Bariatric surgery did not reduce healthcare costs over the long term when surgery patients were compared with matched obese patients who did not have surgery, a review of almost 30,000 cases showed.
Surgical patients had lower healthcare costs in the first year after surgery, averaging about $1,000 lower per case, according to Jonathan P. Weiner, DrPH, of the Johns Hopkins School of Public Health, and co-authors. During the next 2 years, bariatric surgery was associated with significantly higher healthcare costs. In years 4 through 6, costs stabilized but remained higher in the surgery cohort for 2 of the 3 years.
Laparoscopic procedures were associated with lower costs only during the first few years after surgery, they reported online in JAMA Surgery.
"Bariatric surgery does not reduce overall healthcare costs in the long term," the authors concluded. "Also, there is no evidence that any one type of surgery is more likely to reduce long-term healthcare costs.
"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."
As evidence has accumulated to support the health benefits of bariatric surgery, the number of procedures has increased dramatically, reaching 220,000 annually as of 2009. Additionally, numerous studies have suggested that bariatric surgery reduces healthcare costs by improving patients' health and well-being.
In particular, laparoscopic bariatric procedures have won favor because of their association with shorter hospital stays and fewer complication rates as compared with open procedures. However, questions have persisted about the potential return on investment, the most cost-efficient surgical procedures, and whether cost savings are sustained over time.
To address some of the unresolved issues, Weiner and colleagues analyzed claims data provided by seven Blue Cross/Blue Shield healthcare plans with total enrollment of 18 million. The authors identified 29,820 plan members who underwent bariatric surgery during 2002 through 2008. Each patient was matched with another plan member who had one or more diagnoses associated with obesity but did not have weight-loss surgery.
The primary outcome was standard costs and adjusted ratios of the surgical patients' healthcare costs as compared with those of the matched nonsurgical group.
Consistent with bariatric surgery clinical experience, women accounted for 80% of the patients included in the study; 54% of the patients were ages 45 t0 64 and 37% were 30 to 44. About half the patients in both groups had hypertension, and 25% to 30% had type 2 diabetes.
The two groups had comparable healthcare costs in the year prior to date of the surgical patients' procedures: $8,850 in the surgical cohort and $9,590 for the comparison group. The standardized cost of surgery was $29,517, including the surgery and 30-day follow-up period.
In the first year after surgery, healthcare costs averaged $8,905 in the surgery cohort and $9,908 in the comparison group. During year 2, total healthcare costs in the surgical cohort peaked at $9,908, whereas costs in the comparison group decreased to $9,264. Costs in the surgery cohort exceeded those of the comparison group for 3 of the next 4 years:
- Year 3 -- $9,211 versus $9,041
- Year 4 -- $9,051 versus $9,232
- Year 5 -- $9,386 versus $8,966
- Year 6 -- $9,259 versus $8,714
Bariatric surgery patients had lower costs for prescriptions and clinic visits but higher costs for inpatient care compared with the comparison group.
In a critique of the study, JAMA deputy editor Edward H. Livingston, MD, said bariatric surgery clearly benefits a subgroup of patients who have a complication or condition known to improve dramatically with weight loss, such as diabetes and osteoarthritis. Reducing body mass index should not be the exclusive indication for the surgery.
"Bariatric surgery has dramatic short-term results, but on a population level, its outcomes are far less impressive," Livingston wrote. "In this era of tight finances and inevitable rationing of healthcare resources, bariatric surgery should be viewed as an expensive resource that can help some patients.
"Those patients should be carefully vetted and the operations offered only if there is an overwhelming probability of long-term success."
The findings are informative but do not necessarily reflect the current practices and economics of bariatric surgery, according to Jaime Ponce, MD, president of the American Society of Metabolic and Bariatric Surgery. In particular, the study reflected a predominance of open procedures, even in the last year of the study period. Since that time, laparoscopic procedures have become predominant.
"We know that open surgery requires a longer follow-up to see the economic benefits of bariatric surgery," said Ponce, of Memorial Hospital in Chattanooga, Tenn. "Even in the last year of the study, a large number of open surgeries were performed. Today about 90% of bariatric surgery procedures are performed laparoscopically."
The findings also contrast with a substantial amount of literature documenting cost benefits of bariatric surgery, he continued. Most of that literature is based on more contemporary trends in bariatric surgery.
Ponce also noted that the study did not take into account the economic impact of the indirect benefits of bariatric surgery, such as improved employability, improvement in overall health, resolution of diabetes and other metabolic disturbances, and better quality of life.