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Review
November 21, 2018

Comparative Effectiveness and Safety of Bariatric Procedures in Medicare-Eligible Patients: A Systematic Review

Author Affiliations
  • 1Evidence-based Practice Center, Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
  • 2Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
  • 3Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
  • 4Department of Hygiene & Epidemiology, University of Ioannina, School of Medicine, Ioannina, Greece
  • 5Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island
  • 6Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, Rhode Island
  • 7The Miriam Hospital Weight Control and Diabetes Research Center, Providence, Rhode Island
  • 8Department of General Surgery, Brown University Warren Alpert Medical School, Providence, Rhode Island
JAMA Surg. 2018;153(11):e183326. doi:10.1001/jamasurg.2018.3326
Key Points

Question  What is the effectiveness and safety of bariatric surgery procedures in the Medicare-eligible population?

Findings  In this systematic review of 16 nonrandomized comparative studies, bariatric procedures and their association with weight loss, postoperative complications, mortality, metabolic, cardiovascular, respiratory, orthopedic, and renal outcomes, and medication use were assessed. Bariatric surgery overall, and in particular Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding, appear to be associated with improvements in weight loss outcomes beyond 1 year after surgery.

Meaning  In the Medicare population, low to moderate strength of evidence exists regarding bariatric surgery as a weight loss treatment and its association with non–weight loss outcomes.

Abstract

Importance  The prevalence of obesity in patients older than 65 years is increasing. A substantial number of beneficiaries covered by Medicare meet eligibility criteria for bariatric procedures.

Objective  To assess the comparative effectiveness and safety of bariatric procedures in the Medicare-eligible population.

Evidence Review  This systematic review was conducted according to the PRISMA guidelines. Articles were identified through searches of PubMed, Embase, CINAHL, PsycINFO, Cochrane Central Trials Registry, Cochrane Database of Systematic Reviews, and scientific information packages from manufacturers, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and US Food and Drug Administration drugs and devices portals from January 1, 2000, to June 31, 2017. Randomized and nonrandomized comparative studies that evaluated bariatric procedures in the Medicare-eligible population were eligible. Six researchers extracted data on design, interventions, outcomes, and study quality. Findings were synthesized qualitatively; a planned meta-analysis was not undertaken owing to clinical heterogeneity.

Findings  A total of 11 455 citations were screened for eligibility. Of those, 16 met the eligibility criteria. Compared with no surgery or conventional weight-loss treatment, bariatric surgery results in greater weight loss. Overall mortality after 30 days is lower among bariatric patients (hazard ratio, HR, 0.50; 95% CI, 0.31-0.79, in the study with the longest follow-up of 5.9 years), although, based on 1 study, mortality within 30 days of surgery was higher than in nonsurgically treated controls (1.55% vs 0.53%; P < .001). Bariatric surgery is associated with lower risk of cardiovascular disease (HR, 0.59; 95% CI, 0.44-0.79 in the largest study comparison) and with improvements in respiratory, musculoskeletal, metabolic, and renal outcomes (increase in estimated glomerular filtration rate, 9.84; 95% CI, 8.05-11.62 mL/min/1.73m2). Compared with sleeve gastrectomy (SG) and adjustable gastric banding (AGB), Roux-en-Y gastric bypass (RYGB) appears to be associated with greater weight loss (percent excess weight loss, 23.8% [95% CI, 16.2%-31.4%] at the longest follow-up of 4 years) but the 3 procedures have similar associations with most non–weight loss outcomes. Overall postoperative complications are not statistically significantly different between RYGB and SG, although major and/or serious complications are more common after RYGB. However, these associations are susceptible to at least moderate risk of confounding, selection, or measurement biases.

Conclusions and Relevance  In the Medicare population, there is low to moderate strength of evidence that bariatric surgery as a weight loss treatment improves non–weight loss outcomes. Well-designed comparative studies are needed to credibly determine the treatment effects for bariatric procedures in this patient population.

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