Cost-effectiveness of gastric bypass for severe obesity

doi:10.1016/S0002-9343(02)01266-4

The American Journal of Medicine

Volume 113, Issue 6, 15 October 2002, Pages 491-498

https://doi.org/10.1016/S0002-9343(02)01266-4 Get rights and content

Abstract

Purpose

To estimate the cost-effectiveness of gastric bypass in the treatment of severe obesity.

Subjects and methods

We performed a cost-effectiveness analysis of gastric bypass versus no treatment from the payer perspective. We discounted quality-adjusted life-years (QALYs), life-years, and cost during the patient’s lifetime. Our target group comprised women and men aged 35 to 55 years with a body mass index between 40 and 50 kg/m², and who did not have cardiovascular disease and in whom conservative bariatric therapies had been unsuccessful.

Results

The base case cost-effectiveness ratios ranged from $5000 to $16,100 per QALY for women and from $10,000 to $35,600 per QALY for men, depending on age and initial body mass index. In a few subgroups of older, less obese men, variation in parameters such as loss of excess weight, obesity-related quality of life, complication rates, and perioperative mortality affected the cost-effectiveness ratios. Parameter variation did not result in meaningful changes in the remaining patients.

Conclusion

Gastric bypass is a cost-effective alternative to no treatment, providing substantial lifetime benefits in patients who are severely obese.

Section snippets

Decision model and sample

We used a deterministic decision model (12) to compare the lifetime expected costs and outcomes between gastric bypass and no treatment of severe obesity from the payer perspective (Figure 1). Patients in each arm were assigned to health outcomes by rates, instead of drawn from distributions. The cost-effectiveness ratio was determined by dividing the difference in total lifetime medical cost by the difference in quality-adjusted life-years (QALYs). Cost and QALYs were discounted at 3% to

Base case analysis

In all risk subgroups, the cost-effectiveness ratios of gastric bypass versus no treatment were favorable, at less than $50,000 per QALY. In four risk subgroups representing the upper and lower bounds of the cost-effectiveness ratios (Table 3, Table 4, Figure 2), the ratios ranged from about $5000 to $16,100 per QALY for women and from about $10,000 to $35,600 per QALY for men, depending on age and initial body mass index. These variations suggest that gastric bypass is more cost-effective

Discussion

Our results suggest that gastric bypass is not cost saving from the payer perspective. However, the cost-effectiveness ratio estimates compare favorably with those of other accepted interventions and appear robust to parameter variation, especially among women and younger, more obese men (25). In comparison with no treatment, gastric bypass is a cost-effective alternative.

Our study sample comprised subjects who were severely obese but who did not have the chronic medical conditions typically

Acknowledgements

We thank Richard L. Atkinson, Dennis Fryback, Khin Mae Hla, and William Lawrence for their guidance in this analysis. We are grateful to Mokdad Ali for his assessment of the prevalence of severe obesity using the Behavior Risk Factor Surveillance System. We also thank Ralph Insinga and Deborah Topol for their thoughtful comments on earlier versions of the manuscript.

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A retrospective analysis of 2012–2013 Healthcare Cost and Utilization Project - Nationwide Inpatient Sample (HCUP-NIS).
We included all patients with a diagnosis of morbid obesity (ICD9 278.01) and a Diagnosis Related Group code related to procedures for obesity, who underwent Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), or adjustable gastric banding (AGB) as their primary procedure. We converted “hospital charges” to “cost,” using hospital specific cost-to-charge ratio. Inflation was adjusted using the annual consumer price index. Increased cost was defined as the top 20th percentile of the expenditure and its associated factors were analyzed using the logistic regression multivariate analysis.
A total of 45,219 patients (20,966 RYGBs, 22,380 SGs, and 1,873 AGBs) were included. The median (interquartile range) calculated costs for RYGB, SG, and AGB were $12,543 ($9,970–$15,857), $10,531 ($8,248–$13,527), and $9,219 ($7,545–$12,106), respectively (P<.001). Robotic-assisted procedures had the highest impact on the cost (odds ratio 3.6, 95% confidence interval 3.2–4). Hospital cost of RYGB and SG increased linearly with the length of hospital stay and almost doubled after 7 days. Furthermore, multivariate analysis showed that certain co-morbidities and concurrent procedures were associated with an increased cost.
Factors contributing to the cost variation of bariatric procedures include co-morbidities, robotic platform, complexity of surgery, and hospital length of stay.
A population-based analysis of the drivers of short-term costs after bariatric surgery within a publicly funded regionalized center of excellence system
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The most significant driver of healthcare utilization for bariatric surgery is the index admission and readmissions within the first 30 days after a procedure. Identifying areas to create efficiencies during this period is essential to decreasing overall healthcare costs.
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We performed a population-based retrospective analysis including all adult patients who received a bariatric surgical procedure in Ontario from April 2009 until March 2012. Total hospital cost and number of days in hospital was calculated for all index admissions and all readmissions within 30 days of a bariatric surgical procedure. An inverse Gaussian generalized linear model was utilized to model the effect of covariates on costs. A Poisson regression was used to determine the effect on covariates on total days in hospital.
After multivariable adjustment, the sleeve gastrectomy procedure decreased costs by $1447 over gastric bypass (95% confidence interval [CI] $1578 to−$1315]); P<.001). This effect increased when adjusting only for preoperative factors with a cost savings of nearly $2000 ($1953) (95% CI−$3250 to−$533; P = .003). Conversely, complications were the major drivers of increased cost as anastomotic leaks added $24,397 (95% CI $20,688−$28,106; P<.001) to healthcare costs. In addition, medical complications, such as respiratory failure/infection ($19,465) (95% CI $11,007−$27,924; P<.001), were also significant cost drivers.
Major drivers of increased resource utilization included major surgical and medical complications, such as anastomotic leaks and respiratory failure/infection. Days in hospital were affected more by medical complications than surgical complications. Sleeve gastrectomy resulted in a clear short-term cost advantage over Roux-en-Y gastric bypass (RYGB), and this was likely related to the procedure itself as opposed to differences across procedures in co-morbidity and complication rates.
Timing of bariatric surgery for severely obese adolescents: A Markov decision-analysis
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Although controversial, bariatric surgery is increasingly being performed in adolescents. We developed a model to simulate the effect of timing of gastric bypass in obese adolescents on quantity and quality of life.
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For females, early gastric bypass surgery was favored by 2.02 QALYs compared to delaying surgery until age 35 (48.91 vs. 46.89 QALYs). The benefit was even greater for males, where early surgery was favored by 2.9 QALYs (48.30 vs. 45.40 QALYs). The absolute benefit of surgery at age 16 increased; the later surgery was delayed into adulthood. Sensitivity analyses demonstrated that adult surgery was favored only when the values for adverse events were unrealistically high.
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Understanding both the efficacy of upper gastrointestinal (UGI) contrast studies and the factors that impact their accuracy is necessary to optimize postoperative imaging protocols. However, a consensus as to the value of UGI performed after bariatric surgery remains elusive. The objective was to determine the sensitivity and specificity of UGI conducted routinely within 2 days after bariatric surgery for detecting anastomotic leaks.
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As obesity is currently a major public health problem, bariatric surgery has been widely indicated due to the difficulties involved in the clinical management of obese adults.
Assess the quality-of-life (QOL) of patients who had undergone Roux-en-Y Gastric Bypass (RYGB) in the State of Goiás, Brazil, where as yet no studies have been published on the QOL of patients who underwent bariatric surgery.
A retrospective study, using the Bariatric Analysis and Reporting Outcome System (BAROS), was carried out in Goiânia and Rio Verde, Goiás, Brazil, with 50 over 18-year-old patients of both genders, who had undergone RYGB and had at least three months of postoperative time.
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Como a obesidade é atualmente um grande problema de saúde pública, a cirurgia bariátrica tem sido amplamente indicada devido às dificuldades envolvidas no manejo clínico de adultos obesos.
Avaliar a qualidade de vida (QDV) de pacientes submetidos ao Desvio Gástrico em Y-de-Roux (DGYR) no Estado de Goiás, Brasil, onde ainda não há estudos sobre a QDV de pacientes submetidos à cirurgia bariátrica.
Um estudo retrospectivo, utilizando o Bariatric Analysis and Reporting Outcome System (BAROS), foi realizado em Goiânia e Rio Verde, Goiás, Brasil, com 50 pacientes com idade superior a 18 anos, de ambos os gêneros, que realizaram DGYR com tempo pós-operatório mínimo de três meses.
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Resultados preliminares indicaram que a DGYB pode ser um procedimento cirúrgico para promover com sucesso a redução satisfatória e sustentada nas medidas corporais de pacientes com obesidade mórbida provenientes de Goiás, Brasil. Além disso, a pontuação final do BAROS mostrou melhorias das comorbidades associadas e também na QDV desses pacientes.

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^☆: This study was supported by a T32 institutional training grant (HS00083) from the Agency for Healthcare Research and Quality, Rockville, Maryland, to the University of Wisconsin Program in Population Health.

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Clinical studyCost-effectiveness of gastric bypass for severe obesity☆

Abstract

Purpose

Subjects and methods

Results

Conclusion

Section snippets

Decision model and sample

Base case analysis

Discussion

Acknowledgements

Am J Surg

Am J Surg

J Am Coll Surg

Methods for Voluntary Weight Loss and Control. Proceedings of NIH Technology Assessment Conference, Bethesda, MD, March 30–April 1, 1992

Ann Intern Med

Double-blind randomized placebo-controlled trial of sibutramine

Obes Res

Weight control and risk factor reduction in obese subjects treated for 2 years with orlistat: a randomized controlled trial

JAMA

Vertical banded gastroplasty vs gastric bypass in the treatment of obesity

J Natl Med Assoc

Gastric surgery for morbid obesity. The Adelaide Study

Ann Surg

Results of the surgical treatment of obesity

Am J Surg

A randomized prospective trial of gastric bypass versus vertical banded gastroplasty for morbid obesity and their effects on sweets versus non-sweets eaters

Ann Surg

Cost-effectiveness in Health and Medicine

Clinical study
Cost-effectiveness of gastric bypass for severe obesity☆