Does Bariatric Surgery Reduce Health Care Costs?
Invited Commentary
Invited Commentary
Does Bariatric Surgery Reduce Health Care Costs? Weighing the Evidence Justin B. Dimick, MD, MPH
Bariatric surgery is by far the most effective therapy for morbid obesity and obesity-related conditions, especially type 2 diabetes mellitus. Numerous well-designed observational studies and randomized clinical trials show profound weight loss, high rates of comorbidity resolution, improved quality of life, and decreased mortality after bariatric surgery.1-3 Despite these well-known clinical benefits, there is debate about the impact of bariatric surgery on health care expenditures. Bariatric surgery itself is a relatively expensive intervention. Besides the surgical episode itself, there are substantial preoperative costs from testing and referrals Related article to specialists, as well as increased postsurgical costs owing to short- and longer-term complications. Studies evaluating the longer-term health care costs have shown mixed results.4-6 The study in this issue of JAMA Surgery by Lewis et al7 brings important new data to this debate. Using a unique data source, private payer claims from across the United States, the authors were able to measure health care expenditures (from the payer perspective) over time for patients undergoing laparoscopic adjustable gastric banding and laparoscopic gastric bypass procedures. Importantly, the authors used a rigorous longitudinal study design—evaluating health care costs over time in patients who had surgery—that allows patients to serve as their own controls. In many ways, this is superior to using a nonsurgical cohort of control individuals, as there is no way of knowing whether patients who do not have surgery are truly similar to those who do have surgery. The study design used by Lewis et al7 assumes that an individual’s health care spending trend ARTICLE INFORMATION Author Affiliations: Department of Surgery, University of Michigan, Ann Arbor; Surgical Innovation Editor, JAMA Surgery. Corresponding Author: Justin B. Dimick, MD, MPH, Center for Healthcare Outcomes & Policy, Department of Surgery, University of Michigan, 2800 Plymouth Rd, Bldg 16, Office 137E, Ann Arbor, MI 48109 ([email protected]). Published Online: June 3, 2015. doi:10.1001/jamasurg.2015.1095. Conflict of Interest Disclosures: Dr Dimick is a founder and has equity interest in ArborMetrix Inc, a software and analytics company focused on assessing hospital quality and costs. Funding/Support: Dr Dimick receives research funding from the National Institutes of Health and the Agency for Healthcare Research and Quality. Role of the Funder/Sponsor: The funders had no role in the preparation, review, or approval of the
will continue on a similar trajectory (a slow upward trend) if they do not have surgery, which seems quite reasonable. This study has 2 very important findings.7 First, at 3 years after surgery, there was a significant change in trajectory of health care expenditures, with a flattening of the trend in total health care costs and prescription drug costs. Without surgery, it is most likely that this trend would have followed the upward trend demonstrated in the preoperative period. This finding implies that bariatric surgery is certainly not increasing costs as many worry about, and it very well may result in net cost savings in the long term. Second, this study provides important information on the comparative effectiveness of the laparoscopic band vs laparoscopic gastric bypass. Although the laparoscopic band was associated with lower costs and fewer emergency department visits early postoperatively (which has clinical face validity), by 3 years, the laparoscopic gastric bypass was associated with lower total and prescription costs. This conclusively demonstrates that the superior clinical efficacy of laparoscopic gastric bypass demonstrated in clinical trials translates into greater longer-term health care cost savings. This study does leave some important questions to answer. Namely, what happens to health care expenditures beyond 3 years? As the authors pointed out, if this flattening of the cost trend continues, bariatric surgery may be a costsaving procedure,7 which has important implications for expanding insurance coverage. Moreover, how do expenditures for laparoscopic sleeve gastrectomy compare with gastric bypass? Because laparoscopic sleeve gastrectomy is rapidly becoming the most common bariatric procedure subsequent evaluations of this procedure will be essential. 5. Maciejewski ML, Livingston EH, Smith VA, Kahwati LC, Henderson WG, Arterburn DE. Health expenditures among high-risk patients after gastric bypass and matched controls. Arch Surg. 2012;147 (7):633-640.
manuscript, and the decision to submit the manuscript for publication REFERENCES 1. Sjöström L, Peltonen M, Jacobson P, et al. Bariatric surgery and long-term cardiovascular events. JAMA. 2012;307(1):56-65. 2. Ikramuddin S, Korner J, Lee WJ, et al. Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. JAMA. 2013;309(21): 2240-2249. 3. Adams TD, Davidson LE, Litwin SE, et al. Health benefits of gastric bypass surgery after 6 years. JAMA. 2012;308(11):1122-1131.
6. Weiner JP, Goodwin SM, Chang HY, et al. 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. JAMA Surg. 2013;148(6):555-562. 7. Lewis KH, Zhang F, Arterburn DE, Ross-Degnan D, Gillman MW, Wharam JF. Comparing medical costs and use after laparoscopic adjustable gastric banding and Roux-en-Y gastric bypass [published online June 3, 2015]. JAMA Surg. doi:10.1001 /jamasurg.2015.1081.
4. Bleich SN, Chang HY, Lau B, et al. Impact of bariatric surgery on health care utilization and costs among patients with diabetes. Med Care. 2012;50 (1):58-65.
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(Reprinted) JAMA Surgery Published online June 3, 2015
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Invited Commentary
Invited Commentary
Does Bariatric Surgery Reduce Health Care Costs? Weighing the Evidence Justin B. Dimick, MD, MPH
Bariatric surgery is by far the most effective therapy for morbid obesity and obesity-related conditions, especially type 2 diabetes mellitus. Numerous well-designed observational studies and randomized clinical trials show profound weight loss, high rates of comorbidity resolution, improved quality of life, and decreased mortality after bariatric surgery.1-3 Despite these well-known clinical benefits, there is debate about the impact of bariatric surgery on health care expenditures. Bariatric surgery itself is a relatively expensive intervention. Besides the surgical episode itself, there are substantial preoperative costs from testing and referrals Related article to specialists, as well as increased postsurgical costs owing to short- and longer-term complications. Studies evaluating the longer-term health care costs have shown mixed results.4-6 The study in this issue of JAMA Surgery by Lewis et al7 brings important new data to this debate. Using a unique data source, private payer claims from across the United States, the authors were able to measure health care expenditures (from the payer perspective) over time for patients undergoing laparoscopic adjustable gastric banding and laparoscopic gastric bypass procedures. Importantly, the authors used a rigorous longitudinal study design—evaluating health care costs over time in patients who had surgery—that allows patients to serve as their own controls. In many ways, this is superior to using a nonsurgical cohort of control individuals, as there is no way of knowing whether patients who do not have surgery are truly similar to those who do have surgery. The study design used by Lewis et al7 assumes that an individual’s health care spending trend ARTICLE INFORMATION Author Affiliations: Department of Surgery, University of Michigan, Ann Arbor; Surgical Innovation Editor, JAMA Surgery. Corresponding Author: Justin B. Dimick, MD, MPH, Center for Healthcare Outcomes & Policy, Department of Surgery, University of Michigan, 2800 Plymouth Rd, Bldg 16, Office 137E, Ann Arbor, MI 48109 ([email protected]). Published Online: June 3, 2015. doi:10.1001/jamasurg.2015.1095. Conflict of Interest Disclosures: Dr Dimick is a founder and has equity interest in ArborMetrix Inc, a software and analytics company focused on assessing hospital quality and costs. Funding/Support: Dr Dimick receives research funding from the National Institutes of Health and the Agency for Healthcare Research and Quality. Role of the Funder/Sponsor: The funders had no role in the preparation, review, or approval of the
will continue on a similar trajectory (a slow upward trend) if they do not have surgery, which seems quite reasonable. This study has 2 very important findings.7 First, at 3 years after surgery, there was a significant change in trajectory of health care expenditures, with a flattening of the trend in total health care costs and prescription drug costs. Without surgery, it is most likely that this trend would have followed the upward trend demonstrated in the preoperative period. This finding implies that bariatric surgery is certainly not increasing costs as many worry about, and it very well may result in net cost savings in the long term. Second, this study provides important information on the comparative effectiveness of the laparoscopic band vs laparoscopic gastric bypass. Although the laparoscopic band was associated with lower costs and fewer emergency department visits early postoperatively (which has clinical face validity), by 3 years, the laparoscopic gastric bypass was associated with lower total and prescription costs. This conclusively demonstrates that the superior clinical efficacy of laparoscopic gastric bypass demonstrated in clinical trials translates into greater longer-term health care cost savings. This study does leave some important questions to answer. Namely, what happens to health care expenditures beyond 3 years? As the authors pointed out, if this flattening of the cost trend continues, bariatric surgery may be a costsaving procedure,7 which has important implications for expanding insurance coverage. Moreover, how do expenditures for laparoscopic sleeve gastrectomy compare with gastric bypass? Because laparoscopic sleeve gastrectomy is rapidly becoming the most common bariatric procedure subsequent evaluations of this procedure will be essential. 5. Maciejewski ML, Livingston EH, Smith VA, Kahwati LC, Henderson WG, Arterburn DE. Health expenditures among high-risk patients after gastric bypass and matched controls. Arch Surg. 2012;147 (7):633-640.
manuscript, and the decision to submit the manuscript for publication REFERENCES 1. Sjöström L, Peltonen M, Jacobson P, et al. Bariatric surgery and long-term cardiovascular events. JAMA. 2012;307(1):56-65. 2. Ikramuddin S, Korner J, Lee WJ, et al. Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. JAMA. 2013;309(21): 2240-2249. 3. Adams TD, Davidson LE, Litwin SE, et al. Health benefits of gastric bypass surgery after 6 years. JAMA. 2012;308(11):1122-1131.
6. Weiner JP, Goodwin SM, Chang HY, et al. 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. JAMA Surg. 2013;148(6):555-562. 7. Lewis KH, Zhang F, Arterburn DE, Ross-Degnan D, Gillman MW, Wharam JF. Comparing medical costs and use after laparoscopic adjustable gastric banding and Roux-en-Y gastric bypass [published online June 3, 2015]. JAMA Surg. doi:10.1001 /jamasurg.2015.1081.
4. Bleich SN, Chang HY, Lau B, et al. Impact of bariatric surgery on health care utilization and costs among patients with diabetes. Med Care. 2012;50 (1):58-65.
jamasurgery.com
(Reprinted) JAMA Surgery Published online June 3, 2015
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Georgia User on 06/10/2015
E1
