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Surgery cost-effective

Bariatric surgery is cost-effective at ten years

Bariatric surgery was associated with higher costs of €2,909, an additional 0.03 life years, and 1.2 QALYs, which resulted in an incremental cost-effectiveness ratio of €2,457 when compared to conventional medical management
Surgery remained very cost-effective and was well below the assumed ‘willingness-to-pay’ threshold of €35,000/QALY

Bariatric surgery is cost-effective at 10 years and may lead to significant cost-savings to health care system over the patient’s lifetime, according to researchers from the University Medical Center, Hamburg, Germany. In addition, the investigators found that any delay in a patient receiving bariatric surgery could result in “significant losses of clinical benefits”.

In their paper, ‘Cost-utility analysis of bariatric surgery compared with conventional medical management in Germany: a decision analytic modelling,’ published in BMC Surgery, the authors write that according to research, the number of bariatric procedures in Germany increased from 1,500 in 2006 to 5,900 in 2011, however these procedures are still behind other European countries: 72 bariatric surgeries per 1 million of the population in Germany, compared to 928 in Belgium, 571 in France, and 761 in Sweden.

There is considerable evidence to support the clinical and economic value for patients, the healthcare system and society of bariatric and metabolic surgery. However, the authors state, there is limited the long-term clinical and economic German studies to support bariatric surgery. Therefore, the aim of their research was to study evaluate the cost-effectiveness of bariatric surgery in Germany from a statutory health insurance perspective over both mid-term (ten years) and lifetime horizons.

For their research, the investigators used a state-transition decision analytic Markov model to evaluate the cost-effectiveness of bariatric surgery compared with conventional medical treatment.

The model included three of the most common surgical approaches: gastric bypass (GBP), sleeve gastrectomy (SG) and adjustable gastric banding (AGB). The breakdown of these procedures was GBP – 51%, SG – 17%, AGB – 33%, according to the German Quality Assurance in Bariatric Surgery Registry.

Only direct medical costs were included in the analysis and all cost data are presented from 2012 in Euros. The incremental cost-effectiveness ratio (ICER) was calculated by comparing the difference in average total costs with the difference in average quality-adjusted life-years (QALY) among the study cohorts.

In addition, the researchers examined impact on the delayed provision of surgery vs. immediate provision on clinical and economic outcomes in a cohort of non-diabetic patients.


They report that in the base-case analysis at ten years, bariatric surgery was associated with higher costs of €2,909, an additional 0.03 life years, and 1.2 QALYs, which resulted in an incremental cost-effectiveness ratio of €2,457 when compared to conventional medical management.

Over the lifetime of the patient cohort, bariatric surgery led to cost savings of €8,522 and generated an additional 0.7 life years and 3.2 QALYs (Table 1), and the write that “surgery is a dominating alternative to conservative management, as it is both more effective and less expensive.”

Table 1: Results of cost-effectiveness analysis

They also found that bariatric surgery led to a substantial reduction in lifetime risk of obesity-related adverse events with an 11% reduction in the risk of transient ischemic attack to a 29% decrease in the incidence of T2D. It was also noted that surgery had the potential to reduce the risk of obesity-related adverse events significantly, for both 10 years and lifetime horizons.

Diabetics and non-diabetic

For non-diabetic cohorts, surgery was found to be cost-effective in all cohorts, moderately obese males (ICER €9,835/QALY) and females (ICER €10,436/QALY), severely obese males (ICER €8,019/QALY) and females (ICER €8,451/QALY), morbidly obese males (ICER €4,048/QALY) and females (ICER €4,320/QALY), and super obese males (ICER €1,880/QALY) and females (ICER €2,016/QALY). The cost-effectiveness of surgery was driven by a higher baseline BMI level of the cohort.

Bariatric surgery was also cost-saving in all eight diabetic cohorts considered over a lifetime horizon. Surgery remained very cost-effective and was well below the assumed ‘willingness-to-pay’ threshold of €35,000/QALY.

A delay of surgery for up to three years led to a significant loss of clinical benefit and was associated with differences of 0.1 life years gained and 0.4 QALYs compared to immediate operation (Figure 1), the researcher report. The cost for provision of surgery decreased with the delay of surgery provision, compared with the cost of immediate surgery provision. The cost of the surgery over the lifetime horizon accounted for €40,585 with the immediate operation, €40,152 with a one-year, €39,514 with two-year, and €39,841 with a three-year delay.

Figure 1: Life years and QALYs gained with performing surgery immediately and with a delay

“The results of our analysis, driven by a mix of currently used surgical techniques, imply that bariatric surgery is cost-effective over the period of 10 years,” the authors write. “It has a cost-saving effect on the health care system over a patient’s lifetime, in a German setting, and is associated with substantial clinical benefits.”

The analysis demonstrated that operative obesity treatment was cost-saving in Germany and lead to an additional 1.34 QALY with GBP and 1.03 QALY with AGB over the base case time horizon of five years.

Moreover, the study showed that a three-year delay in surgery provision might slightly reduce the total cost of treatment, but a delay in surgery may lead to loss of clinical benefits up to 0.1 life-years and 0.4 QALYs over a lifetime.

“Despite wide acknowledgment of bariatric surgery’s short and medium-term effectiveness and cost benefits, operative treatment in Germany is underutilised…Referral pathways should be enhanced, and clearly defined conservative treatment criteria should be established before a wider adoption of bariatric surgery in Germany,” the authors note.

To access this paper, please click here

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