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Are we operating too late?  Mortality Analysis and Stochastic Simulation of Costs Associated with Bariatric Surgery: Reconsidering the BMI Threshold

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Abstract

Background

Present guidelines recommend bariatric surgery at BMI ≥40 kg/m2 or BMI ≥35 kg/m2 with obesity-related morbidity.

Methods

Evidence for cost and mortality/morbidity risk of bariatric surgery and obesity-related diseases was evaluated determining equivalency point of absolute incremental mortality risk by BMI and risks associated with bariatric surgery. A stochastic model was developed evaluating costs related to surgical procedure at a given BMI.

Results

Bariatric surgery produces significant lifetime cost savings associated with diabetes, gallstones, hypertension, high cholesterol, colon cancer, heart disease, and stroke in men at BMI 30 kg/m2 for laparoscopic gastric bypass. For women, laparoscopic gastric bypass saves cost at BMI 32 kg/m2 and laparoscopic gastric banding at BMI 37 kg/m2. In white men, relative to single-year mortality risks by BMI, surgical intervention becomes risk-beneficial at BMI 25 kg/m2 for laparoscopic gastric banding, BMI 27 kg/m2 for laparoscopic gastric bypass procedure and open gastric banding, and BMI 37 kg/m2 for open gastric bypass. Risk benefit for African-American men by procedure occurs at BMI <25 kg/m2, BMI 27 kg/m2, and BMI 42 kg/m2, respectively. In white women, surgical intervention is beneficial at BMI 25.5 kg/m2 (laparoscopic gastric banding), BMI 28.5 kg/m2 (laparoscopic gastric bypass procedure), and BMI 45 kg/m2 (open gastric banding). Risk benefit for black women by procedure occurs at BMI 27.5 kg/m2, BMI 33.5 kg/m2, and BMI 50+ kg/m2, respectively.

Conclusion

Risk and cost benefit suggest surgical guidelines should be reconsidered. Threshold for bariatric surgery should be redefined to BMI 35 kg/m2 or BMI 30 kg/m2 with comorbidities.

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References

  1. Sturm R, Hattori A. Morbid obesity rates continue to rise rapidly in the United States. Int J Obes. 2013;37(6):889–91.

    Article  CAS  Google Scholar 

  2. Finkelstein EA, Khavjou OA, Thompson H, Trogdon JG, Pan L, Sherry B, et al. Obesity and severe obesity forecasts through 2030. Am J Prev Med. 2012;42(6):563–70.

    Article  PubMed  Google Scholar 

  3. Dietz WH. The response of the US centers for disease control and prevention to the obesity epidemic. Annu Rev Public Health. 2015;36:575–96.

    Article  PubMed  Google Scholar 

  4. Flegal KM, Graubard BI, Williamson DF. Methods of calculating deaths attributable to obesity. Am J Epidemiol. 2004;160(4):331–8.

    Article  PubMed  Google Scholar 

  5. Dee A, Kearns K, O’Neill C, Sharp L, Staines A, O’Dwyer V, et al. The direct and indirect costs of both overweight and obesity: a systematic review. BMC Res Notes. 2014;7:242.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Lagerros YT, Rössner S. Obesity management: what brings success? Ther Adv Gastroenterol. 2013;6(1):77–88.

    Article  Google Scholar 

  7. Tsai AG, Wadden TA. Systematic review: an evaluation of major commercial weight loss programs in the United States. Ann Intern Med. 2005;142(1):56–66.

    Article  PubMed  Google Scholar 

  8. Hemmingsson E, Johansson K, Eriksson J, Sundström J, Neovius M, Marcus C. Weight loss and dropout during a commercial weight-loss program including a very-low-calorie diet, a low-calorie diet, or restricted normal food: observational cohort study. Am J Clin Nutr. 2012;96(5):953–61.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  9. Dixon JB. Surgical management of obesity in patients with morbid obesity and nonalcoholic fatty liver disease. Clin Liver Dis. 2014;18(1):129–46.

    Article  PubMed  Google Scholar 

  10. Chang S-H, Stoll CRT, Song J, Varela JE, Eagon CJ, Colditz GA. The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003–2012. JAMA Surg. 2014;149(3):275–87.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Picot J, Jones J, Colquitt JL, Gospodarevskaya E, Loveman E, Baxter L, et al. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgery for obesity: a systematic review and economic evaluation. Health Technol Assess. 2009;13(41):1–190. 215–357, iii–iv.

    Article  CAS  Google Scholar 

  12. NIH conference. Gastrointestinal surgery for severe obesity. Consensus development conference panel. Ann Intern Med. 1991;115(12):956–61.

    Article  Google Scholar 

  13. Guidelines for Clinical Application of Laparoscopic Bariatric Surgery—A SAGES Guideline [Internet]. SAGES. [cited 2015 Jun 18]. Available from: http://www.sages.org/publications/guidelines/guidelines-for-clinical-application-of-laparoscopic-bariatric-surgery/

  14. Arterburn D, Powers JD, Toh S, Polsky S, Butler MG, Portz JD, et al. Comparative effectiveness of laparoscopic adjustable gastric banding vs laparoscopic gastric bypass. JAMA Surg. 2014;149(12):1279–87.

    Article  PubMed  Google Scholar 

  15. Colquitt JL, Pickett K, Loveman E, Frampton GK. Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014;8, CD003641.

    PubMed  Google Scholar 

  16. Calle EE, Thun MJ, Petrelli JM, Rodriguez C, Heath CW. Body-mass index and mortality in a prospective cohort of U.S. adults. N Engl J Med. 1999;341(15):1097–105.

    Article  PubMed  CAS  Google Scholar 

  17. Buchwald H, Estok R, Fahrbach K, Banel D, Sledge I. Trends in mortality in bariatric surgery: a systematic review and meta-analysis. Surgery. 2007;142(4):621–32. discussion 632–5.

    Article  PubMed  Google Scholar 

  18. Sonnenberg FA, Beck JR. Markov models in medical decision making: a practical guide. Med Decis Mak. 1993;13(4):322–38.

    Article  CAS  Google Scholar 

  19. Manning WG. Panel on cost-effectiveness in health and medicine recommendations: identifying costs. J Clin Psychiatry. 1999;60 Suppl 3:54–6. discussion 57–8.

    PubMed  Google Scholar 

  20. Siegel JE, Weinstein MC, Russell LB, Gold MR. Recommendations for reporting cost-effectiveness analyses. Panel on cost-effectiveness in health and medicine. JAMA. 1996;276(16):1339–41.

    Article  PubMed  CAS  Google Scholar 

  21. Field AE, Coakley EH, Must A, Spadano JL, Laird N, Dietz WH, et al. Impact of overweight on the risk of developing common chronic diseases during a 10-year period. Arch Intern Med. 2001;161(13):1581–6.

    Article  PubMed  CAS  Google Scholar 

  22. Wilson PWF, D’Agostino RB, Sullivan L, Parise H, Kannel WB. Overweight and obesity as determinants of cardiovascular risk: the Framingham experience. Arch Intern Med. 2002;162(16):1867–72.

    Article  PubMed  Google Scholar 

  23. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724–37.

    Article  PubMed  CAS  Google Scholar 

  24. Zlabek JA, Grimm MS, Larson CJ, Mathiason MA, Lambert PJ, Kothari SN. The effect of laparoscopic gastric bypass surgery on dyslipidemia in severely obese patients. Surg Obes Relat Dis. 2005;1(6):537–42.

    Article  PubMed  Google Scholar 

  25. Nguyen NT, Varela E, Sabio A, Tran C-L, Stamos M, Wilson SE. Resolution of hyperlipidemia after laparoscopic Roux-en-Y gastric bypass. J Am Coll Surg. 2006;203(1):24–9.

    Article  PubMed  Google Scholar 

  26. Meneghini LF. Impact of bariatric surgery on type 2 diabetes. Cell Biochem Biophys. 2007;48(2–3):97–102.

    Article  PubMed  CAS  Google Scholar 

  27. Anderson RN. A method for constructing complete annual U.S. life tables. Vital Health Stat. 2000;2(129):1–28.

    Google Scholar 

  28. Zhang J, Yu KF. What’s the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA. 1998;280(19):1690–1.

    Article  PubMed  CAS  Google Scholar 

  29. Livingston EH. Hospital costs associated with bariatric procedures in the United States. Am J Surg. 2005;190(5):816–20.

    Article  PubMed  Google Scholar 

  30. Paxton JH, Matthews JB. The cost effectiveness of laparoscopic versus open gastric bypass surgery. Obes Surg. 2005;15(1):24–34.

    Article  PubMed  Google Scholar 

  31. Brandle M, Zhou H, Smith BRK, Marriott D, Burke R, Tabaei BP, et al. The direct medical cost of type 2 diabetes. Diabetes Care. 2003;26(8):2300–4.

    Article  PubMed  Google Scholar 

  32. Drake BB, Arguedas MR, Kilgore ML, Hawn MT, Wilcox CM. Economical and clinical outcomes of alternative treatment strategies in the management of common bile duct stones in the elderly: wait and see or surgery? Am J Gastroenterol. 2006;101(4):746–52.

    Article  PubMed  Google Scholar 

  33. Odell TW, Gregory MC. Cost of hypertension treatment. J Gen Intern Med. 1995;10(12):686–8.

    Article  PubMed  CAS  Google Scholar 

  34. Tasosa J, Schuster R, McAlearney JS. Cost-effectiveness of treating hypertension, hyperglycemia, and hyperlipidemia in African Americans and the general population with type 2 diabetes. J Health Care Poor Underserved. 2010;21(1):161–76.

    Article  PubMed  Google Scholar 

  35. Taplin SH, Barlow W, Urban N, Mandelson MT, Timlin DJ, Ichikawa L, et al. Stage, age, comorbidity, and direct costs of colon, prostate, and breast cancer care. J Natl Cancer Inst. 1995;87(6):417–26.

    Article  PubMed  CAS  Google Scholar 

  36. Yanmei Liu KD. Review of cost-effectiveness analysis of medical treatment for myocardial infarction. Int J Prev Med. 2011;2(2):64–72.

    PubMed  PubMed Central  Google Scholar 

  37. Taylor TN, Davis PH, Torner JC, Holmes J, Meyer JW, Jacobson MF. Lifetime cost of stroke in the United States. Stroke. 1996;27(9):1459–66.

    Article  PubMed  CAS  Google Scholar 

  38. Demaerschalk BM, Hwang H-M, Leung G. US cost burden of ischemic stroke: a systematic literature review. Am J Manag Care. 2010;16(7):525–33.

    PubMed  Google Scholar 

  39. Kral JG, Näslund E. Surgical treatment of obesity. Nat Clin Pract Endocrinol Metab. 2007;3(8):574–83.

    Article  PubMed  Google Scholar 

  40. Gloy VL, Briel M, Bhatt DL, Kashyap SR, Schauer PR, Mingrone G, et al. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. BMJ. 2013;347:f5934.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Terranova L, Busetto L, Vestri A, Zappa MA. Bariatric surgery: cost-effectiveness and budget impact. Obes Surg. 2012;22(4):646–53.

    Article  PubMed  Google Scholar 

  42. Hoerger TJ, Zhang P, Segel JE, Kahn HS, Barker LE, Couper S. Cost-effectiveness of bariatric surgery for severely obese adults with diabetes. Diabetes Care. 2010;33(9):1933–9.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Laiteerapong N, Huang ES. The public health implications of the cost-effectiveness of bariatric surgery for diabetes. Diabetes Care. 2010;33(9):2126–8.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Borisenko O, Adam D, Funch-Jensen P, Ahmed AR, Zhang R, Colpan Z, et al. Bariatric surgery can lead to net cost savings to health care systems: results from a comprehensive European decision analytic model. Obes Surg. 2015.

  45. Pollock RF, Muduma G, Valentine WJ. Evaluating the cost-effectiveness of laparoscopic adjustable gastric banding versus standard medical management in obese patients with type 2 diabetes in the UK. Diabetes Obes Metab. 2013;15(2):121–9.

    Article  PubMed  CAS  Google Scholar 

  46. Tice JA, Karliner L, Walsh J, Petersen AJ, Feldman MD. Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures. Am J Med. 2008;121(10):885–93.

    Article  PubMed  Google Scholar 

  47. Jackson TD, Hutter MM. Morbidity and effectiveness of laparoscopic sleeve gastrectomy, adjustable gastric band, and gastric bypass for morbid obesity. Adv Surg. 2012;46:255–68.

    Article  PubMed  Google Scholar 

  48. Frühbeck G. Bariatric and metabolic surgery: a shift in eligibility and success criteria. Nat Rev Endocrinol. 2015.

  49. Reha JL, Lee S, Hofmann LJ. Prevalence and predictors of nonalcoholic steatohepatitis in obese patients undergoing bariatric surgery: a department of defense experience. Am Surg. 2014;80(6):595–9.

    PubMed  Google Scholar 

  50. Wadhwa A, Singh PM, Sinha AC. Airway management in patients with morbid obesity. Int Anesthesiol Clin. 2013;51(3):26–40.

    Article  PubMed  Google Scholar 

  51. Berenbaum F, Eymard F, Houard X. Osteoarthritis, inflammation and obesity. Curr Opin Rheumatol. 2013;25(1):114–8.

    Article  PubMed  CAS  Google Scholar 

  52. King CM, Hamilton GA, Cobb M, Carpenter D, Ford LA. Association between ankle fractures and obesity. J Foot Ankle Surg. 2012;51(5):543–7.

    Article  PubMed  Google Scholar 

  53. Akyüz F, Uyanıkoglu A, Ermis F, Arıcı S, Akyüz Ü, Baran B, et al. Gastroesophageal reflux in asymptomatic obese subjects: an esophageal impedance-pH study. World J Gastroenterol. 2015;21(10):3030–4.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among us adults, 1999–2010. JAMA. 2012;307(5):491–7.

    Article  PubMed  Google Scholar 

  55. Lawley J. Weighing up the evidence: a meta-analysis and therapeutic audit of the treatments for obesity. Biosci Horiz. 2014;7, hzu003.

    Article  Google Scholar 

  56. Wang G, Zhang Z, Ayala C, Dunet D, Fang J. Costs of hospitalizations with a primary diagnosis of acute myocardial infarction among patients aged 18–64 years in the United States. In: Gaze D, editor. Ischemic Heart Disease [Internet]. InTech; 2013 [cited 2015 Aug 9]. Available from: http://www.intechopen.com/books/ischemic-heart-disease/costs-of-hospitalizations-with-a-primary-diagnosis-of-acute-myocardial-infarction-among-patients-age

  57. Mark DB, Hlatky MA, Califf RM, Naylor CD, Lee KL, Armstrong PW, et al. Cost effectiveness of thrombolytic therapy with tissue plasminogen activator as compared with streptokinase for acute myocardial infarction. N Engl J Med. 1995;332(21):1418–24.

    Article  PubMed  CAS  Google Scholar 

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Acknowledgments

We wish to acknowledge the effort taken by Hawa Abubakar, Drexel School of Medicine, USA, for helping us to edit the language for the manuscript.

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Authors and Affiliations

  1. Department of Anesthesiology and Perioperative Medicine, Drexel University College of Medicine, 245 N. 15th Street; MS 310, Philadelphia, PA, 19102, USA

    Ashish C. Sinha

  2. Department of Anesthesia, All India Institute of Medical Sciences, New Delhi, India

    Preet Mohinder Singh

  3. Department of Orthopedics, Jefferson Medical College, Philadelphia, PA, USA

    Suneel Bhat

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  1. Ashish C. Sinha
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Correspondence to Ashish C. Sinha.

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Sinha, A.C., Singh, P.M. & Bhat, S. Are we operating too late?  Mortality Analysis and Stochastic Simulation of Costs Associated with Bariatric Surgery: Reconsidering the BMI Threshold. OBES SURG 26, 219–228 (2016). https://doi.org/10.1007/s11695-015-1934-x

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