Improved Bariatric Surgery Pathways Could Reduce Health Care Burden, Costs in Canada

By Marilynn Larkin

January 23, 2020

NEW YORK (Reuters Health) - A shorter time to bariatric surgery and better postop care could save money and years of obesity-related comorbidities in Canadian patients, an economic modeling study suggests.

"For adults cleared for surgical treatment of obesity, there can be delays to receiving surgery and, in many cases, poor weight loss trajectories afterwards," Dr. Jason Davis of Coreva Scientific GmbH and Co KG in Germany told Reuters Health by email. "The combination of these pre- and post-surgical challenges is associated with additional burden of comorbidity treatment - i.e., diabetes, hypertension and dyslipidemia."

"The study was performed in the specific example of Canada, but would be relevant anywhere there are delays pre-surgery or issues with weight trajectory after surgery," he said. "In the U.S., for example, patients may have insurance-mandated waiting periods or outright denials that are contrary to medical opinion, delaying surgery."

"After surgery, many studies from around the world show high rates of attrition, that patients get lost to follow-up and don't maintain regular appointments," he added. "This attrition appears to trend with poorer weight trajectories - that is, poorer loss and greater weight regain - and the corollary has also been suggested, that greater weight loss is associated with closer care during follow-up, among other factors."

The study modeled weight trajectory after sleeve gastrectomy and resolution rates for comorbidities, comparing Canada's standard of care with an improved care pathway to estimate differences in patient-years of comorbidity treatment over 10 years following referral, and the associated costs.

A time horizon of 10 years was chosen given mean waits of 3.5 years across Canada, the authors note. The comparator improved pathway of surgery at one year was assumed to be reasonable given past achievement of median 1.2 years for delivery in a program in Ontario, Canada, and the upper quartile of longest wait times in a U.S. state of approximately 204 days.

As reported in JAMA Network Open, the 100-patient model cohort (88% women) had a mean age of 63.6; mean body mass index of 49.4; and mean comorbidity prevalence of 50% for diabetes, 66% for hypertension, and 59.3% for dyslipidemia.

Over 10 years following referral, the improved versus standard care pathway was associated with a median reduction of 324 patient-years of treatment for diabetes, 245 for hypertension, and 255 for dyslipidemia. This corresponded to a total savings of $900,000 for public payers in the base case.

Relative to standard of care, the associated reduction in costs was approximately 29% in the improved pathway. Sensitivity analyses showed independent associations with overall savings of earlier surgery and various levels of post-surgical weight trajectory improvements.

Dr. Davis said, "According to their local situation - e.g., population, available resources, degree of inefficiencies in the bariatric surgical care pathway - clinicians and decision makers may want to consider how resources are deployed to reduce the impact of clinical and non-clinical obstacles to provision of surgery for suitable patients, and ways to maintain or improve patient contact and follow-up after surgery."

Dr. Marc Bessler, Director of the Center for Metabolic and Weight Loss Surgery at Columbia University Medical Center in New York City, commented in an email to Reuters Health, "The study showed that delays in patients getting to bariatric surgery cost more money for healthcare, as they delay the savings that bariatric surgery offers."

Like Dr. Davis, he noted, "Though the healthcare systems are quite different between U.S. and Canada, many insurers require lengthy and unnecessary barriers for patients. Especially disturbing is the requirement that patients who have almost always already failed dietary and other management be required to again do six months of medically supervised weight-loss efforts in the year before surgery. This is not supported by any clinical study but certainly delays care."

"Reducing unnecessary delays and helping patients navigate the pre-op education and evaluation pathway would help," he said. "Bariatric surgery waiting times can be likened to transplant waiting lists. We have seen patients literally die or develop serious problems while waiting for bariatric surgery."

The study was funded by Medtronic. Dr. Davis and one coauthor have received fees from the company.

SOURCE: JAMA Network Open, online January 17, 2020.