Health Care Utilization and Expenditure Changes Associated With Bariatric Surgery

Bariatric arterial embolization slows gastric emptying and improves postprandial glycaemia in obese dogs with impaired glucose tolerance

AIM

To evaluate the effects of bariatric arterial embolization (BAE) on gastric emptying of, and the glycaemic response to, an oral glucose load in an obese canine model with impaired glucose tolerance.

METHODS

Eleven male dogs were fed a high-fat, high-fructose diet for 7 weeks before receiving BAE, which involved selective embolization of the left gastric artery (n = 5; 14.9 ± 0.8 kg), or the sham (n = 6; 12.6 ± 0.8 kg) procedure. Postprocedural body weight was measured weekly for 4 weeks. Prior to and at 4 weeks postprocedure, a glucose solution containing 13C-acetate was administered orally for evaluation of the gastric half-emptying time (T50) and the glycaemic response. The relationship between the changes in the blood glucose area under the curve over the first 60 minutes (AUC0-60min) and the T50 was also assessed.

RESULTS

At 4 weeks postprocedure, BAE reduced body weight (BAE vs. the sham procedure: -5.7% ± 0.9% vs. 3.5% ± 0.9%, P < .001), slowed gastric emptying (T50 at baseline vs. postprocedure: 75.5 ± 2.0 vs. 82.5 ± 1.8 minutes, P = .021 in the BAE group; 73.8 ± 1.8 vs. 74.3 ± 1.9 minutes in the sham group) and lowered the glycaemic response to oral glucose (AUC0-60min at baseline vs. postprocedure: 99.2 ± 13.7 vs. 67.6 ± 9.8 mmol·min/L, P = .043 in the BAE group; 100.2 ± 13.4 vs. 103.9 ± 14.6 mmol·min/L in the sham group). The change in the glucose AUC0-60min correlated inversely with that of the T50 (r = -0.711; P = .014).

CONCLUSIONS

In a canine model with impaired glucose tolerance, BAE, while reducing body weight, slowed gastric emptying and attenuated the glycaemic response to an oral glucose load.

Resource utilization and disaggregated cost analysis of bariatric surgery in the Australian public healthcare system

OBJECTIVES

To present a comprehensive real-world micro-costing analysis of bariatric surgery.

METHODS

Patients were included if they underwent primary bariatric surgery (gastric banding [GB], gastric bypass [GBP] and sleeve gastrectomy [SG]) between 2013 and 2019. Costs were disaggregated into cost items and average-per-patient costs from the Australian healthcare systems perspective were expressed in constant 2019 Australian dollars for the entire cohort and subgroup analysis. Annual population-based costs were calculated to capture longitudinal trends. A generalized linear model (GLM) predicted the overall bariatric-related costs.

RESULTS

N = 240 publicly funded patients were included, with the waitlist times of ≤ 10.7 years. The mean direct costs were $11,269. The operating theatre constituted the largest component of bariatric-related costs, followed by medical supplies, salaries, critical care use, and labour on-costs. Average cost for SG ($12,632) and GBP ($15,041) was higher than that for GB ($10,049). Operating theatre accounted for the largest component for SG/GBP costs, whilst medical supplies were the largest for GB. We observed an increase in SG and a decrease in GB procedures over time. Correspondingly, the main cost driver changed from medical supplies in 2014-2015 for GB procedures to operating theatre for SG thereafter. GLM model estimates of bariatric average cost ranged from $7,580 to $36,633.

CONCLUSIONS

We presented the first detailed characterization of the scale, disaggregated profile and determinants of bariatric-related costs, and examined the evolution of resource utilization patterns and costs, reflecting the shift in the Australian bariatric landscape over time. Understanding these patterns and forecasting of future changes are critical for efficient resource allocation.

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.

Determining the incidence of postbariatric surgery emergency department utilization: an analysis of a statewide insurance database

BACKGROUND

Prior studies have found rates of emergency department (ED) visits after bariatric surgery approach 15% with the majority (>60%) not requiring admission. The timeframe for which ED utilization remains elevated postoperatively remains unknown. We hypothesize that ED utilization following bariatric surgery remains elevated for months after surgery with the majority of visits not requiring admission.

OBJECTIVE

No study has determined the impact bariatric surgery has on health care resource utilization in the two years following surgery. The aim of this study is to determine the frequency of ED visitation in the 2 years following bariatric surgery.

SETTINGS

Database study, single state-wide insurance database.

METHODS

We queried the Colorado All Payers Claim Database. Patients with data 1 year before and 2 years after surgery were included. Primary outcomes of interest were ED visits or readmissions during the 2-year period. Bariatric surgeries were identified using CPT codes. Diagnoses for an ED visit or readmission were determined by ICD codes.

RESULTS

A total of 5399 patients underwent bariatric surgery from January 2013-November 2017. Of these, 59% underwent sleeve gastrectomy, 38% Roux-en-Y, 2% gastric band, and 1% another surgery. Median age was 44 (IQR 35-54) years, and 82% were female. Overall, 3103 patients (57%) visited the ED at least once with a total of 12,988 visits, 1267 of which (9.8%) resulted in admission. ED use was highest in the 30 days following surgery (17%) but remained above presurgery baseline for 8 months (7.4% at 8 mo compared with baseline mean 6.4% [95% CI 6.0%-6.8%]).

CONCLUSIONS

ED visits remain elevated for 8 months post bariatric surgery with over 90% of visits not requiring an admission. Interventions that prevent emergency department utilization should be key focus of quality improvement projects to limit health care resource utilization following bariatric surgery.

Association of Roux-en-Y Gastric Bypass With Postoperative Health Care Use and Expenditures in Canada

Importance

Results of previous studies are mixed regarding the economic implications of a Roux-en-Y gastric bypass (RYGB).

Objective

To assess the 5-year incremental health care use and expenditures after RYGB.

Design, Setting, and Participants

This population-based cohort study conducted in Ontario, Canada, used a difference-in-differences approach to compare health care use and expenditures between patients who underwent a publicly funded RYGB from March 1, 2010, to March 31, 2013, and propensity score-matched control individuals who did not undergo a surgical bariatric procedure. The study period allowed for a minimum 60 months of follow-up because, at that time, the most recent date for which administrative data on health care and expenditures were available was March 31, 2018. Data sources included the Ontario Bariatric Registry linked to several Ontario health administrative databases and the Electronic Medical Record Administrative Data Linked Database. Health care use and expenditures data for 5 years before and 5 years after the index date (procedure date for RYGB group; random date for controls) were analyzed. Data analyses were performed March 12, 2019, to March 10, 2020.

Intervention

RYGB procedure.

Main Outcomes and Measures

The primary outcome was total health care expenditures.

Results

The final propensity score-matched cohorts comprised 1587 individuals in the RYGB group (mean [SD] age, 47 [10.2] years) and 1587 controls (mean [SD] age, 47 [12.2] years); each group had 1228 women (77.4%) and a mean body mass index (calculated as weight in kilograms divided by height in meters squared) of 46. Mean total health care expenditures (2017 Canadian dollars) per patient in the RYGB group increased from CAD $15 594 (95% CI, CAD $14 743 to CAD $16 614) (US $12 008 [95% CI, US $11 353 to US $12 794]) in the 5 years before the procedure to CAD $30 389 (95% CI, CAD $28 789 to CAD $32 232) (US $23 401 [95% CI, US $22 169 to US $24 821]) over the 5 years after the procedure, a difference of CAD $14 795 (95% CI, CAD $13 172 to CAD $16 480) (US $11 393 [95% CI, US $10 143 to US $12 691]). For the control group, mean total health care expenditures per individual increased from CAD $16 109 (95% CI, CAD $14 727 to CAD $17 591) (US $12 405 [95% CI, US $11 341 to US $13 546]) 5 years before the index date to CAD $20 073 (95% CI, CAD $18 147 to CAD $22 169) (US $15 457 [95% CI, US $13 974 to US $17 071]) 5 years after the date, a difference of CAD $3964 (95% CI, CAD $2250 to CAD $5875) (US $3053 [95% CI, US $1733 to US $4524]). Overall, the difference-in-differences estimate of the net cost of RYGB was CAD $10 831 (95% CI, CAD $8252 to CAD $13 283) (US $8341 [95% CI, $6355 to $10 229]) over the 5-year period. This amount excluded the mean (SD) cost associated with the index date: CAD $6501 (CAD $1087) (US $5006 [US $837]) for the RYGB cohort and CAD $9 (CAD $72) (US $7 [US $55]) for the controls. The cost differential was primarily associated with increased hospitalizations in the first months immediately after RYGB. Expenditures leveled off in year 3 after the index date; differences in total expenditures between the RYGB and control cohorts were not statistically significantly different in years 4 and 5.

Conclusions and Relevance

Health care expenditures in the 3 years after publicly funded RYGB were higher in patients who underwent the procedure than in control individuals, but the costs were similar thereafter. This finding suggests the need to decrease hospital and emergency department readmissions after surgical bariatric procedures because such use is associated with increased spending.

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.

The effect of bariatric surgery on health care costs: A synthetic control approach using Bayesian structural time series

Surgical measures to combat obesity are very effective in terms of weight loss, recovery from diabetes, and improvement in cardiovascular risk factors. However, previous studies found both positive and negative results regarding the effect of bariatric surgery on health care utilization. Using claims data from the largest health insurance provider in Germany, we estimated the causal effect of bariatric surgery on health care costs in a time period ranging from 2 years before to 3 years after bariatric intervention. Owing to the absence of a control group, we employed a Bayesian structural forecasting model to construct a synthetic control. We observed a decrease in medication and physician expenditures after bariatric surgery, whereas hospital expenditures increased in the post-intervention period. Overall, we found a slight increase in total costs after bariatric surgery, but our estimates include a high degree of uncertainty.

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.

Bariatric Arterial Embolization: Effect of Microsphere Size on the Suppression of Fundal Ghrelin Expression and Weight Change in a Swine Model

Purpose To determine whether microsphere size effects ghrelin expression and weight gain after selective bariatric arterial embolization (BAE) in swine. Materials and Methods BAE was performed in 10 swine by using smaller (100-300 μm; n = 5) or larger (300-500 μm; n = 5) calibrated microspheres into gastric arteries. Nine control pigs underwent a sham procedure. Weight and fasting plasma ghrelin levels were measured at baseline and weekly for 16 weeks. Ghrelin-expressing cells (GECs) in the stomach were assessed by using immunohistochemical staining and analyzed by using the Wilcoxon rank-sum test. Results In pigs treated with smaller microspheres, mean weight gain at 16 weeks (106.9% ± 15.0) was less than in control pigs (131.9% ± 11.6) (P < .001). Mean GEC density was lower in the gastric fundus (14.8 ± 6.3 vs 25.0 ± 6.9, P < .001) and body (27.5 ± 12.3 vs 37.9 ± 11.8, P = .004) but was not significantly different in the gastric antrum (28.2 ± 16.3 vs 24.3 ± 11.6, P = .84) and duodenum (9.2 ± 3.8 vs 8.7 ± 2.9, P = .66) versus in control pigs. BAE with larger microspheres failed to suppress weight gain or GECs in any stomach part compared with results in control swine. Plasma ghrelin levels were similar between BAE pigs and control pigs, regardless of microsphere size. Week 1 endoscopic evaluation for gastric ulcers revealed none in control pigs, five ulcers in five pigs embolized by using smaller microspheres, and three ulcers in five pigs embolized by using larger microspheres. Conclusion In bariatric arterial embolization, smaller microspheres rather than larger microspheres showed greater weight gain suppression and fundal ghrelin expression with more gastric ulceration in a swine model. © RSNA, 2018.

Diverse approaches to the health economic evaluation of bariatric surgery: a comprehensive systematic review

BACKGROUND

Health economic evaluations inform healthcare resource allocation decisions for treatment options for obesity including bariatric/metabolic surgery. As an important advance on existing systematic reviews, we aimed to capture, summarize and synthesize a diverse range of economic evaluations on bariatric surgery.

METHODS

Studies were identified by electronic screening of all major biomedical/economic databases. Studies included if they reported any quantified health economic cost and/or consequence with a measure of effect for any type of bariatric surgery from 1995 to September 2015. Study screening, data extraction and synthesis followed international guidelines for systematic reviews.

RESULTS

Six thousand one hundred eighty-seven studies were initially identified. After two levels of screening, 77 studies representing 17 countries (56% USA) were included. Despite study heterogeneity, common themes emerged, and important gaps were identified. Most studies adopted the healthcare system/third-party payer perspective; reported costs were generally healthcare resource use (inpatient/shorter-term outpatient). Out-of-pocket costs to individuals, family members (travel time, caregiving) and indirect costs due to lost productivity were largely ignored. Costs due to reoperations/complications were not included in one-third of studies. Body-contouring surgery included in only 14%. One study evaluated long-term waitlisted patients. Surgery was cost-effective/cost-saving for severely obese with type 2 diabetes mellitus. Study quality was inconsistent.

DISCUSSION

There is a need for studies that assume a broader societal perspective (including out-of-pocket costs, costs to family and productivity losses) and longer-term costs (capture reoperations/complications, waiting, body contouring), and consequences (health-related quality-of-life). Full economic evaluation underpinned by reporting standards should inform prioritization of patients (e.g. type 2 diabetes mellitus with body mass index 30 to 34.9 kg/m(2) or long-term waitlisted) for surgery. © 2016 World Obesity.

Clinical Outcomes of Metabolic Surgery: Microvascular and Macrovascular Complications

Understanding of the long-term clinical outcomes associated with bariatric surgery has recently been advanced. Research related to the sequelae of diabetes-in particular, long-term microvascular and macrovascular complications-in patients who undergo weight-loss surgery is imperative to this pursuit. While numerous randomized control trials have assessed glucose control with bariatric surgery compared with intensive medical therapy, bariatric surgery outcome data relating to microvascular and macrovascular complications have been limited to observational studies and nonrandomized clinical trials. As a result, whether bariatric surgery is associated with a long-term reduction in microvascular and macrovascular complications when compared with current intensive glycemic control therapy cannot be determined because the evidence is insufficient. However, the consistent salutary effects of bariatric surgery on diabetes remission and glycemic improvement support the opportunity (and need) to conduct high-quality studies of bariatric surgery versus intensive glucose control. This review provides relevant background information related to the treatment of diabetes, hyperglycemia, and long-term complications; reports clinical findings (to date) with bariatric surgery; and identifies ongoing research focusing on long-term vascular outcomes associated with bariatric surgery.

Comparing Medical Costs and Use After Laparoscopic Adjustable Gastric Banding and Roux-en-Y Gastric Bypass

IMPORTANCE

There is conflicting evidence about how different bariatric procedures impact health care use.

OBJECTIVE

To compare the impact of laparoscopic adjustable gastric banding (AGB) and laparoscopic Roux-en-Y gastric bypass (RYGB) on health care use and costs.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective interrupted time series with comparison series study using a national claims data set. The data analysis was initiated in September 2011 and completed in January 2015. We identified bariatric surgery patients aged 18 to 64 years who underwent a first AGB or RYGB between 2005 and 2011. We propensity score matched 4935 AGB to 4935 RYGB patients according to baseline age group, sex, race/ethnicity, socioeconomic variables, comorbidities, year of procedure and baseline costs, emergency department (ED) visits, and hospital days. Median postoperative follow-up time was 2.5 years.

MAIN OUTCOMES AND MEASURES

Quarterly and yearly total health care costs, ED visits, hospital days, and prescription drug costs. We used segmented regression to compare pre-to-post changes in level and trend of these measures in the AGB vs the RYGB groups and difference-in-differences analysis to estimate the magnitude of difference by year.

RESULTS

Both AGB and RYGB were associated with downward trends in costs; however, by year 3, AGB patients had total annual costs that were 16% higher than RYGB patients (P < .001; absolute change: $818; 95% CI, $278 to $1357). In postoperative years 1 and 2, AGB was associated with 27% to 29% fewer ED visits than RYGB (P < .001; absolute changes: -0.6; 95% CI, -0.9 to -0.4 and -0.4; 95% CI, -0.6 to -0.1 visits/person, respectively); however, by year 3, there were no detectable differences. Postoperative annual hospital days were not significantly different between the groups. Although both procedures lowered prescription costs, annual postoperative prescription costs were 17% to 32% higher for AGB patients than RYGB patients (P < .001).

CONCLUSIONS AND RELEVANCE

Both laparoscopic AGB and RYGB were associated with flattened total health care cost trajectories but RYGB patients experienced lower total and prescription costs by 3 years postsurgery. On the other hand, RYGB was associated with increased ED visits in the 2 years after surgery. Clinicians and policymakers should weigh such differences in use and costs when making recommendations or shaping regulatory guidance about these procedures.

A marginalized two-part model for longitudinal semicontinuous data

In health services research, it is common to encounter semicontinuous data, characterized by a point mass at zero followed by a right-skewed continuous distribution with positive support. Examples include health expenditures, in which the zeros represent a subpopulation of patients who do not use health services, while the continuous distribution describes the level of expenditures among health services users. Longitudinal semicontinuous data are typically analyzed using two-part random-effect mixtures with one component that models the probability of health services use, and a second component that models the distribution of log-scale positive expenditures among users. However, because the second part conditions on a non-zero response, obtaining interpretable effects of covariates on the combined population of health services users and non-users is not straightforward, even though this is often of greatest interest to investigators. Here, we propose a marginalized two-part model for longitudinal data that allows investigators to obtain the effect of covariates on the overall population mean. The model additionally provides estimates of the overall population mean on the original, untransformed scale, and many covariates take a dual population average and subject-specific interpretation. Using a Bayesian estimation approach, this model maintains the flexibility to include complex random-effect structures and easily estimate functions of the overall mean. We illustrate this approach by evaluating the effect of a copayment increase on health care expenditures in the Veterans Affairs health care system over a four-year period.

Predictors of initial weight loss after gastric bypass surgery in twelve Veterans Affairs Medical Centers

The objective of this study was to identify determinants of significant weight loss one year after gastric bypass surgery among United States veterans. Using data from the Veterans Affairs (VA) Surgical Quality Improvement Program, we identified 516 veterans who had gastric bypass surgery (24% laparoscopic) in one of twelve VA bariatric centers in 2000-2006 and one or more postoperative weight measures. The probability of losing 30% or more of baseline weight at one year was estimated via logistic regression, examining the following potential predictor variables: age, gender, race, marital status, body mass index (BMI), American Society of Anesthesiologists class, comorbidity burden, smoking status, diabetes medications taken and surgical procedure (open or laparoscopic). The 516 cases had a mean BMI of 49 kg/m(2), mean age of 51.5 years, 74% were male, 77% were Caucasian, and 55% were married. The predicted mean weight loss was 76 (95% CI: 73-79) pounds (22%) at six months and 109 (95% CI: 104-114) pounds (32%) at one-year. Based upon estimated individual trajectories of 370 patients with adequate follow-up data, 58% of the sample lost 30% or more of their baseline weight at one year; and <1% lost <10% of their baseline weight at 1 year. In the logistic regression, patients were more likely to lose 30% or more of their baseline weight if they were female (odds ratio (OR) = 2.5, p < 0.01) or Caucasian (OR = 2.3, p < 0.01). We conclude that gastric bypass surgery yields significant weight loss for most patients in Veterans Affairs Medical Centers, but is particularly effective for female and Caucasian patients.

The business case for bariatric surgery revisited: a non-randomized case-control study

BACKGROUND AND AIM

Prior studies reporting that bariatric surgery (including laparoscopic adjustable gastric band (LAGB) and [laparoscopic Roux-en-Y] Gastric Bypass (LRYGB)) is cost-saving relied on a comparison sample of those with a morbid obesity (MO) diagnosis code, a high cost group who may not be reflective of those who opt for the procedures. We re-estimate net costs and time to breakeven using an alternative sample that does not rely on this code.

MATERIALS AND METHODS

Non-randomized case-control study using medical claims data from a commercial database in the USA. LAGB and LRYGB claimants were propensity score matched to two control samples: one restricted to those with a MO diagnosis code and one without this restriction.

RESULTS

When using the MO sample, costs for LAGB and LRYGB are recovered in 1.5 (Confidence Interval [CI]: 1.45 to 1.55) and 2.25 years (CI: 2.07 to 2.43), and 5 year savings are $78,980 (CI: 62,320 to 100,550) for LAGB and $61,420 (CI: 44,710 to 82,870) for LRYGB. Without the MO requirement, time to breakeven for LAGB increases to 5.25 (CI: 4.25 to 10+) years with a 5 year net cost of $690 (CI: 6,800 to 8.400). For LRYGB, time to breakeven exceeds 10 years and 5 year net costs are $18,940 (CI: 10,390 to 26,740).

CONCLUSIONS

The net costs and time to breakeven resulting from bariatric surgery are likely less favorable than has been reported in prior studies, and especially for LRYGB, with a time to breakeven of more than twice the 5.25 year estimate for LAGB.

Actual medical and pharmacy costs for bariatric surgery: 6-year follow-up

OBJECTIVE

To determine the change in total medical expenditures, total pharmacy expenditures, and subcategories of medical and pharmacy expenditures in obese individuals following weight loss surgery (WLS), and to compare these costs with expenditures in obese individuals not receiving WLS.

METHODS

Louisiana Office of Group Benefits (OGB), the state-managed health insurer, invited members to be evaluated for insurance-covered WLS. Of 951 obese members who provided written consent to begin the WLS screening process, 40 were selected for surgery. Medical and pharmaceutical claims cost data of the 911 patients who did not have surgery and the 39 individuals who completed surgery were compared over a 2-year presurgical and 6-year postsurgical period.

RESULTS

Total nonpharmacy medical costs were lower for WLS patients compared with non-WLS patients beginning 4 years postsurgery and lasting through 6 years postsurgery. No differences were found between WLS and non-WLS patients in expenditures for most medical subcategories examined, including emergency department, physical and occupational therapy, office visits, and laboratory/pathology; whereas sleep facility and all remaining medical expenditures not represented by a subcategory were lower for WLS patients during some postsurgery years. Total pharmacy costs were lower for WLS participants at 2 and 3 years postsurgery, but these lower costs were not maintained; however, costs remained lower for antidiabetic agents, antihypertensive agents, and dyslipidemic agents through all 6 postsurgery years under study.

CONCLUSIONS

The cost of WLS may begin to be recouped within the first 4 years postsurgery with continued effects 6 years postsurgery.

Risk stratification of serious adverse events after gastric bypass in the Bariatric Outcomes Longitudinal Database

BACKGROUND

There is now sufficient demand for bariatric surgery to compare bariatric surgeons and bariatric centers according to their postsurgical outcomes, but few validated risk stratification measures are available to enable valid comparisons. The purpose of this study was to develop and validate a risk stratification model of composite adverse events related to Roux-en-Y gastric bypass (RYGB) surgery.

METHODS

The study population included 36,254 patients from the Bariatric Outcomes Longitudinal Database (BOLD) registry who were 18-70 years old and had RYGB between June 11, 2007, and December 2, 2009. This population was randomly divided into a 50% testing sample and a 50% validation sample. The testing sample was used to identify significant predictors of 90-day composite adverse events and estimate odds ratios, while the validation sample was used to assess model calibration. After validating the fit of the risk stratification model, the testing and validation samples were combined to estimate the final odds ratios.

RESULTS

The 90-day composite adverse event rate was 1.48%. The risk stratification model of 90-day composite adverse events included age (40-64, ≥ 65), indicators for male gender, body mass index (50-59.9, ≥ 60), obesity hypoventilation syndrome, back pain, diabetes, pulmonary hypertension, ischemic heart disease, functional status, and American Society of Anesthesiology classes 4 or 5. Our final gastric bypass model was predictive (c-statistic = .68) of serious adverse events 90 days after surgery.

CONCLUSIONS

With additional validation, this risk model can inform both the patient and surgeon about the risks of bariatric surgery and its different procedures, as well as enable valid outcomes comparisons between surgeons and surgical programs.

Preliminary outcomes of laparoscopic sleeve gastrectomy in a Veterans Affairs medical center

BACKGROUND

Preliminary results of a new bariatric surgery program in a VA Medical Center using laparoscopic sleeve gastrectomy (LSG).

METHODS

Prospective review of the first 50 patients who underwent LSG. Percentage change in body mass index (BMI), comorbidities, serum glucose, glycosylated hemoglobin (HbA1c), lipid profiles, and medications were recorded.

RESULTS

Mean age was 52 years. Average BMI was 46 kg/m(2). There were no mortalities or staple line leaks. The percentage excess BMI loss was 47% and 54% at 6 and 12 months, respectively. After 6 months, fasting glucose level decreased from 127 to 93 mg/dL, and mean glycosylated hemoglobin decreased from 6.8% to 5.7%. At 1-year follow-up evaluation, serum cholesterol decreased from 182 to 168 mg/dL, mean triglycerides from 179 to 93 mg/dL, low-density lipoprotein from 110 to 94 mg/dL, and high-density lipoprotein increased from 42 to 50 mg/dL.

CONCLUSIONS

Laparoscopic sleeve gastrectomy is safe and effective for morbidly obese VA patients and resulted in significant discontinuation of medication for hypertension, diabetes and hyperlipidemia.

Impact of bariatric surgery on health care utilization and costs among patients with diabetes

BACKGROUND

The effect of bariatric surgery on health care utilization and costs among individuals with type 2 diabetes remains unclear.

OBJECTIVE

To examine health care utilization and costs in an insured cohort of individuals with type 2 diabetes after bariatric surgery.

RESEARCH DESIGN

Cohort study derived from administrative data from 2002 to 2008 from 7 Blue Cross Blue Shield Plans.

PARTICIPANTS

Seven thousand eight hundred six individuals with type 2 diabetes who had bariatric surgery.

MEASURES

Cost (inpatient, outpatient, pharmacy, and others) and utilization (number of inpatient days, outpatient visits, specialist visits).

RESULTS

Compared with presurgical costs, the ratio of hospital costs (excluding the initial surgery), among beneficiaries who had any hospital costs, was higher in years 2 through 6 of the postsurgery period and increased over time [post 1: odds ratio (OR)=0.58; 95% confidence interval (CI), 0.50-0.67; post 6: OR=3.43; 95% CI, 2.60-4.53]. In comparison with the presurgical period, the odds of having any health care costs was lower in the postsurgery period and remained relatively flat over time. Among those with hospitalizations, the adjusted ratio of inpatient days was higher after surgery (post 1: OR=1.05; 95% CI, 0.94-1.16; post 6: OR=2.77; 95% CI, 1.57-4.90). Among those with primary care visits, the adjusted OR was lower after surgery (post 1: OR=0.80; 95% CI, 0.78-0.82; post 6: OR=0.66; 95% CI, 0.57-0.76).

CONCLUSIONS

: In the 6 years after surgery, individuals with type 2 diabetes did not have lower health care costs than before surgery.