Patients that are obese visit their physician 27% more often, have 80% higher spending on prescription drugs and 46% increased inpatient costs compared with individuals of normal body weight.3 In 2004, Christou et al. reported that bariatric surgery significantly decreased overall mortality and the development of new co-morbid conditions in morbidly obese patients.261 Following 1,035 bariatric surgery patients and 5,746 morbidly obese controls (mean follow-up 5.3 ± 3.8 years), the authors found that these reductions resulted in lower healthcare costs for surgery patients over the course of the study: CAD 8,813 (± 2,344) compared with CAD 11,854 (± 2,1220) for controls (P = 0.001).261 Likewise, a 6-year follow up study of subjects from Louisiana, US, showed that
over the course of a few years bariatric surgery led to a reduction in medical costs, with cost savings apparent from year 3 onwards.161 Surgery patients had significantly (P < 0.0001) lower costs in years 3, 4 and 5 post-surgery compared with obese controls that remained on conventional treatment.161 By the 5th post-surgical year, mean medical expenditure was USD 5,000 lower in patients that underwent surgery compared with obese controls (Figure 2-16).161 Cost savings following bariatric surgery were also identified by Mullen and Marr, who investigated the longitudinal cost burden associated with gastric bypass.262 The authors analysed 7.5 years of administrative claim records from 224 gastric bypass patients, which covered the patients preoperative, surgical, and postoperative years.262 Future care costs for gastric bypass patients were not based on a control group but were individually estimated from preoperative cost trends and were adjusted for the annualized actuarial trends. The outcomes were, however, evaluated against trends in medical expenditure for the overall population and the overweight/obese sub-population.262 Within the first postsurgical year, mean costs for gastric bypass patients were lower than their pre- operative costs and by year 2 the gastric bypass patients had incurred fewer costs than the general
obese population.262 At 3.5 years post-surgery the cost of surgery had been recouped through cost savings.262
As demonstrated in Section 2.3, bariatric surgery is associated with remission and reduction in severity of co-morbid conditions. This is likely to be one factor in the reduced medical claims after bariatric surgery identified by Myers et al. and Mullen and Marr.161, 262 Examining the health outcomes in 605 patients in the 6 months before and 6 months after RYGB, Hodo et al. found that the mean number of prescription claims per patient in months 3-6 pre- and post-RYGB decreased from 6.93 (± 7.16) to 4.88 (± 5.84), respectively (P < 0.001).25 The incidence of obesity-associated co-morbid conditions reduced after bariatric RYGB, with the OR for conditions after compared with before surgery being
• Diabetes 0.71 (95% CI: 0.43-1.17)25 • OSA 0.35 (95% CI: 0.24–0.52)25
• Hypertension 0.53 (95% CI: 0.39–0.73)25 • GERD 0.44 (95% CI: 0.26–0.75)25 In line with these reductions, prescription claims for co-morbid conditions were reduced after RYGB, with the largest decrease in claims per person observed for medication for cardiac conditions, which decreased from a mean of 1.03 claims per patient (± 1.97) pre- to 0.40 claims per patient (± 1.23) postsurgery.25 The mean pharmacy claim pre-RYGB was USD 221.30 (±USD 341.25) compared with USD 158.90 (± USD 454.13) post-surgery.25 Although the average number of claims for inpatient visit increased after surgery, from 0.04 (± 0.31) to 0.07 (± 0.52) claims per person (P = 0.04), claims for office and outpatient visits decreased post-surgery.25 The mean number of office claims decreased from 5.52 to. 3.94 (P = 0.0028) per patient and claims for outpatient visits were reduced from 0.75 per patient pre- RYGB to 0.40 per patient post-RYGB (P < 0.001).25
Figure 2-16 Significant reduction in medical claims after bariatric surgery
Figure 2-17 Reduction in claims for prescription medication following bariatric surgery in France
Source: Cremieux et al.169 Y-axis indicates the % of patients at baseline who are also claiming for medication at each time point
Equivalent savings were identified by Cremieux et al. when comparing reimbursement claims before bariatric surgery with those from 30 days to 1,110 days after surgery.169 The study followed 5,502 patients in France, of whom 58.3% received RYGB, 14.6% underwent gastric restriction with bypass and small-bowel reconstruction, and 10.3% had short LRYGB.169 Following surgery, the prevalence of co-morbid conditions decreased substantially over a short period and these reductions were sustained for up to 3 years of follow-up.169 Compared to the pre-surgery period, significant decreases (P < 0.05) were observed after 3 years for total cardiovascular disorders (43.6% vs. 14.2%), diabetes mellitus (19.9% vs. 7.7%), respiratory conditions (57.7% vs. 16.2%), musculoskeletal and connective tissue disorders (32.6% vs.27.7%), and mental disorders (30.7% vs. 14.8%).169 Claims for medications decreased also, and notably, between 30 and 120 days postsurgery, claims for obesity and related hyperalimentation decreased by over 70%, going from claims by 81.8% of patients pre-surgery to 23% postsurgery.169 During the same period claims for other obesity-associated conditions also decreased, for example asthma claims
decreased over 60%, from 7.6% pre surgery to 3.0%
postsurgery (Figure 2-17).169 Post bariatric surgery the use of nutritional supplements did increase, as did the prevalence of anemia, which went from 3.8% pre-surgery to 9.9% after surgery.169
The impact of bariatric surgery on co-morbid conditions was also demonstrated by the work of Al Harakeh et al.20 From 2001 to 2007, the authors compared the incidence of comorbid conditions in a group of 587 obese patients who received bariatric surgery with that in a group of 189 obese controls who were denied bariatric surgery.20 The two groups had equivalent baseline demographics for age, gender and BMI, the prevalence of comorbid conditions at baseline for the surgery and denied groups, respectively, was 20% vs. 25% (diabetes), 51% vs. 43% (hypertension), 20% vs. 22% (OSA), 62% vs. 49% (GERD) and 34% vs. 24% (lipid disorders).20 Over the 3 year post- surgical follow-up period the incidence of new co-morbidities in the surgery group was 0.2% for T2DM, 0.9% for HTN, 0.4% for OSA, 0.7% for GERD, and 0.2% for lipid disorders (Figure 2-18). Over the same period, the incidence of comorbid conditions in the denied group was significantly higher (P < 0.001 in all cases): ~9% diabetes,
Figure 2-18 Incidence of obesity-associated co-morbid conditions developed within the 3-year follow up period in subjects who underwent bariatric surgery and subjects denied bariatric surgery
~42% hypertension, ~34% OSA, ~19% GERD, and ~9% lipid disorders (approximate values derived from Figure 2-18, actual values not provided in the manuscript).20 Cost saving from sustained reduction in comorbid condition was also
observed in a Brazilian study, in which pre-surgical healthcare costs were USD 1,706 per patient per year.196 In the years post-surgery, costs reduced to USD 1,174, USD 713 and USD 431 in years 1, 2 and 3, respectively.196
Following 73 obese patients in Scotland from before bariatric surgery to up to 42 months post- surgery (median 24 months), Karim et al. found that after surgery outpatient visits reduced by 13.8% per year (P = 0.04) and hospital admission decreased by 40.2% (P = 0.01), from 17.9 per year to 10.69 per year on average.263 Where hospital admission did occur, the total length of hospital stay was significantly reduced, 52.28% shorter than before surgery (P = 0.04).263 The authors estimated that the total cost savings were USD 32,593–41,177 and included USD 18,240–26,825 per year of savings from reduced hospital bed days.263 Lorentz et al. demonstrated that postoperative patient care could be improved and healthcare costs reduced through the use of group rather than individual follow-up visits.264 In this case control study of combined group and individual visits (CGV), 199 patients (61.4% of 324 bariatric surgery patients) met inclusion criteria and agreed to attend group sessions.264 Patient acceptance of CGV was high, 90% attended all post-operative meetings and 92.5%, 93.0%, and 88.6% of CGV patients were happy with CGV when surveyed at 3-, 6-, and 12-months post-surgery, respectively.264 Furthermore, over 75% of patients reported that they would not have preferred only individual visits with their HCP.264 From the physician and payer perspective, CGV resulted in time efficiency and cost reductions, a mean of 5 patients being seen for every 4.9 physician hours using the CGV
protocol, compared with 10.4 physician hours for 5 patients using individual-only visits.264 A reduction in charges for medical nutrition therapy using the CGV protocol was also realized, with this item being 50–64% less than the equivalent individual medical nutrition therapy used in individual-only visits.264