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How Obesity Surgery Can Save Billions



As an internist, who does not perform operations on people, it is indeed humbling having to acknowledge that surgery is perhaps the best treatment for severe obesity, something widely considered a “medical” condition. To add insult to injury, there is now an accumulating body of evidence that illustrates not only that bariatric surgery is one of the most effective treatments known to man in terms of reducing morbidity and mortality, but also a treatment that can literally save the health care system billions of dollars.

This slightly embarrassing (for non-surgeons) fact is once again illustrated by the latest study on this topic just published in this month’s issue of Diabetes Care by Catherine Keating and colleagues from Monash University, Melbourne, Australia.

In this paper, the researchers compared the cost-effectiveness of surgically induced weight loss to conventional therapy for the management of recently diagnosed type 2 diabetes in class I/II obese patients. The analysis compares the lifetime costs and quality-adjusted life-years (QALYs) between two intervention groups: surgically treated patients vs. conventionally treated obese patients with type 2 diabetes.

Intervention costs were extrapolated based on observed resource utilization during the trial. Health care costs for patients with type 2 diabetes and outcome variables required to derive estimates of QALYs (Quality-Adjusted Life Years) were sourced from published literature. A health care system perspective was adopted for the analysis. Costs and outcomes were discounted annually at 3% and presented in 2006 Australian dollars (AUD) (current currency exchange: 1 AUD = 0.87 CND).

The mean number of years in diabetes remission over a lifetime was 11.4 for surgical therapy patients and 2.1 for conventional therapy patients. Over the remainder of their lifetime, surgical and conventional therapy patients lived 15.7 and 14.5 discounted QALYs, respectively.

The mean discounted lifetime costs were 98,900 AUD per surgical therapy patient and 101,400 AUD per conventional therapy patient. Relative to conventional therapy, surgically induced weight loss was associated with a mean health care saving of 2,400 AUD and 1.2 additional QALYs per patient.

Obviously, when extrapolated to the millions of patients diagnosed with type 2 diabetes, most of who have Class 1 obesity (or greater), the potential savings are in the billions.

And this analysis only accounts for the saving from treating diabetes – when you add the costs for reducing heart disease, cancers, need for joint replacements, incontinence, sleep apnea, liver disease, fertility treatments and other important obesity related comorbidities, the savings to the health care system are probably in the 10s of billions. Remember, this analysis looked at class I and II obesity – the potential savings are far greater in patients with more severe obesity.

So what is stopping us from offering more obesity surgery to the 100s of 1000s of Canadians who would benefit. Is it simply bias and discrimination against obese people? Or do we really think that somehow magically the obesity epidemic will suddenly disappear?

As I’ve written before, no health system can afford to NOT increase spending on obesity management. If we don’t, we will never have enough diabetes centres, heart hospitals, cancer wards or orthopedic clinics to deal with the multitudes of patients disabled and defeated by obesity.

As the authors of this study conclude, surgically induced weight loss is a dominant intervention (it both saves health care costs and generates health benefits) for managing recently diagnosed type 2 diabetes in class I/II obese patients in Australia – I have no doubt that the savings would be as great in Canada.

AMS
Edmonton, Alberta

7 Comments

  1. You once again make an excellent case that obesity surgery is an effective treatment, and one that needs to be available to far more people. However, since these surgeries are used to treat obesity rather than prevent it, I hope that we put equal time and money into preventing obesity in the next generation, while we treat it in the current generation.

    Travis

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  2. Great blog, yet again. The politics of spending money for benefits 10-20 years down the the road seem insurmountable. I would strongly suspect that there is no cost benifit measued in QUALYs for any of our other big ticklet surgical operations like open heart surgery or joint replacements. Clearly preventing obesity is the way to go but right now we don’t know how to begin to address that.

    Bill

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  3. This study compares two groups:surgically treated patients vs. conventionally treated obese patients.

    I read the abstract but still have 2 questions:

    1. Division of the patients into the two groups:
    In previous blogs you have spoken about the selection criteria for a patient to get surgery – only people who meet strict criteria get surgery.

    To compare two groups getting different treatment, the two groups would have to start out meeting the same criteria. Then, all the people meeting all the criteria would be randomly assigned to either “surgery group” or “conventional treatment group.”

    Sometimes comparison is made between bariatric surgery and other treatments, but when you read the details, the surgery patients are those who have been carefully selected to be those likely to be successful for medical, psychological, and even social considerations as well as surgical criteria, and the other group is just everybody and anybody else, including people rejected for bariatric surgery as being unlikely to succeed.

    Is this study based on criteria-meeting people randomly split into two groups, or is it based on one group of carefully selected surgical patients, and a group of the leftover patients getting conventional treatment?

    2. Did the two groups of patients get the same treatment in all aspects except for the actual surgery?

    Surgery patients get counselling, and blood tests, and other medical tests. They undergo a hospital stay , with attention due a surgery patient. They get follow up medical rests and monitoring.

    “Conventional treatment ” ranges from intensive to “Follow the Canada Food Guide but eat a little less and take walks”.

    To compare surgery to non-surgical treatment, it is necessary to separate the surgery itself from all the accompanying factors, including the fact that being a surgery patient means you are taken more seriously and given more attention. ( It’s funny when you laugh about interns compared to surgeons, its significant if you’re a patient.)

    Ideally both groups of patients would get exactly the same treatment, except in the operating room the surgeon would get a randomly assigned instruction to either do “bariatric surgery” or “make incision, cloiseup”, and all post – op care would be identical. Not feasible!!! So statistics might help sort out differences in non-surgical aspects of treatment.

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  4. Just to answer Ann Hatings, these patients were in a randomized control study, involving 60 patients. They were diabetic, randomly assigned to Lap Band or medical therepy and were the same otherwise, so 30 had surgery and 30 did not. They also did an anlysis to see how much a surgial remission of diabetes cost compared to a medical remission of diabetes. It cost 25,500 per medical remission and 16,600 per surgical remission.

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  5. Thank you Mr. Graber

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  6. Web Address is: http://www.springerlink..com/content/012pl1161010n53x/
    8 April 2008

    Conclusion Weight regain was observed within 24 months after surgery in approximately 50% of patients. Both weight regain and surgical failure were higher in the superobese group. Studies in regard to metabolic and hormonal mechanisms underlying weight regain might elucidate the causes of this finding.

    Keywords Morbid obesity – Gastric bypass – Gastroplasty – Weight regain

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  7. Hi Bill:
    10 or 20 years down the road there are not only benefits but lots of complications for your patients.

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