Bariatric Surgery: No Link to Reduced Healthcare Costs

Ricki Lewis, PhD

July 16, 2012

June 16, 2012 — Bariatric surgery was not associated with lowered healthcare costs 3 years after the procedure in a population of older, mostly male patients, according to results from a study published in the July 16 issue of the Archives of Surgery.

The new results run counter to prior observational studies in which researchers saw a substantial drop in healthcare costs after bariatric surgery in primarily young, white, female patients.

As bariatric surgery has grown in popularity, the patient population has become more diverse. More nonwhite, male, and older patients, with more obesity-related comorbidities, are opting for these procedures. However, little is known about the effects bariatric surgery might have on future healthcare expenditures.

Therefore, Matthew L. Maciejewski, PhD, from the Center for Health Services Research in Primary Care, Durham Veterans Administration Medical Center, North Carolina, and colleagues conducted a retrospective cohort study that compared healthcare expenditures of 847 veterans 3 years pre- and postsurgery to expenditures among 847 propensity-matched veterans who did not have the surgery. Characteristics for matching included age, sex, race, marital status, and body mass index. All participants were from the same dozen Veterans Administration medical centers and were evaluated from 2000 to December 2006.

Healthcare costs included costs associated with the procedure and peaked for the surgical group around the time of the surgery. The investigators found that expenditures among the treated patients were $4397 higher in the first 6 months after surgery compared with the untreated group. However, the costs were similar between the 2 groups from 31 to 36 months after surgery. The researchers thus disproved their hypothesis that 3 years later the cohort that underwent surgery would have lower expenditures than the matched control patients.

The investigators attribute the lack of predicted savings to examining a different population than previous observational studies. The cohort of the current study was largely male and had more severe health problems than the previous studies, which included younger, mostly female patients.

Limitations of the study, according to the authors, include its nongeneralizability to younger, healthier, more predominantly female populations. It is possible that bariatric surgery leads to lowered healthcare costs for younger, but not older and sicker, individuals, the researchers note. Future studies, they suggest, might compare subgroups based on age and/or comorbidities.

Another limitation of the study is that it did not assess patients who had laparoscopic gastric banding, which is an increasingly popular method of bariatric surgery. In addition, the study used administrative data, rather than conducting a randomized trial, and the findings revealed a lack of association, rather than a lack of causation.

In an editorial, Harry C. Sax, MD, from Cedars Sinai Medical Center, points out that the strength of the study is the "truly integrated delivery system" that patients in both groups experienced. A major limitation, however, is lack of a breakdown of expenditure categories, such as drugs and costs related to quality of life.

Dr. Sax mentions a possible subtle explanation for the findings: the death rate among the nontreated control patients was nearly twice that of the patients who had surgery. "In other words, 50 more surgical patients were alive to consume resources during the 6 years studied," he concludes.

This study was supported by grants from the Office of Research and Development, Health Services Research and Development Service, Department of Veterans Affairs, and by a Research Career Scientist award from the Department of Veterans Affairs to Dr Maciejewski Dr. Maciejewski has consulted for Takeda Pharmaceuticals, Novartis, and the Surgical Review Corp and owns Amgen stock. One coauthor has consulted for Texas Instruments and is a contributing editor to JAMA. Another coauthor receives research funding and has received salary support as a medical editor for the Foundation for Informed Medical Decision Making, which has an arrangement with Health Dialog to coproduce and market these programs to healthcare organizations. Dr. Sax has disclosed no relevant financial relationships.

Arch Surg. 2012;147:633-640. Full text

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