Ask the Leadership: The Cost-effectiveness of Bariatric Surgery

This column is dedicated to sharing the vast knowledge and opinions of the American Society for Metabolic and Bariatric Surgery leadership on relevant topics in the field of bariatric surgery.

This Month’s Interview with:

John M. Morton, MD, MPH, FACS, FASMBS
Chief of the Section of Bariatric and Minimally Invasive Surgery,
Stanford University, Stanford, California, and Secretary-Treasurer of ASMBS

Bruce M. Wolfe, MD
Professor of Surgery, Co-director of Bariatric Surgery, Oregon Health and Science University, Portland, Oregon

This month’s topic: The Cost-effectiveness of Bariatric Surgery

Bariatric Times. 2013;10(5):10.

Dr. Rosenthal: Drs. Morton and Wolfe, what was your initial reaction to the study “Impact of bariatric surgery on health care costs of obese persons: a 6-year follow-up of surgical and comparison cohorts using health plan data,”[1] which was published online ahead on print in JAMA Surgery?

Drs. Morton and Wolfe: Our initial reaction was concern that this study was published at all. There are several methodological flaws with the study. The authors’ comparison cohort has not been replicated and is predicated on International Classification of Diseases (ICD)9 codes associated with obesity, not actual weight. In addition, inclusion of patients with unknown surgery is unsuitable given that they could be cancer patients or bariatric surgery revisions.
There is dramatic reduction in follow up over the six years. Among the 29,820 study patients, the follow up at Years 2 through 6 is 65, 43, 25, 15, and seven percent respectively. This exceedingly low, six-year follow-up rate is exacerbated for laparoscopic gastric bypass at 1.9 percent (217).  It is entirely unclear how many patients are available for follow up or how to account for missing data or patients without cost claims.

Dr. Rosenthal: The article’s main conclusion was “bariatric surgery does not reduce overall healthcare costs in the long term.” Do you agree with this conclusion? Were there any elements to the study that may have altered the findings, for instance the fact that the group evaluated procedures done between 2002 and 2008 (i.e., safety and effectiveness of procedures were different and a greater percentage of procedures were performed open compared to today)? Might researchers reach a different conclusion if, in the future, they evaluate procedures done between 2008 and 2014?

Drs. Morton and Wolfe: The study time period predates modern bariatric surgery, which includes the accreditation initiative and laparoscopic approach. The laparoscopic approach renders lower cost and complications. Open procedures are excessive in this study at 35 percent while current rates are less than 10 percent. Clearly, with improvement in safety and effectiveness we would expect to see cost savings.

Dr. Rosenthal: Do you feel it is important to evaluate the cost-effectiveness of bariatric surgery? What articles exist that prove bariatric surgery is cost-effective?

Drs. Morton and Wolfe: Numerous publications overwhelmingly support the cost-benefit of bariatric surgery, including a recent systematic review by Wang et al[2] and formal cost-effectiveness analysis by Picot et al.[3] Even with poor follow up and the questionable comparison group in the Weiner et al study,[1] lower pharmaceutical costs and equivalent clinic visits were seen for the surgical cohort. The only increase in cost for the surgical cohort was for surgery in the second and third years, indicating that costs did not emanate from the perioperative period. This potentially increased cost could be a reflection of “pent up” demand for previously deferred and needed services, such as joint replacement or hernia repair.

Dr. Rosenthal: Do you think this study and its findings might impact insurance coverage for bariatric procedures?

Drs. Morton and Wolfe: We believe that a reasonable review of the literature supports coverage for bariatric surgery in the right patients and in the right hands. We fully anticipate that insurers will continue to provide coverage for this safe and effective procedure for patients in need and without recourse for their serious health concerns. Moreover, it is medically irresponsible to withhold needed care when safe, effective therapy is available. The larger question regarding obesity discrimination arises when bariatric surgery is held to an inappropriate standard with this flawed study and accompanying editorial.

Dr. Rosenthal: Drs. Morton and Wolfe, thank you for taking the time to speak with me on this important issue.

References
1.    Weiner JP, Goodwin SM, Chang HY, et al. Impact of bariatric surgery on healthcare costs of obese persons: a 6-Year follow-up of surgical and comparison cohorts using health plan data. JAMA Surg. 2013 Feb 20:1–8. [Epub ahead of print].
2.    Wang BC, Wong ES, Alfonso-Cristancho R, et al. Cost-effectiveness of bariatric surgical procedures for the treatment of severe obesity. Eur J Health Econ. 2013 Mar 24.
3.    Picot J, Jones J, Colquitt JL, et al. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess. 2009;13(41):1–190, 215–357, iii–iv.

Funding: No funding was provided in the preparation of this manuscript.

Financial disclosures: The author reports no conflicts of interest relevant to the content of this article.

Category: Ask the Leadership, Past Articles