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Cost of surgery

Bariatric surgery does not reduce overall costs

Future studies should focus on the potential benefit of improved health and well-being rather than cost savings

Bariatric surgery does not reduce overall healthcare costs in the long term with no evidence that any one type of surgery is more likely to reduce these costs, according to a study published in JAMA Surgery.

The outcomes from the six year study, which compared 29,820 patients who underwent bariatric surgery against the same number of well-matched patients who did not have the surgery, revealed that the surgery group had reduced costs in terms of office visits and prescriptions, but these were offset by their significant increases in inpatient costs.

"Many uncertainties remain about whether and when a return on investment can be expected, which type of bariatric surgical procedure produces the greatest cost reduction, and whether cost-reductions are sustained over time," said the researchers.

The study was designed to provide a comprehensive, multiyear (2002-2008) analysis of healthcare costs by type of procedure within a large cohort of privately insured persons who underwent bariatric surgery.

The researchers report that healthcare costs for the bariatric surgery patients did decline in the fourth, fifth, and sixth years following the operation, although not sufficiently to offset the initial expenses incurred during the first three postoperative years.

In an unadjusted analysis of the data, the surgical group showed an approximately 30% decrease in pharmacy costs during the first three years after the procedure. The control group showed no reduction.

Nevertheless, the surgical group had significantly more hospital admissions for gastro-intestinal-related events than the control group during all six years of follow-up, primarily occurring in the second and third years following surgery.

The researchers claim that the study "adds substantially to the existing literature on cost of bariatric surgery" because the study population was the largest to date and was representative of a broad cross section of the commercially insured US population.

The study also boasts one of the longest follow-ups of bariatric surgery outcomes in the United States, since previous studies generally had follow-ups of only six months to two years.

The researchers concluded that in order “To assess the value of bariatric surgery, future studies should focus on the potential benefit of improved health and well-being of persons undergoing the procedure rather than on cost savings.”

Editorial

In an accompanying editorial, Drs Matthew L Maciejewski (Center for Health Services Research in Primary Care, Durham, VA Medical Center) and David E Arterburn (Group Health Research Institute, Seattle, WA) state that bariatric surgery may still be cost-effective, if not cost-saving.

"Does bariatric surgery need to be cost-effective (i.e., more effective but more costly than usual care), or does it need to achieve the higher standard of cost savings (i.e., more effective and less costly than usual care) to justify broader insurance coverage?" they asked.

The procedures are so expensive that they are unlikely to meet the threshold of "cost saving" for most patients they write. Indeed, if half a patient’s total healthcare costs are cut, they claim it would take some 20 years to achieve “cost neutrality”.

This study was supported in part by Ethicon Endo-Surgery (a division of Johnson & Johnson), Pfizer, and GlaxoSmithKline, as well as by the National BlueCross BlueShield Association and the seven local plans that participated.

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