Bariatric Surgery in Teens Cost-effective Over Time

Kristin Jenkins

October 28, 2016

For adolescents with severe obesity who have run out of treatment options, bariatric surgery is a reasonable choice, the landmark Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study showed. Now, a cost analysis of the study demonstrates that although bariatric surgery is expensive, it becomes cost-effective with longer follow-up.

Bariatric surgery was not cost-effective over the 3-year follow-up reported in the Teen-LABS study, according to Chin Hur, MD, MPH, associate professor of medicine at Harvard Medical School, Boston, Massachusetts, and colleagues.

However, when the cost analysis was extended to 5 years, it fell below a willingness-to-pay threshold of $100,000 per quality-adjusted life-years (QALYs), they said in a report published online October 26 in JAMA Surgery.

"Our model shows that bariatric surgery can become cost-effective over a relatively short time horizon, even without incorporating the potential cost savings that may follow bariatric surgery because of decreased healthcare resource use," the researchers say.

"Our results underscore the need for long-term clinical trials in adolescents with at least 5 years of follow-up data that track quality of life, weight loss, comorbidity resolution, and healthcare costs to confirm our findings."

The study, which analyzed a mathematical state transition model using a willingness-to-pay threshold of $100,000 QALYs, showed that over 5 years, bariatric surgery had an incremental cost-effectiveness ratio (ICER) of $91,032 per QALY.

After only 3 and 4 years, however, the ICER was still well above the willingness-to-pay threshold, at $154,684 and $114,078 per QALY, respectively.

The procedure incurs substantial initial cost and morbidity and remains controversial, Dr Hur and colleagues say. Each year, about 1000 teens with severe obesity, defined as a body mass index (BMI) of 35 kg/m2 or greater, undergo bariatric surgery, they noted.

In spite of everything, bariatric could be worth it, the researchers say.

"From an individual-patient perspective…bariatric surgery can result in life-altering weight loss, which not only leads to the resolution and prevention of disease but also allows patients to avoid the stigma, bullying, and isolation that often accompany severe obesity.

"As evidence supporting the safety and efficacy of bariatric surgery continues to accrue for the adolescent population, it will likely become a more accepted and commonly used therapeutic option," they say.

As reported previously by Medscape Medical News, the Teen-LABS study demonstrated that after bariatric surgery, most patients had lost 28% of their weight — an average of 41 kg — and kept it off during the 3-year follow-up period.

When compared with adults, teens with severe obesity had even better clinical outcomes following bariatric surgery, which included higher rates of remission for type 2 diabetes and hypertension — 95% and 80%, respectively — at 3 years' postop.

There was also a 76% reduction in the prevalence of prediabetes, a 66% reduction in dyslipidemia, and an 86% reduction in abnormal kidney function. Mean quality-of-life scores improved by about 33% after 3 years, say Thomas Inge, MD, PhD, and colleagues in another report.

Dr Inge is director of the surgical weight-loss program for teens at Cincinnati Children's Hospital Medical Center, Ohio.

These results demonstrate "the durability of the benefit, the reductions in comorbid conditions that everyone would agree are clinically significant, and improvement in quality-of-life measures," he said.

Importantly, bariatric surgery can be a game-changer in young patients caught in a downward spiral.

"We have all cared for patients who, despite what we feel have been appropriate efforts, continue to gain weight and begin to develop compounding comorbid conditions that further exacerbate their ability to manage their weight," Dr Inge said. "For a very selected number of these patients, gastric bypass has been one of the few interventions that has produced clinical benefits."

Better identification of patients appropriate for bariatric procedures is the challenge facing clinicians now, he added.

First Long-term Prospective Analysis

While several analyses have examined the cost-effectiveness of bariatric surgery in adults, until Teen-LABS, there haven't been any prospective studies in adolescents that had more than 1 year of follow-up data, Dr Hur and colleagues point out.

For the study, the researchers compared surgery and no-surgery strategies in 228 patients using Teen-LABS surgical-outcomes data. At baseline, participants had a mean age of 17 years, mean BMI of 53, and 75% were female.

In the no-surgery strategy, patients stayed at the same BMI over time.

In the bariatric-surgery strategy, patients faced risk of perioperative mortality and complications as well as significant morbidity, Dr Hur and colleagues acknowledge.

However, they also experienced resolution and prevention of disease as well as quality-of-life improvements brought about by weight loss, the researchers say.

What's needed now are longer-term studies assessing the impact of weight-loss surgery on other chronic diseases such as diabetes and heart disease and on patients' psychological health and quality of life, Dr Hur told Medscape Medical News.

Awareness of the barriers that prevent clinicians from referring youth for bariatric surgery assessment also needs to increase "among relevant healthcare providers, patients, and their parents."

Given the association between lower socioeconomic status and obesity, the high cost of bariatric surgery could prevent some of the most vulnerable patients from being considered for bariatric surgery, Dr Hur noted in an interview. "This barrier is a concern that policy makers and the medical community should try to rectify," he said.

Meanwhile, the prevalence of severe obesity, which affects 4% to 6% of US youth, continues to grow. Even if the number of teens undergoing bariatric surgery were to quadruple, it would have little effect on the overall prevalence, the researchers admitted.

For this reason, they added, many obesity experts will continue to put their energies into prevention, supporting public-health interventions that call for higher taxes on sugar-laden drinks, restaurant menus that disclose the caloric intact of offerings, and higher nutrition standards for schools.

The study authors disclosed no relevant financial relationships.

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JAMA Surg. Published online October 26, 2016. Abstract




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