A study that differed dramatically with prior research of its kind has found that gastric bypass operations did not lower healthcare costs in the three years after surgery, at least in a cohort of older male patients in the Veterans Affairs Medical System, although they did save lives.
"Given that prior studies have shown lower (healthcare) cost reductions for patients who underwent bariatric surgery, I think we were quite surprised," says principal author, Matthew Maciejewski, of the Center for Health Services Research in Primary Care at the Durham VA Medical Center in North Carolina and colleagues.
Maciejewski suggested two possible explanations:
1. Costs may eventually drop significantly, but only after three years, however the study hasn't gone on that long to determine that.
2. This patient population of older males who already had health issues differs significantly from populations of bariatric surgery patients previously studied. "It could be that their opportunity to improve their co-morbidities and reduce their risk for adverse events was harder to realize, compared to benefits in women who were younger and not as sick," he suggests. The mean age in the study group was 49.5 for surgical patients and 54.7 for non-surgical patients.
The study enrolled 847 obese veterans who underwent surgery, commonly the Roux en Y gastric bypass procedure. Their healthcare costs were compared for both the three-year period prior to the surgery and three years after with another 847 obese veterans who did not undergo surgery. The patients were followed at 12 VA medical centers between the year 2000 and 2006.
"Adjusted total expenditures converged in the three years after the operation, from $4397 higher in the first six postsurgical months to similar expenditures in the 31 to 36 postsurgical months," according to the study.
It found, however, that more than twice as many lives were saved within the cohort that underwent the surgery compared with the group that did not undergo the procedure. The two-year death rate for patients who did not undergo surgery was 4.6%. But for those who underwent surgery, it was only 2.2%.
Maciejewski could not say what costs were incurred in the higher expenditure for this population of older male veterans that were not incurred in patient populations that are younger, healthier, or more likely to include females. That is part of a much larger study that Maciejewski hopes will answer some questions.
The report was published Tuesday in the Archives of Surgery. Maciejewski says the information about cost of care is important for a variety of reasons. For starters, he says, "The VA system is facing increasing challenges and demands for care from the veterans coming back from Iraq and Afghanistan, and it continues to serve the needs of veterans from the Vietnam War and other wars since. It does not have an unlimited budget to provide all services for all veterans.
"So—and this is my perspective, not that of the VA—the VA needs to make some intelligent decisions about what services it's going to provide and prioritize in some way," Maciejewski says. In bariatric surgery, that's one program where the demand is much greater than the supply, and so the VA needs to figure out how it is going to prioritize that, and make sure the veterans who will have the best outcomes can get it."
He cautions that his paper is in no way meant to indicate a policy for commercial health plans or any other payers to restrict bariatric surgery to younger or female or non-veteran patients. Rather, it may be an important indicator that additional interventions must be implemented to keep older sicker patients from returning to former, unhealthy habits, especially since their health status is more vulnerable.
He adds that after the surgeon's job is done, bariatric surgery patients "have a challenge of weight maintenance, and there's lots of room for improvement to help patients maintain that loss and the clinical benefits from it."
The study has several limitations, Maciejewski acknowledges. It ended in 2006, and since then other types of bariatric procedures, some involving less invasive and more efficient and effective techniques, have been put into practice. Surgeons now have more experience with an increasing number of procedures and quality benchmarks have been established.
It may be that when taking those changes into consideration, the results would be different.
Bariatric surgeries are increasingly considered an effective way to reduce long-term impacts on health. An estimated 109,000 procedures are performed annually in an increasing number of surgical centers, at an estimated average cost of about $26,000 each.
In an accompanying editorial, Harry Sax, MD, of the Department of Surgery at Cedars Sinai Medical Center in Los Angeles, writes that Machiewski's study is "important because total expenditures were higher for the bariatric population, taking into account perioperative expenses. It is unfortunate that a more detailed breakdown of categories of costs could not be performed," to illuminate whether pharmacy costs were and what the quality of life was for those who had the operation compared with those who did not.
"A final point," Sax wrote," is a rather blunt one: Patients who die no longer consume resources," and among those patients who had the surgery, "50 more patients were alive to consume resources during the six years studied."