Cost and Weight Loss Drive Patient Choices in Bariatric Surgery

The cost of bariatric surgery, as well as how much weight they can be expected to lose following the procedure, strongly influence patient preference for the type of operation they chose, new survey results suggest.

And the ability of the surgery to resolve existing medical conditions is another important determinant behind patient preference for the chosen procedure, the same survey indicates.

"Instead of asking patients about the reasons for, or against, particular procedures, we asked patients to tell us what procedure characteristics mattered to them the most," said lead author Michael Rozier, PhD, Saint Louis University College for Public Health and Social Justice, Missouri.

"We find that excess weight loss, initial out-of-pocket costs, and resolution of medical conditions are most important in patient decision making," he and his colleagues write in their article, published online November 28 in JAMA Surgery.

Largest Study on Patient Preferences for Bariatric Surgery to Date

The Internet-based survey was completed by 815 candidates recruited from bariatric surgery information sessions held in Michigan. The mean age of the group was 44.5 years and almost 80% were women.

The authors say that this is, "to our knowledge, the largest study on patient preferences for bariatric surgery to date."

"For this study, we used a discrete choice experiment, a type of conjoint analysis that asked respondents to make a choice among two or more alternatives based on component characteristics of the alternatives," the researchers write. This has previously been employed to gain insight into how people decide on vaccinations, newborn screenings, and other health choices.

The attributes or "surgical profiles" of the four most common bariatric procedures done in the United States were then evaluated. The procedures included laparoscopic adjustable gastric banding, Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy, and duodenal switch.

Findings were expressed in terms of a coefficient value.

A coefficient value from a discrete choice experiment that is greater than zero indicates that including that attribute level in a surgical profile makes it more likely that the profile will be selected.

The most significant attributes for respondent choice were total weight loss (coefficient value for loss of 80% of excess weight, 0.460), initial out-of-pocket costs (coefficient value for $100 out-of-pocket costs, 0.309), and resolution of medical conditions (coefficient value for no weight-associated conditions, 0.229).

Perhaps not surprisingly, "each amount of additional cost made a surgical profile less likely to be selected, with an initial out-of-pocket expense of $15,000 as the most significant negative characteristic in the study," the researchers note.

However, respondents indicated that they would be willing to pay more for a given procedure if that procedure led to greater amounts of weight loss.

Patients were also willing to pay more if a procedure would resolve a weight-related medical condition such as sleep apnea, hypertension, hypercholesterolemia, and/or diabetes.

A procedure profile that failed to resolve any of those conditions made it less likely to be selected, however.

The risk of complications and any adverse effects arising from the procedure were also important but less so, the authors note.

In contrast, patient choice was not influenced by how a given surgical procedure works, nor by the time the procedure has been available as a treatment, nor by any dietary changes necessitated by the procedure itself.

Discussing Cost of Surgery Is a Unique Aspect of Survey

The authors point out that a unique aspect of their study was how important initial out-of-pocket costs were in patient preference for a given procedure.

And they stress that healthcare providers are not really trained to discuss the costs of procedures with patients, including bariatric surgery.

Indeed, "we often discourage providers from entering into that area of conversation because we don't want money to influence the relationship between providers and patients," Rozier noted in a press release from his institution.

"Our results show [cost] matters a great deal to patients," he added.

"So we probably need to figure out an appropriate way to incorporate cost into conversations providers have with their patients," Rozier concluded.

Currently, the two most commonly performed bariatric surgeries in the United States are sleeve gastrectomy and RYGB.

The authors have reported no relevant financial relationships.

JAMA Surgery. Published online November 28, 2018. Full text

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