A strong evidence base supports the long-term clinical efficacy and safety of modern bariatric procedures, particularly for the 2 most common bariatric operations worldwide: sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB).1 However, data from randomized trials and observational studies1 indicate that there are important trade-offs to consider between these 2 approaches. Sleeve gastrectomy appears to be safer in the short term, with fewer perioperative complications, reoperations, and rehospitalizations than RYGB. Roux-en-Y gastric bypass appears to promote greater weight loss and more durable improvements in comorbidities such as type 2 diabetes.1 However, 2 important unanswered questions for patients and policy makers are (1) whether the increased need for health care resources due to the sequelae of bariatric surgery is counterbalanced by a decreased need for chronic disease care and (2) whether this balance differs between sleeve gastrectomy and RYGB. Studying changes in medical costs is a helpful way to understand overall health care resource use, but data sets that allow careful long-term study of costs are rare.
In JAMA Network Open, Tarride et al7 used surgical registry and administrative data from Canada’s public insurance program to help understand whether health care costs differ after sleeve gastrectomy and bypass as in a previous study.2 The authors conducted a retrospective observational cohort study involving propensity-matched cohorts of 812 patients who underwent either sleeve gastrectomy or RYBG from 2010 to 2015. Unlike administrative data sets from private payers, retention of their publicly insured cohorts was excellent, with 97.4% follow-up at 4 years. Somewhat surprisingly, they found no differences in medical costs in the 4 years after these procedures: mean (SD) costs were $33 682 ($31 169) for sleeve gastrectomy vs $33 948 ($32 633) for RYGB (P = .86). In both groups, nearly 50% of all postoperative expenditures were due to hospitalizations (RYBG, 47%; sleeve gastrectomy, 49%). Furthermore, although there were no differences in the overall rate of hospitalizations, nonelective hospitalizations occurred more often with RYGB vs sleeve gastrectomy (472 vs 339, respectively; P = .002). Notably, more patients underwent a second bariatric procedure after a sleeve gastrectomy (37 [4.6%]) compared with RYGB (8 [1.0%]; P < .001). In essence, the authors observed a different mix of postoperative health care needs for patients undergoing sleeve gastrectomy vs RYGB that ultimately led to very similar health care costs. This finding may disappoint payers and other stakeholders hoping for cost savings resulting from the shift toward more sleeve operations, but it has potentially important implications for patients, who would likely view health care dollars spent on elective care much more favorably than those spent on urgent interventions for complications.
The finding of no difference in 4-year costs between these procedures may also be partly because of the bariatric surgery eligibility criteria used in Canada during the study period. The authors indicate that sleeve gastrectomy was only publicly reimbursed when bypass was not possible owing to small-bowel disease and/or adhesions or previous surgery, or when the sleeve gastrectomy was performed as a planned 2-stage bariatric surgery in patients with a body mass index (calculated as weight in kilograms divided by height in meters squared) of greater than 60. As a result, the sleeve cohort in this study was likely very different from (and potentially higher-risk than) the average contemporary sleeve gastrectomy cohort in the US, where this procedure is considered first-line and accounts for roughly 60% of bariatric operations. Indeed, prior large US-based cohorts have estimated that overall rates of reoperation are 20% to 30% lower with sleeve gastrectomy than with RYGB,3-5 although the specific risk of a second bariatric operation appears to be slightly higher after a sleeve gastrectomy. Aligning with this lower-risk profile, Chhabra et al4 reported that sleeve gastrectomy was associated with lower 2-year postoperative health care spending than RYGB ($47 891 vs $55 213; P = .003) in a nationwide US claims database. Callaway et al6 examined a separate nationwide US claims database and found that patients undergoing sleeve gastrectomy had lower odds of high acute-care costs (odds ratio, 0.77; 95% CI, 0.66-0.90) in early follow-up, but these cost differences disappeared by year 4 (odds ratio, 1.10; 95% CI, 0.92-1.31).
Another potential explanation for similar observed costs between these cohorts is the lack of data on the costs of prescription drugs. Pharmaceutical costs for chronic comorbidities are significantly reduced after bariatric surgery, but there are likely to be differences between sleeve gastrectomy and RYGB, with greater and more durable decreases among patients undergoing RYGB, owing to more durable chronic disease remission and control.
Those limitations aside, when this report and prior literature are combined, they suggest that although sleeve gastrectomy may be associated with lower acute health care spending than RYGB early after surgery, these economic benefits may not be durable. This convergence of costs with longer follow-up could be partly explained by findings that the sleeve gastrectomy has been associated with greater weight regain and more diabetes relapse than RYGB.1 Other reports3,6 have suggested that early risks of complications with RYGB may begin to wane by 2 to 3 years out, and at that point, we may start to see more balance in use of health care resources.
Longer-term economic studies may reveal a shift in evidence that favors RYGB, given the apparent durability of its clinical effect, and this effect may not be captured until much longer (eg, 5-10 years) after surgery. Studies of long-term economic outcomes are not possible in most US-based insurance claims data sets but should be the focus of future study in this Canadian cohort and other single-payer and integrated care systems. Future studies should also more carefully examine the types of care received, reasons for care, and other associated costs, including costs of medications.
Published: September 9, 2021. doi:10.1001/jamanetworkopen.2021.22541
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Arterburn D et al. JAMA Network Open.
Corresponding Author: David Arterburn, MD, MPH, Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Ste 1600, Seattle, WA 98101 (email@example.com).
Conflict of Interest Disclosures: Dr Arterburn reported receiving nonfinancial support from the World Congress for Interventional Therapy for Diabetes and the International Federation for the Surgery of Obesity and Metabolic Disorders Latin America Chapter during the conduct of the study and grants from the National Institutes of Health and Patient-Centered Outcomes Research Institute outside the submitted work. Dr Lewis reported receiving personal fees from the National Committee for Quality Assurance Payment for contribution toward obesity continuing medical education activity outside the submitted work. No other disclosures were reported.
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Arterburn D, Lewis KH. Different Risks and Benefits Leading to Similar Costs After Sleeve Gastrectomy and Roux-en-Y Gastric Bypass. JAMA Netw Open. 2021;4(9):e2122541. doi:10.1001/jamanetworkopen.2021.22541
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