Commentary by Martin Neovius, PhD and Frank Greenway, MD
The study is the first to examine real-world data on the long-term effect of bariatric surgery on healthcare costs in obese patients according to their diabetes status.
“We, together with several other research groups across the world, believe that greater weight should be given to preoperative glucose status to help identify the patients who have the most benefit of bariatric surgery,” said coauthor of the study Martin Neovius, PhD, Senior Researcher, Department of Medicine, Karolinska Institutet, Stockholm, Sweden, and member of the Swedish Obese Subjects (SOS) team at Sahlgrenska Academy, Gothenburg. “We have shown previously that this makes sense from a health outcomes perspective.1,2 Now, we show that it also makes sense from an economic perspective,” Dr. Neovius told EndocrineWeb.
“The article assessing the long-term costs of bariatric surgery shows that, unlike the people without abnormal glucose tolerance or pre-diabetes, people with diabetes do not generate higher costs when having bariatric surgery over the course of the subsequent 15 years, and those with early diabetes have the greatest benefit for the cost from bariatric surgery,” commented Frank Greenway, MD, Vice President of the Obesity Treatment Foundation and Medical Director of the Pennington Biomedical Research Center, Baton Rouge, LA. “This suggests that, of the people who qualify for bariatric surgery on the basis of their BMI, the ones who have early diabetes are the ones that will benefit the most and should be given priority for bariatric surgery,” Dr. Greenway said.
Data From the Swedish Obese Subjects Study
The findings are based on data from the SOS study, which prospectively followed 2,010 adults (age 37–60 years; BMI of ≥34 in men and ≥38 in women) who had bariatric surgery and 2,037 contemporaneously matched controls given conventional treatment ranging from no treatment to lifestyle intervention and behavioral modification between 1987 and 2001. Patients were excluded from the study if they had previously undergone gastric or bariatric surgery, a recent malignancy or myocardial infarction, select psychiatric disorders, and other contraindicating disorders to bariatric surgery.
Lower Drug Costs Found in Patients With Prediabetes or Diabetes Treated Surgically
The mean drug costs over the 15 years of followup did not differ between the surgery and control group in patients without diabetes at baseline, but were lower in surgery patients who had prediabetes (mean difference, -$3,329 per patient in U.S. dollars; P=0.007) or diabetes (mean difference, -$5,487 per patient; P<0.0001). Inpatient hospital costs were significantly higher in the surgery group that in the conventional treatment group (+22,931, +$27,152, +18,697, in the subgroups without diabetes, with prediabetes, and with diabetes; P<0.0001 for all comparisons). No differences in outpatient costs were observed.
Bariatric Surgery Does Not Significantly Increase Total Costs in Patients With Diabetes
Total healthcare costs (accounting for costs of surgery, inpatient and outpatient hospital care and prescription drugs) were higher with bariatric surgery among the subgroups of patients without diabetes (+$22,390 per patient; P<0.0001) or who had prediabetes (+$26,292 per patients; P<0.0001), but were not significantly different among patients with diabetes (+$9,081; P=0.090).
“For patients, postoperative costs may be interesting both from a health perspective, as lower costs generally is a reflection of better health, and from an economic perspective, if there is some sort of co-pay scheme in the country where they live,” Dr. Neovius said.
BMI Should Not Be the Only Indication for Bariatric Surgery
“There has been much discussion around the cost of bariatric surgery and the unreasonable burden to the healthcare system that it represents to provide it for all that qualify by body mass index (BMI),” Dr. Greenway said. “There also has been much discussion around the use of BMI alone to measure risk of obesity. In fact, new methods of assessing the risk of obesity have been proposed, and one of these called the Edmonton Obesity Staging System has shown that stages based on pre-disease (like pre-diabetes), disease (like diabetes) and disease complications (like diabetic eye disease) gives a progressive risk of mortality which BMI does not,” Dr. Greenway said.
“It is important to appreciate that the degree of obesity is not the only consideration when assessing the risks, benefits, and costs of employing different obesity treatments,” Dr. Greenway said. “This article gives us information that will allow us to select the people with obesity who will benefit the most from obesity surgery. Hopefully, in the future, we will be able to identify those patients who will benefit the most from the medications that have now been approved to treat obesity as well,” Dr. Greenway told EndocrineWeb.
“I hope that this article reinforces that obesity is a chronic disease, and like other chronic diseases, the treatments should be tailored to optimize their delivery to those who will benefit the most,” Dr. Greenway said. “With that in mind, I would hope that people with qualifying degrees of obesity, and early diabetes will be preferentially referred for obesity surgery,” Dr. Greenway said.
October 27, 2015
Keating C, Neovius M, Sjöholm K, et al. Health-care costs over 15 years after bariatric surgery for patients with different baseline glucose status: results from the Swedish Obese Subjects study. Lancet Diabetes Endocrinol. 2015 Sep 16. pii: S2213-8587(15)00290-9. doi: 10.1016/S2213-8587(15)00290-9. [Epub ahead of print]
Cohen R. Bariatric surgery: time to move beyond clinical outcomes. Lancet Diabetes Endocrinol. 2015 Sep 16. pii: S2213-8587(15)00320-4. doi: 10.1016/S2213-8587(15)00320-4. [Epub ahead of print]
1. Carlsson LM, Peltonen M, Ahlin S, et al. Bariatric surgery and prevention of type 2 diabetes in Swedish obese subjects. N Engl J Med. 2012;367(8):695-704.
2. Sjöström L, Peltonen M, Jacobson P, et al. Bariatric surgery and long-term cardiovascular events. JAMA. 2012;307(1):56-65.