Excess use of general practitioners by obese adults: Does health-related quality of life account for the association?

Utilization of hospital services by obese patients before and after bariatric surgery

PURPOSE

To compare the utility of various hospital services used by morbidly obese patients before and after bariatric surgery.

METHODS

The subjects of this retrospective study were 73 consecutive patients, who underwent elective laparoscopic bariatric surgery between May 2008 and December 2010. There were 58 women and 15 men, with a median age of 45 years (IQR 26-65 years). The preoperative period ranged from 42 to 72 months (median 60 months) and the follow-up period ranged from 12 to 42 months (median 24 months). The health services analyzed included visits to emergency and outpatient departments, admissions to hospital, length of stay in hospital, and changes in regular medication before and after surgery. We also analyzed the economic results.

RESULTS

In the post-procedure period, outpatient clinic visits were reduced by 13.8% per year (p = 0.04), the number of hospital admissions per year were reduced by 40.2% (p = 0.01), the total length of stay in hospital was reduced by 52.28% per year (p = 0.04), and regular medications were reduced by 26% (p = 0.003). There was no change in the use of emergency services. The total estimated cost saving ranged between $32,593 and 41,177 per year.

CONCLUSION

The utilization of various health services decreased soon after bariatric surgery, which translated into significant cost savings. This was mainly due to each patient's reduction in body weight and improvement in their chronic metabolic disorders.

Body weight changes and outpatient medical care utilisation: Results of the MONICA/KORA cohorts S3/F3 and S4/F4

Objectives: To test the effects of body weight maintenance, gain, and loss on health care utilisation in terms of outpatient visits to different kinds of physicians in the general adult population.

Methods: Self-reported utilisation data were collected within two population-based cohorts (baseline surveys: MONICA-S3 1994/95 and KORA-S4 1999/2001; follow-ups: KORA-F3 2004/05 and KORA-F4 2006/08) in the region of Augsburg, Germany, and were pooled for present purposes. N=5,147 adults (complete cases) aged 25 to 64 years at baseline participated. Number of visits to general practitioners (GPs), internists, and other specialists as well as the total number of physician visits at follow-up were compared across 10 groups defined by body mass index (BMI) category maintenance or change. Body weight and height were measured anthropometrically. Hierarchical generalized linear regression analyses with negative binomial distribution adjusted for sex, age, socioeconomic status (SES), survey, and the need factors incident diabetes and first cancer between baseline and follow-up were conducted.

Results: In fully adjusted models, compared to the group of participants that maintained normal weight from baseline to follow-up, the following groups had significantly higher GP utilisation rates: weight gain from normal weight (+36%), weight loss from preobesity (+39%), maintained preobesity (+34%), weight gain after preobesity (+43%), maintained moderate obesity (+48%), weight gain from moderate obesity (+107%), weight loss from severe obesity (+114%), and maintained severe obesity (+83%). Regarding internists, those maintaining moderate obesity reported +107% more visits; those with weight gain from moderate obesity reported +91%. The latter group also had +41% more consultations with other physicians. Across all physicians, mean number of visits were estimated at 7.8 per year for maintained normal weight, 9 for maintained preobesity, 11 for maintained moderate obesity, and 12 for maintained severe obesity. Among those with weight loss, the mean number of visits were 8.7, 10.6 and 10.8 for baseline preobesity, moderate obesity, and severe obesity, respectively. Finally, those with weight gain from normal weight and preobesity reported 9.4 and 9.3 visits, respectively, and those with baseline moderate and follow-up severe obesity reported 13.1 visits (the most overall). Women reported higher GP and other physician utilisation. While all utilisation rates increased with age, GP utilisation was lower in middle to high SES groups.

Conclusion: Compared to maintained normal weight over a 7- to 10-year period, maintained overweight, weight gain and weight loss are associated with higher outpatient physician utilisation in adults, especially after baseline obesity. These effects only partly became insignificant after inclusion of incident diabetes or first cancer into the model. Future research should further elucidate the associations between weight development and health care utilisation by BMI status and the mechanisms underlying these associations.

Future direct and indirect costs of obesity and the influence of gaining weight: results from the MONICA/KORA cohort studies, 1995-2005

Over the last two decades, the prevalence of obesity has risen worldwide. As obesity is a confirmed risk factor for a number of diseases, its increasing prevalence nurtures the supposition that obesity may present a growing and significant economic burden to society. The objective of this study is to analyse the correlation between body mass index (BMI) and future direct and indirect costs, as well as the correlation between changing BMI and future in(direct) costs. Health care utilisation and productivity losses were based on data from 2581 participants aged 25-65 years (1994/95) from two cross-sectional, population-representative health surveys (MONICA/KORA-survey-S3 1994/95 and follow-up KORA-survey-F3 2004/05) in Augsburg, Germany. The predicted average adjusted total direct costs per year and per user were estimated to be €1029-(healthy weight), €1093-(overweight) and €1040-(obesity). There are significantly greater future costs in the utilisation of general practitioners per user and per year at higher obesity levels (€72; €75; €96). The average total direct costs per person for those who stay in the same BMI class are €982, €1000 and €973. An overweight participant who becomes obese incurs significant costs of internists of €160 compared with those who remain overweight (€124). An overweight user incurs indirect costs of €2474, compared with €2136 for those who remain a healthy weight. There is a trend for higher predicted (in)direct costs when people are overweight or obese compared with healthy weight persons 10 years earlier. Potential cost savings could be attained if preventive programs effectively targeted these individuals.

Excess direct medical costs of severe obesity by socioeconomic status in German adults

Objective: Excess direct medical costs of severe obesity are by far higher than of moderate obesity. At the same time, severely obese adults with low socioeconomic status (SES) may be expected to have higher excess costs than those with higher SES, e.g. due to more comorbidities. This study compares excess costs of severe obesity among German adults across different SES groups.

Methods: In a subsample (N=947) of the KORA-Survey S4 1999/2001 (a cross-sectional health survey in the Augsburg region, Germany; age group: 25–74 years), visits to physicians, inpatient days in hospital, and received and purchased medication were assessed via computer-assisted telephone interviews (CATI) over half a year. Body mass index (BMI in kg/m²) was measured anthropometrically. SES was determined via reports of education, income, and occupational status from computer-assisted personal interviews (CAPI) (used both as single indicators, and as indexed by the Helmert algorithm); due to small subsample sizes all were median-split. Data of respondents in normal weight (18.5 ≤ BMI < 25), preobese (25 ≤ BMI < 30), moderately (class 1:30 ≤ BMI < 35) and severely obese (classes 2–3: BMI ≥ 35) range were analysed by generalized linear models with mixed poisson-gamma (Tweedie) distributions. Physician visits and inpatient days were valuated as recommended by the Working Group Methods in Health Economic Evaluation (AG MEG), and drugs were valuated by actual costs. Sex, age, kind of sickness fund (statutory/private) and place of residence (urban/rural) were adjusted for, and comorbidities were considered by the Physical Functional Comorbidity Index (PFCI).

Results: Excess costs of severe obesity were higher in respondents with high SES, regardless of the SES indicator used. For instance, annual excess costs were almost three times higher in those with an above-median SES-Index as compared with those with a median or lower SES-Index (plus € 2,966 vs. plus € 1,012; contrast significant at p<.001). Mediation of excess costs of severe obesity by physical comorbidities pertained to the low SES-Index and the low occupational status groups: differences in costs between severe obesity and normal weight were still positive, but statistically insignificant, in the lower status groups after adjusting for the PFCI, but still positive and significant given higher SES. For example, severe obesity’s excess costs were € 2,406 after PFCI-adjustment in the high SES-Index group (p<.001), but € 539 in the lower status group (p=.17). At the same time, physical comorbidities as defined by the PCFI increased with BMI and decreased with SES, however the factors BMI and SES did not significantly interact in this context.

Conclusions: To our knowledge, this is the first study to show in Germany that excess direct medical costs of severe obesity are not distributed equitably across different SES groups, do not reflect comorbidity status, and are significantly higher in those with high SES than in those with lower SES. Thus, allocation of health care resources spent on severely obese adults seems to be in need of readjustment towards an equitable utilization across all socioeconomic groups.