Are bariatric surgical outcomes worth their cost? A systematic review

Economic Evaluations of Anti-obesity Interventions in Obese Adults: An Umbrella Review

This umbrella review amalgamates the outcomes of economic evaluations pertaining to bariatric surgeries, pharmacotherapy, and gastric balloon for adult obesity treatment. Six databases were systematically searched. The inclusion criteria were established following the Patient/population Intervention Comparison and Outcomes (PICO) statement. Fifteen reviews met all the inclusion criteria. Eight studies focused on surgical interventions, four on pharmacotherapy, and three on both interventions. No systematic review of the economic evaluation of gastric balloons was identified. The majority of reviews advocated bariatric surgery as a cost-effective approach; however, there was discordance in the interpretation of pharmacological cost-effectiveness. Most of the economic evaluations were conducted from the payer and the healthcare system perspectives. We propose that future economic evaluations assessing weight loss interventions in adults adopt a societal perspective and longer-term time horizons.

LAPAROSCOPIC AND LAPAROTOMY BARIATRIC SURGERY IN A PUBLIC HOSPITAL IN BRAZIL: ARE THERE DIFFERENCES IN COSTS AND COMPLICATIONS?

BACKGROUND

Despite its increasing popularity, laparoscopy is not the option for bariatric surgeries performed in the Brazilian public health system.

AIMS

To compare laparotomy and laparoscopic access in bariatric surgery, considering aspects such as morbidity, mortality, costs, and length of stay.

METHODS

The study included 80 patients who were randomly assigned to perform a Roux-en-Y gastric bypass. They were equally divided in two groups, laparoscopic and laparotomy. The results obtained in the postoperative period were evaluated and compared according to the Ministry of Health protocol, and later, in their outpatient returns.

RESULTS

The surgical time was similar in both groups (p=0.240). The costs of laparoscopic surgery proved to be higher, mainly due to staplers and staples. The patients included in the laparotomy group presented higher rates of severe complications, such as incisional hernia (p<0.001). Costs related to social security and management of postoperative complications were higher in the open surgery group (R$ 1,876.00 vs R$ 34,268.91).

CONCLUSIONS

The costs related to social security and treatment of complications were substantially lower in laparoscopic access when compared to laparotomy. However, considering the operative procedure itself, the laparotomy remained cheaper. Finally, the length of stay, the rate of complications, and return to labor had more favorable results in the laparoscopic route.

Comparison of safety and efficacy of intragastric botulinum toxin-A versus gastric balloon

BACKGROUND

A prospective case-matched study was conducted to compare the safety and efficacy of endoscopic intragastric botulinum toxin-A (EIBT) versus endoscopically planned gastric balloon (EPGB), as a treatment for obesity.

METHODS

A total of 176 patients (matched for age and sex) were equally divided to undergo EIBT (n = 88) or EPGB (n = 88). Patients who received EIBT were restricted to a body mass index (BMI) of 25 to 35 kg/m², whereas a BMI >25 kg/m² was allowed in the EPGB group. The main measured outcomes were weight loss, procedure duration, complications, early satiety, and quality of life (QoL).

RESULTS

The patients were followed up for a mean of 6 months. The mean weight loss was greater in the EPGB group than in the EIBT group (15.6 kg vs. 9.3 kg, P < 0.001). However, the percentage excess weight loss and the satiety score were greater in the EIBT group (59.1% vs. 42.2%, P < 0.001; and 3.5 vs. 2.3, P < 0.001) respectively. The procedure duration was shorter for EIBT patients (10 min vs. 15 min, P < 0.001). The postoperative complication rate recorded in the EPGB group was significantly higher (30% vs. 9%, P = 0.001). Adverse symptoms lasted longer in EPGB (5.2 days vs. 0.7 days, P < 0.001). Both groups enjoyed similar improvements in QoL.

CONCLUSION

EIBT is a safe and effective treatment for mild obesity. Although the weight loss was greater in the EPGB group, the percentage excess weight loss, procedure duration, postoperative complications, and symptom duration were significantly better in the EIBT group. QoL improvement was comparable between the two groups.

SERPINE-1 Gene Methylation and Protein as Molecular Predictors of Laparoscopic Sleeve Gastrectomy Outcome

BACKGROUND

Body weight is subjected to genetic and epigenetic modifiers that might affect the success of weight loss interventions. Because of its possible complications and disparity in patients' response, identification of predictors to the outcome of bariatric surgery is indispensable.

OBJECTIVES

This prospective study aims to investigate serpin peptidase inhibitor type 1 (SERPINE-1) protein and gene methylation as molecular predictors to the outcome of bariatric surgery.

PATIENTS AND METHODS

One hundred participants were enrolled and divided to control group (n = 50) and obese patients who underwent laparoscopic sleeve gastrectomy (LSG) (n = 50). Anthropometric measurements were assessed and blood samples were collected preoperatively and 6 months postoperatively for assessment of SERPINE-1 protein and gene methylation, C-reactive protein (CRP), and homeostatic model assessment of insulin resistance (HOMA-IR). Moreover, subjects were followed for 2 years for weight loss parameters.

RESULTS

Patients with obesity showed high baseline SERPINE-1 protein and gene hypermethylation where LSG was followed by a drop in SERPINE-1 protein level but not gene hypermethylation. Baseline SERPINE-1 gene methylation was negatively related to postoperative weight loss and was the independent predictor to weight loss after LSG. Likewise, postoperative SERPINE-1 protein was negatively related to weight loss with independent expression from its gene methylation state. Furthermore, postoperative SERPINE-1 gene methylation correlated to CRP and HOMA-IR.

CONCLUSION

Baseline SERPINE-1 gene methylation might be a predictor of weight loss after LSG. Meanwhile, postoperative SERPINE-1 protein could be a predictor to weight loss maintenance after LSG. Lastly, postoperative SERPINE-1 gene methylation might serve as an index to postoperative changes in obesity-related comorbidities.

Factors influencing long-term weight loss after bariatric surgery

BACKGROUND

Bariatric surgery provides sustained weight loss and improves comorbidities. However, long term data has shown that patients gradually regain weight after 1 year. Several factors have been associated with poor weight loss after bariatric surgery.

OBJECTIVE

Our goal is to investigate factors associated with poor weight loss following laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB).

SETTING

Military academic medical center.

METHODS

Retrospective review of 247 patients who underwent laparoscopic SG or RYGB between 2010-2012 at Eisenhower Army Medical Center and followed for 5 years postoperatively. Factors of age, type of surgery, sex, hypertension, depression, and type 2 diabetes (T2D) are analyzed in univariate and multivariate analysis with percent total weight loss (%TWL) and Body Mass Index (BMI) change as primary endpoints measured at 3 and 5 years.

RESULTS

Average BMI change are maximized at 1 year and decreased at 3 and 5 years post-surgery. Age, diabetes, hypertension and type of surgery significantly influenced weight loss at 3 and 5 years on univariate analysis. However, patients with diabetes, hypertension and sleeve gastrectomy were significantly older than comparable control group. Multivariable analysis showed that age and type of surgery, not diabetes or hypertension, were associated with poor %TWL and BMI change at 3 and 5 years.

CONCLUSION

While presence of hypertension and diabetes initially appeared to be associated with weight recidivism, their impacts were negligible on multivariable analysis. However, age and sleeve gastrectomy are independent risk factors. Our data can be used to counsel patients on expected weight loss after bariatric surgery.

Bariatric Surgery Modulates Urinary Levels of MicroRNAs Involved in the Regulation of Renal Function

Background: Obesity and diabetes cause chronic kidney disease with a common pathophysiology that is characterized by the accumulation of collagen in the extracellular matrix. Recent evidence has implicated the epithelial-to-mesenchymal transition (EMT) as a key step in this pathology with regulation by microRNAs. Weight loss leads to improvements in renal function; therefore, this study hypothesized that bariatric-surgery aided weight loss would lead to changes in urinary microRNAs involved in the regulation of renal function. Materials and methods: Twenty-four bariatric patients undergoing Roux-en-Y gastric bypass and sleeve gastrectomy donated urine pre-operatively and at 2-6 months and 1-2 years post-operatively. Urine samples were also obtained from 10 healthy weight and 7 morbidly obese non-surgical controls. Expression levels of kidney microRNAs were assessed in urine and the function of microRNAs was assessed through the in vitro transfection of HK-2 cells, a kidney proximal tubule cell line. Results: Levels of miR 192, miR 200a, and miR 200b were upregulated in urine following bariatric surgery. This increase was consistent across surgical type and diabetes status and was maintained and enhanced with time. Bariatric surgery alters urinary miR 192 expression from levels seen in morbidly obese patients to levels seen in healthy weight control patients. In mechanistic studies, the transfection of miR 192 in HK-2 cells increased miR 200a expression and decreased ZEB2, a key transcriptional promoter of kidney fibrosis. Conclusions: Bariatric surgery increased miR 192 and miR 200 urinary levels, key anti-fibrotic microRNAs that could contribute to a renal-protective mechanism and may be of value as urinary biomarkers following surgery. These findings suggest that urinary microRNAs may represent potential novel biomarkers for obesity-associated renal function.

Metabolic and Bariatric Surgery: An Effective Treatment Option for Obesity and Cardiovascular Disease

Obesity is a chronic and debilitating disease that has become a global epidemic. Especially severe in the Unites States, obesity currently affects almost 40% of the population. Obesity has a strong causal relationship with numerous serious comorbidities that impair quality of life, shorten life expectancy, and carry a major economic burden. Obesity has particular relevance to cardiologists because it contributes directly to several major cardiovascular diseases and, consequently, increases overall cardiovascular mortality. Multiple treatment options are available, but metabolic and bariatric surgery offers the most effective and durable treatment for obesity. Moreover, metabolic and bariatric operations alleviate and often completely eliminate numerous comorbidities, particularly type 2 diabetes and other cardiovascular risk factors, such as hypertension and dyslipidemia. With their low risk of complications and morbidity, metabolic and bariatric operations significantly improve quality of life and overall survival, particularly reducing death due to cardiovascular disease.

Predictors of Excess Weight Loss in Obese Patients After Gastric Bypass: a 60-Month Follow-up

BACKGROUND

The objective of this study was to analyze the factors associated with change in body mass index (BMI) and with percentage of excess weight loss (%EWL) in patients undergoing Roux-en-Y gastric bypass (RYGB). The following factors were analyzed: sex, age, surgical access (laparotomy vs. laparoscopy), preoperative BMI, waist circumference (WC), type 2 diabetes mellitus (T2DM), high blood pressure, and dyslipidemia.

METHODS

Retrospective cohort study using a convenience sample of 2070 patients of both sexes, aged 18 to 65 years, undergoing RYGB between 2000 and 2013. The outcomes of interest were BMI and %EWL at 0, 6, 12, 18, 24, 30, 36, 42, 48, 54, and 60 months after RYGB.

RESULTS

After 36, 48, and 60 months, approximately 50 % of patients had BMI >30 kg/m(2). As for %EWL, 60-month results were poor for 17 % of patients (%EWL <50 %), good for 40 % of patients (%EWL 50-75 %), very good for 24 % of patients (%EWL from >75-90 %), and excellent for 19 % of patients (%EWL >90 %). The four most significant predictors of BMI change 60 months after RYGB (in descending order of magnitude) were preoperative BMI, preoperative WC, surgical access, and age; and of %EWL, surgical access, preoperative BMI, preoperative WC, and age.

CONCLUSIONS

After 60 months of follow-up, the most relevant predictors of weight loss after RYGB were lower preoperative BMI and WC, videolaparoscopy as surgical access, and younger age. Further studies must be carried out to elucidate the impact of these factors on RYGB outcomes.

The Newfoundland and Labrador Bariatric Surgery Cohort Study: Rational and Study Protocol

Background

In Canada, there has been a disproportionate increase in adults with Class II (BMI 35.0–39.9 kg/m²) or Class III obesity (BMI ≥ 40 kg/m²) affecting 9 % of Canadians with increases projected. Individuals affected by severe obesity (BMI ≥ 35) are at increased risk of high blood pressure, cardiovascular disease, diabetes, cancer, impaired quality of life, and premature mortality. Bariatric surgery is the most effective treatment for severe obesity. Laparoscopic sleeve gastrectomy (LSG), a relatively new type of bariatric surgery, is growing in popularity as a treatment. The global prevalence of LSG increased from 0 to 37.0 % between 2003 and 2013. In Canada and the US, between 2011 and 2013, the number of LSG surgeries increased by 244 % and LSG now comprises 43 % of all bariatric surgeries. Since 2011, Eastern Health, the largest regional health authority in Newfoundland and Labrador (NL), Canada has performed approximately 100 LSG surgeries annually.

Methods

A population-based prospective cohort study with pre and post surgical assessments at 1, 3, 6, 12, 18, 24 months and annually thereafter of patients undergoing LSG. This study will report on short - to mid-term (2–4 years) outcomes. Patients (n = 200) followed by the Provincial Bariatric Surgery Program between 19 and 70 years of age, with a BMI between 35.0 and 39.9 kg/m² and an obesity-related comorbidity or with a BMI ≥ 40 kg/m² are enrolled. The study is assessing the following outcomes: 1) complications of surgery including impact on nutritional status 2) weight loss/regain 3) improvement/resolution of comorbid conditions and a reduction in prescribed medications 4) patient reported outcomes using validated quality of life tools, and 5) impact of surgery on health services use and costs. We hypothesize a low complication rate, a marked reduction in weight, improvement/resolution of comorbid conditions, a reduction in related medications, improvement in quality of life, and a decrease in direct healthcare use and costs and indirect costs compared to pre-surgery.

Discussion

Limited data on the impact of LSG as a stand-alone procedure on a number of outcomes exist. The findings from this study will help to inform evidence-based practice, clinical decision-making, and the development of health policy.

Life Expectancy Benefits of Gastric Bypass Surgery

Bariatric surgery is the most effective treatment for achieving sustained weight loss in morbidly obese patients. Although the use of gastric bypass is growing rapidly, the potential life expectancy benefits of the procedure are unknown. We created a Markov decision analysis model to examine the effect of gastric bypass surgery on life expectancy in morbidly obese patients (body mass index [BMI] = 40 kg/m2). Input assumptions for the model were obtained from published life tables (baseline mortality risks), epidemiologic studies (obesity-related excess mortality), and large case series (surgical outcomes). In our baseline analysis, a 40-year-old woman (BMI = 40 kg/m2) would gain 2.6 years of life expectancy by undergoing gastric bypass (38.7 years versus 36.2 years without surgery). In sensitivity analysis, life-years gained with surgery remained substantial when assumptions were varied across reasonable ranges for surgical mortality risk (1.0-3.0 years) and effectiveness (0.9-4.4 years). Life-years gained with gastric bypass surgery did not vary considerably by age and sex subgroups. Relative to other major surgical procedures, gastric bypass for morbid obesity is associated with substantial gains in life expectancy. Long- term data from prospective studies are needed to confirm this finding.

Gap Between Evidence and Patient Access: Policy Implications for Bariatric and Metabolic Surgery in the Treatment of Obesity and its Complications

Despite consistently supportive evidence of clinical effectiveness and economic advantages compared with currently available non-surgical obesity treatments, patient access to bariatric and metabolic surgery (BMS) is impeded. To address this gap and better understand the relationship between value and access, the objectives of this study were twofold: (i) identify the multidimensional barriers to adoption of BMS created by clinical guidelines, public policies, and health technology assessments; and, most importantly, (ii) develop recommendations for stakeholders to improve patient access to BMS. Updated public policies focused on treatment and clinical guidelines that reflect the demonstrated advantages of BMS, patient education on safety and effectiveness, updated reimbursement policies, and additional data on long-term BMS effectiveness are needed to improve patient access.

Cost effectiveness of primary care referral to a commercial provider for weight loss treatment, relative to standard care: a modelled lifetime analysis

BACKGROUND

Because of the high prevalence of overweight and obesity, there is a need to identify cost-effective approaches for weight loss in primary care and community settings.

OBJECTIVE

To evaluate the long-term cost effectiveness of a commercial weight loss programme (Weight Watchers) (CP) compared with standard care (SC), as defined by national guidelines.

METHODS

A Markov model was developed to calculate the incremental cost-effectiveness ratio (ICER), expressed as the cost per quality-adjusted life year (QALY) over the lifetime. The probabilities and quality-of-life utilities of outcomes were extrapolated from trial data using estimates from the published literature. A health sector perspective was adopted.

RESULTS

Over a patient's lifetime, the CP resulted in an incremental cost saving of AUD 70 per patient, and an incremental 0.03 QALYs gained per patient. As such, the CP was found to be the dominant treatment, being more effective and less costly than SC (95% confidence interval: dominant to 6225 per QALY). Despite the CP delaying the onset of diabetes by ∼10 months, there was no significant difference in the incidence of type 2 diabetes, with the CP achieving <0.1% fewer cases than SC over the lifetime.

CONCLUSION

The modelled results suggest that referral to community-based interventions may provide a highly cost-effective approach for those at high risk of weight-related comorbidities.

Drug safety evaluation of naltrexone/bupropion for the treatment of obesity

INTRODUCTION

Obesity is a known health risk for the development of several preventable diseases. Obesity-related metabolic alterations negatively impact different physiological mechanisms, which supports the rationale for the use of combined drug therapy. Naltrexone is an opioid antagonist for the treatment of opioid and alcohol dependency, whereas bupropion is a norepinephrine/dopamine reuptake inhibitor used to treat depression and smoking cessation. Although not effective as individual monotherapies for obesity, naltrexone and bupropion in combination produce weight loss and a metabolic profile beneficial for the potential treatment of obesity.

AREAS COVERED

This review examines the safety and antiobesity effects of naltrexone and bupropion alone and in combination. It reviews the results of four Phase III clinical trials of a novel fixed dose of sustained-released naltrexone/bupropion.

EXPERT OPINION

Naltrexone/bupropion has a greater weight loss efficacy than two FDA-approved medications, orlistat and lorcaserin. Although the weight loss produced by phentermine/topiramate is superior to naltrexone/bupropion, the safety profile of naltrexone/bupropion has less severe adverse effects. In addition, naltrexone/bupropion is well tolerated, with nausea being the most reported adverse event. Unlike other centrally acting medications, lorcaserin and phentermine/topiramate, naltrexone/bupropion has no abuse potential.

Robotic versus laparoscopic Roux-en-Y gastric bypass (RYGB) in obese adults ages 18 to 65 years: a systematic review and economic analysis

BACKGROUND

In the United States, 37.5 % of adults (78 million) are obese. The direct medical costs of treating obesity-related disease account for more than 6 % of the national health expenditure. Robotic bariatric surgery is becoming more common, but it is unclear whether robotic procedures result in lower complication rates. Additionally, some evidence is conflicting regarding the costs of robotic Roux-en-Y gastric bypass (RYGB) compared with those of laparoscopic RYGB. This study aimed to compare complication rates, operative characteristics, and expected costs between robotic and laparoscopic RYGB.

METHODS

A systematic review of the literature was performed with searches of five databases and grey literature, hand searches, and reference and forward citation searches. Studies comparing robotic versus laparoscopic RYGB involving patients ages 18-65 years who met the National Institutes of Health (NIH) criteria for bariatric surgery were included in the study if they reported overall or major complication rates. Outcomes were pooled using random-effects metaanalysis. A decision-tree economic analysis was performed to calculate expected costs associated with each technique.

RESULTS

The systematic search strategy returned 1,374 potentially relevant studies. The inclusion criteria were met by 10 of these studies, which included results from 2,557 patients. The overall major and minor complications did not differ significantly between the robotic and laparoscopic groups. The rates for anastomotic leak, bleeding, stricture, and reoperation did not differ significantly. An economic analysis found that the expected costs for robotic RYGB ($15,447) were higher than for laparoscopic RYGB ($11,956). Sensitivity analyses produced similar results.

CONCLUSION

The complication rates did not differ significantly between robotic and laparoscopic RYGB, but the expected costs were greater for robotic RYGB. Further cost effectiveness analyses are recommended before adoption of a robotic approach to RYGB.

Obesity-related cardiorenal disease: the benefits of bariatric surgery

The inexorable increase in the prevalence of obesity is a global health concern, which will result in a concomitant escalation in health-care costs. Obesity-related metabolic syndrome affects approximately 25% of adults and is associated with cardiovascular and renal disease. The heart and kidneys are physiologically interdependent, and the pathological effects of obesity can lead to cardiorenal syndrome and, ultimately, kidney and heart failure. Weight loss can prevent or ameliorate obesity-related cardiorenal syndrome, but long-term maintenance of a healthy weight has been difficult to achieve through lifestyle changes or pharmacotherapy. Bariatric surgery offers both sustained weight loss and favourable metabolic changes, including dramatic improvements in glycaemic control and symptoms of type 2 diabetes mellitus. Procedures such as Roux-en-Y gastric bypass offer immediate multisystemic benefits, including bile flow alteration, reduced gastric size, anatomical gut rearrangement and altered flow of nutrients, vagal manipulation and enteric hormone modulation. In patients with cardiorenal syndrome, bariatric surgery also offers renoprotection and cardioprotection, and attenuates both kidney and heart failure by improving organ perfusion and reversing metabolic dysfunction. However, further research is required to understand how bariatric surgery acts on the cardiorenal axis, and its pioneering role in novel treatments and interventions for cardiorenal disease.

Age as a long-term prognostic factor in bariatric surgery

OBJECTIVE

: To analyze the potential effects of preoperative age on postoperative weight loss in patients who underwent Roux-en-Y gastric bypass (RYGBP) with long-term follow-up data.

BACKGROUND

: The reasons for individual differences in surgically induced weight loss are not completely understood. To date, there are no available studies specifically aimed at analyzing the effects of age on weight loss in patients undergoing the same operation and with long-term follow-up data.

METHODS

: Retrospective analysis of prospectively collected data for all patients who underwent RYGBP between 2006 and 2010. To evaluate weight loss, we used preoperative and follow-up body mass index (BMI), analyzed by the mixed-effects linear model for repeated measures. To evaluate age effects, patients were classified in quartiles (≤35 years, 36-42 years, 43-51 years, ≥52 years).

RESULTS

: A total of 489 patients entered the study; preoperatively, the younger group showed a significantly higher BMI (mean BMI: 48.2 in patients aged ≤35 years, 46.9 in 36-42 years, 45.5 in 43-51 years, 45.7 in ≥52 years, P = 0.014) and a higher percentage of super-obesity (41.6% among patients aged ≤35 years, 28.1% among 36-42 years, 27.6% among 43-51 years, 28.3% among ≥ 52 years, P = 0.047). In spite of this, younger patients experienced a significantly greater and prolonged BMI decrease during the entire follow-up period and the BMI trend over time resulted significantly modified according to age quartiles (P = 0.036).

CONCLUSIONS

: This study provides a new prognostic factor in bariatric surgery: patient age. Because advanced age represents a risk factor for complications and mortality, and given that bariatric surgery may not be as effective in older patients compared to younger subjects, we believe that surgical indications in patients older than 50 years should be carefully weighed up.

Bariatric surgery as potential treatment for nonalcoholic fatty liver disease: a future treatment by choice or by chance?

Morbid obesity is strongly associated with nonalcoholic fatty liver disease (NAFLD) which is one of the most common causes of chronic liver disease worldwide. The current best treatment of NAFLD and NASH is weight reduction through life style modifications, antiobesity medication, and bariatric surgery. Importantly, bariatric surgery is the best alternative option for weight reduction if lifestyle modifications and pharmacological therapy have not yielded long-term success. Bariatric surgery is an effective treatment option for individuals who are grossly obese and associated with marked decrease in obesity-related morbidity and mortality. The most common performed bariatric surgery is Roux-en-Y gastric bypass (RYGB). The current evidence suggests that bariatric surgery in these patients will decrease the grade of steatosis, hepatic inflammation, and fibrosis. NAFLD per se is not an indication for bariatric surgery. Further research is urgently needed to determine (i) the benefit of bariatric surgery in NAFLD patients at high risk of developing liver cirrhosis (ii) the role of bariatric surgery in modulation of complications of NAFLD like diabetes and cardiovascular disease. The outcomes of the future research will determine whether bariatric surgery will be one of the recommended choice for treatment of the most progressive type of NAFLD.

A within-trial cost-effectiveness analysis of primary care referral to a commercial provider for weight loss treatment, relative to standard care--an international randomised controlled trial

Background:

Due to the high prevalence of overweight and obesity there is a need to identify cost-effective approaches for weight loss in primary care and community settings.

Objective:

We evaluated the cost effectiveness of two weight loss programmes of 1-year duration, either standard care (SC) as defined by national guidelines, or a commercial provider (Weight Watchers) (CP).

Design:

This analysis was based on a randomised controlled trial of 772 adults (87% female; age 47.4±12.9 years; body mass index 31.4±2.6 kg m⁻²) recruited by health professionals in primary care in Australia, United Kingdom and Germany. Both a health sector and societal perspective were adopted to calculate the cost per kilogram of weight loss and the ICER, expressed as the cost per quality adjusted life year (QALY).

Results:

The cost per kilogram of weight loss was USD122, 90 and 180 for the CP in Australia, the United Kingdom and Germany, respectively. For SC the cost was USD138, 151 and 133, respectively. From a health-sector perspective, the ICER for the CP relative to SC was USD18 266, 12 100 and 40 933 for Australia, the United Kingdom and Germany, respectively. Corresponding societal ICER figures were USD31 663, 24 996 and 51 571.

Conclusion:

The CP was a cost-effective approach from a health funder and societal perspective. Despite participants in the CP group attending two to three times more meetings than the SC group, the CP was still cost effective even including these added patient travel costs. This study indicates that it is cost effective for general practitioners (GPs) to refer overweight and obese patients to a CP, which may be better value than expending public funds on GP visits to manage this problem.

The long-term cost-effectiveness of obesity prevention interventions: systematic literature review

Obesity prevention provides a major opportunity to improve population health. As health improvements usually require additional and scarce resources, novel health technologies (interventions) should be economically evaluated. In the prevention of obesity, health benefits may slowly accumulate over time and it can take many years before an intervention has reached full effectiveness. Decision-analytic simulation models (DAMs), which combine evidence from diverse sources, can be utilized to evaluate the long-term cost-effectiveness of such interventions. This literature review summarizes long-term economic findings (defined as ≥ 40 years) for 41 obesity prevention interventions, which had been evaluated in 18 cost-utility analyses, using nine different DAMs. Interventions were grouped according to their method of delivery, setting and risk factors targeted into behavioural (n=21), community (n=12) and environmental interventions (n=8). The majority of interventions offered good value for money, while seven were cost-saving. Ten interventions were not cost-effective (defined as >50,000 US dollar), however. Interventions that modified a target population's environment, i.e. fiscal and regulatory measures, reported the most favourable cost-effectiveness. Economic findings were accompanied by a large uncertainty though, which complicates judgments about the comparative cost-effectiveness of interventions.

Short-term outcome and quality of life of endoscopically placed gastric balloon and laparoscopic adjustable gastric band

BACKGROUND/AIM

A prospective longitudinal study was conducted to describe short-term outcome and quality of life (QOL) of endoscopically placed gastric balloon (EPGB) and laparoscopic adjustable gastric band (LAGB).

MATERIALS AND METHODS

Forty seven consecutive patients with body mass index (BMI) of 42 to 72 kg/m² were assigned to undergo EPGB (n=17) or LAGB (n=30) between May 2008 and May 2010. The main measured outcomes included weight loss, resolution or improvement of comorbidities, hospital stay, complications and QOL.

RESULTS

Patients were followed up for a mean of 14 months. Hospital stay was shorter for EPGB patients (one versus two days, P<0.001). Early postoperative complications recorded in EPGB were minor including nausea and vomiting. No late complications were recorded in the EPGB group. One case of band slippage was reported in the LAGB group and fixed laparoscopically. Percent excess weight loss was less in EPGB compared to LAGB (26.2% versus 44.0%, P=0.004). Resolution or improvement of comorbidities was comparable in both groups. The globally impaired preoperative quality of life showed considerable improvement in both groups.

CONCLUSION

EPGB is a safe and effective approach in short-term management of morbid obesity. Weight loss, resolution of comorbidities and improvement in QOL were comparable between both groups.

Development and application of the Imperial College Obesity Strategy Assessment Framework for analysing local obesity strategies

BACKGROUND

Obesity is a major public health issue because of its increasing prevalence and impact on health. The management of overweight and obesity has been a government priority for many years. However, overweight and obesity management at a local level has often been ineffective. Although there is a need to examine obesity strategies and policies for local populations, there is currently no readily available framework for evaluating local obesity strategies. We therefore developed a framework, the Imperial College Obesity Strategy Assessment Framework (IC-OSAF), for examining the content of local obesity strategies.

METHODS

We adapted two previous policy analysis frameworks (Bardach's Eightfold Path Framework and Collins' Health Policy Analysis Framework) and used these with information from national guidelines to develop an obesity strategy analysis framework. We then piloted this framework using the obesity strategy for one London primary care trust (PCT).

RESULTS

The framework was applied successfully and helped identify limitations and omissions in the PCT obesity management strategy.

CONCLUSIONS

The IC-OSAF is a practical, easy-to-use tool for the analysis of local obesity management strategies. The framework can help identify gaps and limitations in strategies to help reduce variations in obesity management between PCTs.

Short-term medication cost savings for treating hypertension and diabetes after gastric bypass

BACKGROUND

The cost of medication for the treatment of hypertension and diabetes in the morbidly obese is a significant economic healthcare burden. In the present study, we assessed the effect of gastric bypass surgery on the average annual costs for hypertension and diabetes medication.

METHODS

A prospective database of gastric bypass patients at the Palo Alto Veterans Affairs Health Care System was reviewed. The preoperative and postoperative medication requirements to treat hypertension and diabetes were identified before surgery and at 1 year postoperatively. Comparisons were made between the annual costs of the antihypertensive and diabetic medications before and after bariatric surgery using the Student paired t test.

RESULTS

Of 106 patients who had undergone gastric bypass, 90 (85%) had either hypertension or diabetes. Of these 90 patients, 88 (98%) had hypertension and 60 (67%) had diabetes before surgery. Complete remission of hypertension occurred in 44% and remission of diabetes in 80% at 1 year after surgery. The annual cost of medications to treat hypertension was reduced by 65% at 1 year after surgery ($63.52 compared with $20.50, P < .0001). To treat diabetes, the annual medication cost was reduced by 88% at 1 year after gastric bypass surgery ($532.06 compared with $64.58, P < .0001). In the subset of patients with persistent hypertension or diabetes after surgery, the annual cost reduction for antihypertensive medications was 58% ($87.14 versus $36.82, P < .002). The annual cost reduction for diabetic medications was 69% ($1036.60 versus $322.90, P < .02).

CONCLUSION

Gastric bypass surgery resulted in a significant reduction in the cost of medications to treat hypertension and diabetes in the morbidly obese at 1 year after surgery. These cost savings were also significant in the subset of patients who had persistent hypertension and diabetes after surgery.

The use of serotonergic drugs to treat obesity--is there any hope?

Surgical interventional strategies for the treatment of obesity are being implemented at an increasing rate. The safety and feasibility of these procedures are questionable for most overweight or obese individuals. The use of long-term pharmacotherapy options, on the other hand, can target a greater portion of the obese population and provide early intervention to help individuals maintain a healthy lifestyle to promote weight loss. Medications that act on the central serotonergic pathways have been a relative mainstay for the treatment of obesity for the last 35 years. The clinical efficacy of these drugs, however, has been encumbered by the potential for drug-associated complications. Two drugs that act, albeit by different mechanisms, on the central serotonergic system to reduce food intake and decrease body weight are sibutramine and lorcaserin. Sibutramine is a serotonin and norepinephrine reuptake inhibitor, whereas lorcaserin is a selective 5HT_2C receptor agonist. The recent worldwide withdrawal of sibutramine and FDA rejection of lorcaserin has changed the landscape not only for serotonin-based therapeutics specifically, but for obesity pharmacotherapy in general. The purpose of this review is to focus on the importance of the serotonergic system in the control of feeding and its potential as a target for obesity pharmacotherapy. Advances in refining and screening more selective receptor agonists and a better understanding of the potential off-target effects of serotonergic drugs are needed to produce beneficial pharmacotherapy.

Weight Management in Overweight and Obese Patients with Type 2 Diabetes Mellitus

Obesity is recognised as an important risk factor for type 2 diabetes, inducing insulin resistance and pancreatic beta-cell dysfunction. These obesity-related defects tend to progress following weight gain and can eventually lead to worsening hyperglycaemia over time. Thus, effective weight management is crucial for glycaemic control in overweight and obese patients with type 2 diabetes. Current standard strategies for weight management in these patients include lifestyle interventions and pharmacotherapy. Bariatric surgery has become a promising new option for the treatment of obese patients with type 2 diabetes and in recent years incretin-based therapies have become available, which exhibit favourable effects on body weight. Herein, the efficacy of available weight loss interventions is assessed and the role of newer antidiabetic agents examined, focusing on incretin-based therapies.

Obesity management interventions: a review of the evidence

The burden of disease associated with the obesity epidemic shortens lives, and prevalence is accelerating. As with other chronic diseases, improved outcomes are associated with effective self-management of obesity across the life span. The disease of obesity, then, fits squarely within the disease management and chronic care models. This article reviews selected interventions, described in peer-reviewed literature, designed to achieve significant weight loss for individuals identified as overweight or obese. The study objective is to provide an overview of the full range of methods and models for weight loss, including some available without medical supervision. The intended audience includes individuals and organizations with an expressed interest in disease management and the chronic care models. Our review identified promising lines of investigation for future research that span diverse medical disciplines applied to obesity. The quality of the studies included in our review was uneven, and compromises the current evidence for effectiveness and efficacy. Generally, our results showed that combination approaches-surgical or pharmacologic, combined with a behavioral intervention-were most likely to be effective.

Factors associated with weight loss after gastric bypass

BACKGROUND

Gastric bypass (GBP) is the most common operation performed in the United States for morbid obesity. However, weight loss is poor in 10% to 15% of patients. We sought to determine the independent factors associated with poor weight loss after GBP.

DESIGN

Prospective cohort study. We examined demographic, operative, and follow-up data by means of multivariate analysis. Variables investigated were age, sex, race, marital and insurance status, initial weight and body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared), comorbidities (diabetes mellitus, hypertension, joint disease, sleep apnea, hyperlipidemia, and psychiatric disease), laparoscopic vs open surgery, gastric pouch area, gastrojejunostomy technique, and alimentary limb length.

SETTING

University tertiary referral center.

PATIENTS

All patients at our institution who underwent GBP from January 1, 2003, through July 30, 2006.

MAIN OUTCOME MEASURES

Weight loss at 12 months defined as poor (< or =40% excess weight loss) or good (>40% excess weight loss).

RESULTS

Follow-up data at 12 months were available for 310 of the 361 patients (85.9%) undergoing GBP during the study period. Mean preoperative BMI was 52 (range, 36-108). Mean BMI and excess weight loss at follow-up were 34 (range, 17-74) and 60% (range, 8%-117%), respectively. Thirty-eight patients (12.3%) had poor weight loss. Of the 4 variables associated with poor weight loss in the univariate analysis (greater initial weight, diabetes, open approach, and larger pouch size), only diabetes (odds ratio, 3.09; 95% confidence interval, 1.35-7.09 [P = .007]) and larger pouch size (odds ratio, 2.77;95% confidence interval, 1.81-4.22 [P <.001]) remained after the multivariate analysis.

CONCLUSIONS

Gastric bypass results in substantial weight loss in most patients. Diabetes and larger pouch size are independently associated with poor weight loss after GBP.

Cost-utility analysis of rimonabant in the treatment of obesity

OBJECTIVE

To estimate the incremental cost-utility ratio (ICUR) of rimonabant 20 mg/day in the treatment of obesity from a third-party payer's perspective.

METHODS

Pooled data from three randomized clinical trials were used to develop a decision tree with five treatment alternatives: 1- and 2-year treatment with rimonabant, 2-year placebo, 1-year rimonabant followed by 1-year placebo, and no treatment. All alternatives, except no treatment, were accompanied by lifestyle interventions. Treatment benefits included gains in quality-adjusted life-years (QALYs) and reduced incidence of type-2 diabetes mellitus and coronary heart disease (CHD). Drug acquisition cost was based on the average wholesale price of a comparator drug minus 15%. One-way and probabilistic sensitivity analyses were conducted to assess the stability of the base-case results.

RESULTS

One-year rimonabant and 1-year rimonabant followed by placebo were extensively dominated. Rimonabant for 2 years showed an average weight reduction of 8.49 kg, a body mass index reduction of 2.98 kg/m(2) and reduced waist circumference by 8.24 cm (placebo: 3.55 kg, 1.22 kg/m(2), 4.18 cm). Two-year rimonabant was associated with a relative reduction in the 5-year incidence of CHD by 7.15% and of diabetes by 9.28%. Incremental benefits (costs) were 0.0984 QALYs ($5209) compared to no treatment and 0.0581 QALYs ($4182) compared to placebo, producing ICURs of $52,936/QALY (95% confidence interval $39K-$69K) and $71,973/QALY ($51K-$98K), respectively.

CONCLUSIONS

Rimonabant combined with lifestyle interventions has the potential to decrease the rate of obesity-related comorbidities and improve health-related quality of life, albeit at considerable cost.

The comparative effects of bariatric surgery on weight and type 2 diabetes

BACKGROUND

Epidemiological evidence confirms that risk of developing type 2 diabetes is related to weight gain. Weight reduction is beneficial as relative risk is reduced to 0.13 for weight loss >20 kg. This raises the question of effectiveness of bariatric surgery on 1) weight loss and 2) diabetes-related outcomes in morbidly obese patients.

METHODS

We reviewed the literature using Medline. Only 2 meta-analyses reporting on both outcomes were included, as well as 50 systematic reviews or primary studies.

RESULTS

Meta-analyses mainly based on case series data as well as controlled studies confirm that bariatric surgery is highly effective in obtaining weight reduction in morbidly obese patients up to 60% of the excess weight, along with resolution of preoperative diabetes in more than 75% of cases. Among bariatric surgery techniques, malabsorptive procedures (biliopancreatic diversion and gastric bypass) appear to be more effective on both outcomes than restrictive procedures (gastroplasty and gastric banding).

CONCLUSION

Even if more studies are needed to confirm current evidence, bariatric surgery is effective for controlling diabetes. It appears as an efficient strategy from economic modeling due to savings from reduction in diabetes-related costs.

Is a model useful in exploring the catabolic mechanisms of weight loss after gastric bypass in humans?

PURPOSE OF REVIEW

In the USA, approximately 3% of adults are morbidly obese, in whom behavior modification and drug therapy is ineffective in inducing major weight loss. Surgery is their only reliable option. The Roux-en-Y gastric bypass accounts for 90% of all bariatric surgeries because it achieves the best weight loss results. Many studies describe weight loss and changes in metabolic blood parameters after Roux-en-Y gastric bypass. We compare recent human data with the findings in our rats to validate the versatility of using a Roux-en-Y gastric bypass rat model to explore the multifactorial molecular and physiological dimensions of weight loss and weight regain.

RECENT FINDINGS

Not only mechanical factors but also changes in gastrointestinal and adipose hormones and hypothalamic neuropeptides contribute to Roux-en-Y gastric bypass induced weight loss by promoting catabolic processes. Nevertheless, the exact mechanisms of weight loss remain unknown.

SUMMARY

To investigate these catabolic mechanisms we used our Roux-en-Y gastric bypass rat model in diet induced obese rats. We found clear morphometric, physiological and biochemical parallelisms between humans and our rats. It is likely that Roux-en-Y gastric bypass induces similar changes in hypothalamic neuropeptides which can only be studied using the rat model. It therefore provides a useful research tool for exploring and studying the development of adjuvant antiobesity therapies.

Bariatric surgery training: getting your ticket punched

Laparoscopic bariatric surgery has gained popularity but has been proven to be a technically challenging set of operations that requires a long learning curve. Trainees must acquire advanced laparoscopic skills and knowledge of the perioperative care of the bariatric patient. The challenge is to ensure that those surgeons performing gastric bypass, gastric banding, and duodenal switch procedure are trained appropriately. In the past, very different opportunities have been available for the general surgeon seeking to practice bariatric surgery. Early on, many surgeons began performing bariatric surgery without any formal training. Later, weekend courses, mini-fellowships, and formal minimally invasive surgery/bariatric fellowships were established. Today, best practice requires an intensive training experience and ongoing commitment to the field.

Obesity, Weight Management, and Health Care Costs: A Primer

Rational decision-making regarding health care spending for weight management requires an understanding of the cost of care provided to obese patients and the potential cost-effectiveness or cost savings of interventions. The purpose of this review is to assist health plans and disease management leaders in making informed decisions for weight management services. Among the review's findings, obesity and severe obesity are strongly and consistently associated with increased health care costs. The cost-effectiveness of obesity-related interventions is highly dependent on the risk status of the treated population, as well as the length, cost, and effectiveness of the intervention. Bariatric surgery offers high initial costs and uncertain long-term cost savings. From the perspective of a payor, obesity management services are as cost-effective as other commonly offered health services, though not likely to offer cost savings. Behavioral health promotion interventions in the worksite setting provide cost savings from the employer's perspective, if decreased rates of absenteeism are included in the analysis.

The cost of laparoscopic myotomy versus pneumatic dilatation for esophageal achalasia

BACKGROUND

The two main treatment options for esophageal achalasia are laparoscopic distal esophageal myotomy (LM) and pneumatic dilatation (PD). Our objective was to compare the costs of these management strategies.

METHODS

We constructed a decision analytic model consisting of two treatment strategies for patients diagnosed with achalasia. Probabilities of events were systematically derived from a literature review, supplemented by expert opinion when necessary. Costs were estimated from the perspective of a third-party payer and society, including both direct and indirect costs. Future costs were discounted at a rate of 5.5% over a time horizon of 5 and 10 years. Uncertainty in the probability estimates was incorporated using probabilistic sensitivity analyses. We tested uncertainty in the model by modifying key assumptions and repeating the analysis.

RESULTS

From the societal perspective, the expected cost per patient was $10,789 (LM) compared with $5,315 (PD) five years following diagnosis, and $11,804 (LM) compared with $7,717 (PD) after 10 years. The 95% confidence interval of the incremental cost per patient treated with LM was ($5,280, $5,668) after five years, and ($3,863, $4,311) after 10 years. The incremental cost of LM was similar from the third-party payer perspective and in the secondary model analyzed.

CONCLUSIONS

Initial LM is a more costly management strategy under all clinically plausible scenarios tested in this model. Further research is needed to determine patients' preferences for the two treatment modalities, and society's willingness to bear the incremental cost of LM for those who choose it.

Paid Work Increases and State Benefit Claims Decrease after Bariatric Surgery

BACKGROUND

Bariatric surgery is a clinically effective treatment for obesity and has been shown to be cost-effective. The impact of bariatric surgery on the subsequent ability to work and the uptake of state-funded benefits is not well documented.

METHODS

A consecutive series of 79 patients who had undergone laparoscopic Roux-en-Y gastric bypass (LRYGBP) or laparoscopic adjustable gastric banding (LAGB) were surveyed to assess changes in their ability to work and the number and type of state benefits claimed after surgery.

RESULTS

59 patients (75%) responded, median age 45, median follow-up 14 months. There was a 32% increase in the number of respondents in paid work after surgery (P<0.05). The mean weekly hours worked increased from 30.1 to 35.8 hours (P<0.01). Respondents also reported a decrease in obesity-related physical and emotional constraints on their ability to do work (P<0.01). Fewer patients claimed state benefits postoperatively (P<0.01).

CONCLUSION

More patients perform paid work after LRYGBP and LAGB than beforehand, and the number of weekly hours they work increases. After surgery, patients claim fewer state benefits.

Financial impact of obesity and bariatric surgery

Obesity constitutes a major health problem with serious social and economic consequences worldwide. In North America, nearly one third of the population is obese, and this figure includes children and adolescents who are likely to become obese adults. Obesity carries a great financial impact on society; consequently, treating morbidly obese patients with surgery may offer substantial economic savings. This article summarizes the financial burdens of obesity and the economics of treating obesity in North America. It addresses the medical effectiveness and cost-effectiveness of bariatric surgery and the new regulations and accreditations for bariatric surgery programs.

Cost-return prediction in morbidly obese employees following weight loss interventions: a study framework

Obesity and its many complications potentially can collapse most medical plans, unless attempts at prevention and therapy become more effective and widespread. An important incentive for providing effective treatment is proper reimbursement. We present here an evaluation of the feasibility, constrains and requirements for comparative cost-effectiveness evaluation of weight loss intervention from the payer's and employer's points of view, and propose a general framework for this type of studies toward decision making.

Coming to a facility near you: the bariatric surgery patient

Bariatric surgery is an increasingly popular intervention for morbid obesity, defined as a BMI>40. Its propensity to cause rapid weight loss can alleviate, if not resolve, obesity's comorbidities. Until recently, people older than 65 have been excluded by age in most established criteria because of a perception of great risk. Recent studies demonstrate that some elders, however, can benefit from bariatric surgery, and the surgery can be performed safely. Surgeons currently perform two types of procedures: restrictive and/or malabsorptive. Immediate risks of surgery are identical to other surgeries, but several additional risks, including an acute syndrome unique to bariatric surgery (APGARS) and rhabdomyolysis, have been identified in bariatric surgery patients. In the long term, four conditions may arise: symptomatic cholelithiasis, dumping syndrome, nutritional deficiencies, and panniculitis. All of these are preventable, and correctable, should they occur. As the high-risk population that undergoes bariatric surgery ages, consultant pharmacists should anticipate bariatric patients' life-long needs.