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ECONOMIC factors should not be the only criteria for judging the worth of bariatric surgery as a treatment for obesity, according to an obesity expert.
Professor Paul O’Brien, director of Monash University’s Centre for Obesity Research and Education, said the point of bariatric surgery was quality of life, not cost-effectiveness.
Professor O’Brien was commenting on research published in JAMA Surgery, which found that bariatric surgery does not reduce overall health costs in the long term. (1)
The US research involved a multi-year analysis of health care costs based on 29 820 privately insured people who underwent bariatric surgery between 2002 and 2008 who were matched with patients who not did not have surgery but had diagnoses closely associated with obesity.
The authors reported that total costs were “greater in the bariatric surgery group during the second and third years following surgery but were similar in the later years”.
“The bariatric group’s prescription and office visit costs were lower and their inpatient costs were higher”, the authors wrote.
“Bariatric surgery does not reduce overall health care costs in the long term”, they concluded.
Professor O’Brien said he was “not too surprised by the results”.
“We did a study on cost-effectiveness of surgically induced weight loss for the management of type 2 diabetes a few years ago and the results were not that different. (2)
“The thing is that costs over time are not the benefit of bariatric surgery”, he said. “Just to look at the costs is to miss the point.
“These people, postoperatively, are lighter, healthier, happier, and they live longer.”
An accompanying editorial in JAMA Surgery said bariatric surgery had “dramatic short-term results, but on a population level its outcomes are far less impressive”. (3)
“Coupled with findings that bariatric surgery confers little to no long-term survival benefit, these observations show that bariatric surgery does not provide an overall societal benefit”, the editorial said.
“Surgery should be offered only to patients with demonstrated compliance to medical and dietary treatment … In this era of tight finances and inevitable rationing of health care resources, bariatric surgery should be viewed as an expensive resource that can help some patients.”
Professor O’Brien disagreed.
“There is no data that I know of that indicates that previous compliance [to medical and dietary treatment] leads to a better outcome for bariatric surgery patients”, he said.
“There is no relationship between ‘readiness to change’ and outcome.
“I’ve been involved in this field since the late 1970s and I’ve never found a way to successfully predict who will have a good outcome from surgery”, Professor O’Brien said.
He also disagreed that bariatric surgery, particularly laparoscopic banding, had little long-term benefit.
“We published our 15-year data on banding in Annals of Surgery in January and we had a good result”, he said. (4)
That study from one centre demonstrated a durable weight loss, with 47% excess weight loss maintained to 15 years. The weight loss occurred regardless of whether any revisional procedures were needed.
“The JAMA Surgery editorial misses the point”, Professor O’Brien said. “Bariatric surgery is not about cost-effectiveness. It’s about quality of life. Weight loss occurs as a result of bariatric surgery and the recipients are happier and live longer”.
– Cate Swannell
1. JAMA Surg 2013; Online 20 February
2. Diabetes Care 2009; 32: 567-574
3. JAMA Surg 2013; Online 20 February
4. Ann Surg 2013; 257: 87-94
Posted 25 February 2013
There is an important corollary of this, which is that the health care costs of the obesity epidemic will not be mitigated by obesity surgery, however effective it may be.
In my view this only underlines the need to address the underlying causes of obesity at a societal level.
It is a capital mistake to assume that a dialysis machine is a cure for kidney failure. Equally, that bariatric surgery without the associated ongoing support is a cure for obesity.
The proponents of lap-band surgery would convince me a little bit more if I didn’t see there ilk doing operations on private patients such as the 21 year old woman who weighed 89 kg with a BMI of about 31.
It is a sad reflection on our society that an expensive surgical procedure is performed to stop people eating too much when so many people in the Third World are starving.
Professor O’Brien makes a very important point here. Costs alone are far too narrow a base from which to analyse the benefits of bariatric surgery. There are dramatic improvements in quality of life post-surgery, and we have no other effective treatment to offer the obese.