

Conclusions

Patients with obesity have higher preoperative absenteeism than the reference population. Operation caused an increase the first 90 days after surgery of 12–13 days. There were no relative increases in absenteeism in the next 3 years; patients did not deviate from preoperative patterns but followed the trend of the reference population. Preoperative diabetes did not elevate that level during FU; diabetes resolution did not lower absenteeism.

Systematic assessment of decision analytic models for the cost-effectiveness of bariatric surgery for morbid obesity

Bariatric surgery among patients with morbid obesity is very effective for providing long-term weight loss and remission of obesity-related co-morbidities. However, it is very expensive and its cost effectiveness is commonly argued. Long-term cost-effectiveness evaluations of bariatric surgery have often relied on decision models. A systematic review was performed on the methodologic approaches and their quality, evaluated the quality of reporting, and summarized findings and conclusions in published cost-effectiveness models of bariatric surgery for morbid obesity. A search from different databases with an end date of October 15, 2017 was completed. The initial search for title and abstract screening resulted in 741 articles. A total of 50 articles were included for full-text review and 23 economic evaluation studies were included in the systematic review. The reporting quality scores of most articles were rated as acceptable between 61% and 100%. Most studies (89%) were modeled for adult patients with age range between 25 and 75 years old. Sixty-one percent of studies defined their health states by the existence or absence of different obesity-related co-morbidities. Eleven percent of studies took the societal perspective. Most studies (61%) used a lifetime horizon. Thirty-nine percent of studies identified the extent of weight loss as the most sensitive and influential parameter. Seventeen (74%) did not report a formal model validation. Laparoscopic Roux-en-Y gastric bypass was reported as the most cost-effective strategy most often when it compared with no treatment or medical management. While most had acceptable quality of reporting levels, several gaps in the quality of reporting and quality of methods emerged, which led to recommendations for how to improve quality in future studies.

An Exploratory Study of Long-Term Publicly Waitlisted Bariatric Surgery Patients' Quality of Life Before and 1 Year After Bariatric Surgery, and Considerations for Healthcare Planners

BACKGROUND

Long-term publicly waitlisted bariatric surgery patients typically experience debilitating physical/psychosocial obesity-related comorbidities that profoundly affect their quality of life.

OBJECTIVES

We sought to measure quality-of-life impacts in a study population of severely obese patients who had multiyear waitlist times and then underwent bariatric surgery.

METHODS

Participants were recruited opportunistically following a government-funded initiative to provide bariatric surgery to morbidly obese long-term waitlisted patients. Participants self-completed the EQ-5D-5L and AQoL-8D questionnaires pre- and postoperatively. Utility valuations (utilities) and individual/super dimension scores (AQoL-8D only) were generated.

RESULTS

Participants' (n = 23) waitlisted time was mean [standard deviation (SD)] 6.5 (2) years, body mass index reduced from 49.3 (9.35) kg/m² preoperatively to 40.8 (7.01) 1 year postoperatively (p = 0.02). One year utilities revealed clinical improvements (both instruments). AQoL-8D improved significantly from baseline to 1 year, with the change twice that of the EQ-5D-5L [EQ-5D-5L: mean (SD) 0.70 (0.25) to 0.78 (0.25); AQoL-8D: 0.51 (0.24) to 0.67 (0.23), p = 0.04], despite the AQoL-8D's narrower algorithmic range. EQ-5D-5L utility plateaued from 3 months to 1 year. AQoL-8D 1-year utility improvements were driven by Happiness/Coping/Self-worth (p < 0.05), and the Psychosocial super dimension score almost doubled at 1 year (p < 0.05). AQoL-8D revealed a wider dispersion of individual utilities.

CONCLUSIONS

Ongoing improvements in psychosocial parameters from 3 months to 1 year post-surgery accounted for improvements in overall utilities measured by the AQoL-8D that were not detected by EQ-5D-5L. Selection of a sensitive instrument is important to adequately assess changes in quality of life and to accurately reflect changes in quality-adjusted life-years for cost-utility analyses and resource allocation in a public healthcare resource-constrained environment.

Paediatric type 2 diabetes in China-Pandemic, progression, and potential solutions

China is gradually taking its place as one of the world's economic giants and concurrently learning to cope with the burden of diseases that are more common in the developed world, such as paediatric type 2 diabetes mellitus. The prevalence of type 2 diabetes has been recently observed among children and adolescents in China; hence, there is a lack of information about the incidence, prevalence, pathogenesis, and pathophysiology of the disease. Diagnosis, treatment, and management have been standardized to a large degree, but there is still a need for data regarding optimal management protocols and how to achieve the best control over current state of the disease. The objective of this review is to consolidate the available information about paediatric diabetes, with a focus on the increasing prevalence of type 2 diabetes in Chinese youth. Here we emphasize the prevention strategies and have included literature with respect to pathogenesis, diagnosis, and treatment published in English and Chinese within the past 10 years.

Health Outcomes and Explant Rates After Laparoscopic Adjustable Gastric Banding: A Phase 4, Multicenter Study over 5 Years

OBJECTIVE

This study aimed to evaluate the real-world safety and effectiveness of the LAP-BAND (Apollo Endosurgery Inc., Austin, Texas) adjustable gastric banding system (LBS) for 5 years following implantation.

METHODS

This prospective, longitudinal, phase 4, multicenter study involved 652 patients who had implantation of the LBS system. The primary outcome was the percentage of subjects who had LBS explant over 5 years. The secondary outcomes included the rate of reoperations, clinical and biochemical measures, and patient-reported outcome measures over 5 years.

RESULTS

The study cohort consisted of 79.3% females with a mean age of 44 years and a mean BMI of 45.4 kg/m² . The primary end point was met with an explant rate of 8.74% (95% CI: 6.6%-10.9%) at 5 years. The rates for completer-only analysis and imputed missing data analysis were 12.81% (95% CI: 9.7%-15.9%) and 12.85% (95% CI: 10.2%-15.5%), respectively. All were significantly lower than the historic rate of 39.4% (P < 0.001). There were 43 patients who required reoperations or revisions excluding explants (6.6%). A mean weight loss of 18.7% was maximally achieved by 2 years, and weight loss was maintained through to 5 years. All patient-reported outcomes showed improvement following LBS treatment throughout 5 years.

CONCLUSIONS

This study validates the long-term safety and effectiveness of LBS for the treatment of patients with obesity and its related conditions.

Relation between cost of drug treatment and body mass index in people with type 2 diabetes in Latin America

AIMS

Despite the frequent association of obesity with type 2 diabetes (T2D), the effect of the former on the cost of drug treatment of the latest has not been specifically addressed. We studied the association of overweight/obesity on the cost of drug treatment of hyperglycemia, hypertension and dyslipidemia in a population with T2D.

METHODS

This observational study utilized data from the QUALIDIAB database on 3,099 T2D patients seen in Diabetes Centers in Argentina, Chile, Colombia, Peru, and Venezuela. Data were grouped according to body mass index (BMI) as Normal (18.5≤BMI<25), Overweight (25≤BMI<30), and Obese (BMI≥30). Thereafter, we assessed clinical and metabolic data and cost of drug treatment in each category. Statistical analyses included group comparisons for continuous variables (parametric or non-parametric tests), Chi-square tests for differences between proportions, and multivariable regression analysis to assess the association between BMI and monthly cost of drug treatment.

RESULTS

Although all groups showed comparable degree of glycometabolic control (FBG, HbA1c), we found significant differences in other metabolic control indicators. Total cost of drug treatment of hyperglycemia and associated cardiovascular risk factors (CVRF) increased significantly (p<0.001) with increment of BMI. Hyperglycemia treatment cost showed a significant increase concordant with BMI whereas hypertension and dyslipidemia did not. Despite different values and percentages of increase, this growing cost profile was reproduced in every participating country. BMI significantly and independently affected hyperglycemia treatment cost.

CONCLUSIONS

Our study shows for the first time that BMI significantly increases total expenditure on drugs for T2D and its associated CVRF treatment in Latin America.