'Business Case' for Gastric Banding, but Is It Appropriate?

Miriam E. Tucker

October 31, 2013

Laparoscopic adjustable gastric band (LAGB) surgery remains cost saving even when the analysis is extended to compare the procedure with control patients who do not have morbid obesity, a new study has found.

In the nonrandomized, case-control study of medical-claims data for bariatric surgery that was not restricted to controls with "morbid obesity (MO)," a diagnostic code that tends to lead to higher incurred costs, Eric A. Finkelstein, PhD, associate research professor with the Duke Global Health Institute, Duke University, Durham, North Carolina, and colleagues report that "the net costs and time to break even resulting from bariatric surgery are less favorable than has been reported in prior studies."

Yet, even with this more conservative approach, "the business case for LAGB appears favorable," write Dr. Finkelstein and colleagues in their paper in PLOS One .

But one bariatric surgeon says a design feature of the study — excluding patients with "multiple bariatric procedure codes on different dates" — means it ignores the fact that LAGB weight-loss failure rates are as high as 50% and long-term complications sit at about 30%.

"People are getting slippage and erosions in the stomach… More and more bariatric surgeons have stopped doing bands because of these long-term complications that are popping up," Justin B. Dimick, MD, assistant professor of surgery and director of policy research at the Center for Healthcare Outcomes & Policy at the University of Michigan, Ann Arbor, told Medscape Medical News.

However, Jaime Ponce, MD, director of bariatric surgery, Hamilton Medical Center, Dalton, Georgia, and president of the American Society for Metabolic and Bariatric Surgery, told Medscape Medical News he feels there is still a role for LAGB in obesity treatment, provided that the procedure is done at an experienced center where patients are followed closely after the procedure and frequent band adjustments are made.

"Some practices really aren't managing the band," he noted. "They're just placing the band and letting the patients go with it… Those practices are going to have a lot of revisions and a lot of bands explanted," he said.

"Definitely, there is still a place for the band. It's not as high as it was before, but 10% to 25% of patients will be able to qualify for a band in the right hands with the right management," he says.

And Dr. Ponce says he does not think economic analyses such as this should be required to demonstrate cost savings for a treatment for obesity; such studies reflect a societal antiobesity bias, he believes. "People are not acknowledging that obesity is a disease, they…think it's just a lifestyle issue, so you have to prove a cost benefit…something I don't think we should be talking about when it's improving the health of patients who are sick."

Dr. Dimick agrees: "We know bariatric surgery is cost-effective and may be cost saving. This study doesn't change that."

Cost Savings Confirmed in Morbid Obesity

Both gastric banding and gastric bypass surgery, when performed laparoscopically in patients with morbid obesity, produce significant weight loss and improve comorbidities such as diabetes. Cost-effectiveness has been demonstrated for both procedures, although the actual procedure costs are slightly higher for the laparoscopic Roux-en-Y gastric bypass (LRYGB) compared with the LAGB, averaging $24,000 vs $20,000, respectively.

Of 4 previous case-control studies that have attempted to determine whether bariatric surgery actually saves money by reducing comorbidities — and if so, when that breakeven point occurs — 3 found that costs were recovered by 4 years. The fourth study, which found no cost saving in a Veterans Administration population, was the only one that did not rely on the morbid obesity "MO" diagnostic code (body mass index 40 kg/m2 or greater) to identify controls for comparison.

Data for the current study were obtained from inpatient, outpatient, and retail pharmaceutical claims from approximately 100 large private-sector payers between January 2003 and September 2009.

The investigators constructed a comparison sample by "propensity matching" the bariatric-surgery patients to randomly sampled individuals with similar demographics and comorbidities who did not have bariatric surgery — the "matched random" group.

They also propensity-matched nonsurgical patients with the MO code to the bariatric-surgery patients, the "matched MO" sample, the more usual method of comparison employed in such studies.

There were approximately 9630 patients in each of the LAGB, LRYGB, matched random, and matched MO groups. A subsample with diabetes totaled approximately 2450 in each of the 4 study groups.

Performing the conventional analysis, comparing surgery patients with the matched MO sample, costs for LAGB and LRYGB appeared to be fully recovered in 1.5 years and 2.25 years, respectively. As a result, the savings at 5 years were estimated at $78,980 for LAGB and $61,420 for LRYGB.

In the diabetes subsample compared with the matched MO sample, costs were fully recovered in 1.25 years with LAGB and 1.75 years for LRYGB. At 5 years, those savings were even larger, $127,590 for LAGB and $103,340 for LRYGB.

Not Restricting to MO Code Leads to Net Costs at 5 Years

However when the analysis was extended and the surgery patients were compared with the matched random sample, the estimated time to recover the cost of an LAGB procedure increased to 5.25 years, with a 5-year net cost of $690. For the LRYGB patients, the net cost at 5 years was $18,940, and more than 10 years would need to pass to fully recover the cost.

In the diabetes subsample comparing surgery patients with the matched random sample, the estimated time to recover costs was 4.25 years for LAGB, with a saving of $3060 at 5 years. For LRYGB, there was a cost of $21,610 at 5 years and a greater-than-10-year window for that cost to be recovered.

The authors acknowledge in their discussion — and both Dr. Dimick and Dr. Ponce agree — that the method used to try to approximate what would happen to similar patients who did not undergo either bariatric procedure was of questionable validity, including the assignation of a "pseudosurgery" date to such individuals.

And Dr. Dimick told Medscape Medical News, "They looked at MO vs not MO… We don't know whether that's the right approach. The truth is probably somewhere in the middle of the 2 estimates."

Dr. Ponce noted, "Ideally, it's best to compare surgery vs nonsurgery with exactly the same features, but that's difficult to do. So you have to imagine what would happen without surgery… It's not a perfect analysis."

Nonetheless, Dr. Dimick said, "On the positive side, the study is fairly rigorous, and they looked at a full accounting of healthcare costs, and they used private insurer claims, which is really the only way to get a full accounting."

Bypass More Effective, but Is There a Role for the Band?

Dr. Dimick told Medscape Medical News: "Every study I've seen with a complete accounting of the cases shows that bypass is more effective than the band in weight loss and resolution of diabetes."

Use of gastric bands in Michigan has dropped from about 40% of all bariatric procedures to just 10% in the past few years, he said, noting that his institution is among those that have stopped using them altogether. "In my practice, the only billing code I've used for bands in the last several years is band removal."

However, Dr. Ponce pointed out that there are centers that do a good job with bands because "they have a different approach to the band: they're more involved. They see the patients more often, they manage the patient more closely, they do more adjustment of the band."

And importantly, he added, those centers also teach patients how to work with the band by chewing food well, eating slowly, using it for hunger/portion control, and not expecting the band to do all the work of weight loss.

Is the Question Even Appropriate?

And beyond the bypass-vs-band issue, both surgeons questioned whether the study question was appropriate to begin with.

Dr. Dimick said, "Most medical interventions are not cost saving, they're cost-effective… If it reduces patients' morbidity, improves their quality of life, gets rid of their comorbid diseases, does it have to save money? No, it has to improve health."

"Unfortunately, insurance companies are still trying to demonstrate a cost benefit" for bariatric surgery, Dr. Ponce told Medscape Medical News. People are not acknowledging that obesity is a disease, they…think it's just a lifestyle issue, so you have to prove a cost benefit…If someone has diabetes, and the diabetes gets better, we shouldn't be looking at costs instead of looking only at the health benefits.

"How much benefit will you get from taking a lung out of a lung-cancer patient who smokes? That is covered widely, but a lot of insurance companies still aren't covering bariatric surgery."

The study was funded by Allergan. Dr. Finkelstein has consulted for Allergan in the past; disclosures for the coauthors are listed in the article. Dr. Dimick is a consultant and equity owner of ArborMetrix, a healthcare analytics and information technology firm. Dr. Ponce is a consultant for Allergan and Covidien and is a speaker for W.L. Gore & Associates, which manufactures bioabsorbable staple line reinforcements. He is also the principal investigator of a trial sponsored by ReShape Medical investigating the use of an intragastric balloon system in obese patients.

PLOS One 2013;8:e75498. Article

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