Will Surgery Cut Diabetes Costs?

For patients with obesity and type 2 diabetes, bariatric surgery is by far the most effective treatment – it is, indeed, the only form of treatment that can put patients into full long-term remission.

But is surgery really a cost-effective option for health systems looking to contain the immense economic and health burden of diabetes?

A paper by Martin Makary and colleagues from Johns Hopkins University, Baltimore, just published in the Archives of Surgery, looks at the annual health care costs in patients with type 2 diabetes before and after bariatric surgery.

The researchers examined administrative claims data from 2235 adults with type 2 diabetes who underwent bariatric surgery in the US during from January 1, 2002, through December 31, 2005.

Surgery eliminated the use of anti-diabetes medication therapy in 75%, 81%, and 85% of patients at 6 months, 1 and 2 years, respectively.

Although the median cost of the surgical procedure and hospitalization was abut $30,000, in the 3 years following surgery, total annual health care costs, which increased by about 10% in the first year after surgery, decreased by around 35% in year 2 and by over 70% in year 3 compared to costs before surery.

As the authors point out, “Because weight loss following bariatric surgery has been observed to be sustained for decades, we believe that the protective effect against complications of diabetes is also likely to be long-term.

This study of administrative data also supports the remarkable safety of bariatric surgery, which in this populations had an in-hospital mortality rate of only 0.3%.

The authors do not fail to point out the tremendous public health implications of these findings,

“Most concerning are the deferred health consequences and costs associated with obesity, auguring the presentation of complications decades into the future. Current trends in rates of obesity and diabetes threaten to overwhelm the already strained health care resources in many countries. Thus the obesity epidemic has created a deferred influx of demand for diabetes-related health care services not yet realized. Until a successful non-surgical means for preventing and reversing obesity is developed, bariatric surgery appears to be the only intervention that can result in a sustained reversal of both obesity and type 2 diabetes mellitus in most patients receiving it.”

An important limitation of the study is that it does not consider the long-term costs of diabetes complications like heart disease, renal failure, and amputations, that are likely to be prevented or at least substantially deferred as a result of surgery.

The report also does not consider the substantial additional savings that could incur from the prevention of obstetric and gynecological complications, such as gestational diabetes and poor fetal outcomes.

In addition, the weight loss experienced may prevent, stabilize, or improve other obesity-related conditions, such as urinary incontinence and osteoarthritis.

Bariatric surgery may also decrease complications after other surgical procedures (ie, orthopedic procedures).

Finally, there is also good evidence to support the notion that obesity surgery prevents cancers.

In light of these finding the authors conclude, “Health insurers, private and public, should pay for bariatric surgery for appropriate candidates, recognizing a potential annualized cost savings in addition to the benefit to health.

Exactly how health service systems can rapidly increase availability of bariatric surgery for eligible patient (with all the necessary pre- and post-surgical management resources) remains to be seen.

However, any health care system that fails to look at this issue now, is likely to go under in the wake of the tremendous obesity costs that are poised to overrun all other health care costs in the foreseeable future.

Toronto, ON

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Makary MA, Clarke JM, Shore AD, Magnuson TH, Richards T, Bass EB, Dominici F, Weiner JP, Wu AW, & Segal JB (2010). Medication utilization and annual health care costs in patients with type 2 diabetes mellitus before and after bariatric surgery. Archives of surgery (Chicago, Ill. : 1960), 145 (8), 726-31 PMID: 20713923