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Original Investigation
October 30, 2019

Association Between Bariatric Surgery and Long-term Health Care Expenditures Among Veterans With Severe Obesity

Author Affiliations
  • 1Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
  • 2Department of Population Health Sciences, Duke University, Durham, North Carolina
  • 3Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina
  • 4Kaiser Permanente Washington Health Research Institute, Seattle
  • 5Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle
  • 6Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
  • 7Department of Surgery, University of California, Los Angeles, Los Angeles
  • 8Division of General Surgery, Northwestern University, Chicago, Illinois
  • 9Deputy Editor, JAMA
JAMA Surg. Published online October 30, 2019. doi:https://doi.org/10.1001/jamasurg.2019.3732
Key Points

Question  Is bariatric surgery associated with health care expenditures 10 years after the procedure in veterans with severe obesity?

Findings  In this cohort study of 9954 veterans with severe obesity, total health care expenditures were higher in the 3 years before surgery and the first 2 years after surgery among patients who underwent surgery compared with those who did not. The expenditures of patients who did and did not undergo bariatric surgery converged 5 to 10 years after surgery.

Meaning  The value of bariatric surgery lies primarily in its association with improvements in health and not in its potential to decrease health care costs.

Abstract

Importance  Bariatric surgery has been associated with improvements in health in patients with severe obesity; however, it is unclear whether these health benefits translate into lower health care expenditures.

Objective  To examine 10-year health care expenditures in a large, multisite retrospective cohort study of veterans with severe obesity who did and did not undergo bariatric surgery.

Design, Setting, and Participants  A total of 9954 veterans with severe obesity between January 1, 2000, and September 30, 2011, were identified from veterans affairs (VA) electronic health records. Of those, 2498 veterans who underwent bariatric surgery were allocated to the surgery cohort. Sequential stratification was used to match each patient in the surgery cohort with up to 3 patients who had not undergone bariatric surgery but were of the same sex, race/ethnicity, diabetes status, and VA regional network and were closest in age, body mass index (calculated as weight in kilograms divided by height in meters squared), and comorbidities. A total of 7456 patients were identified and allocated to the nonsurgery (control) cohort. The VA health care expenditures among the surgery and nonsurgery cohorts were estimated using regression models. Data were analyzed from July to August 2018 and in April 2019.

Interventions  The bariatric surgical procedures (n = 2498) included in this study were Roux-en-Y gastric bypass (1842 [73.7%]), sleeve gastrectomy (381 [15.3%]), adjustable gastric banding (249 [10.0%]), and other procedures (26 [1.0%]).

Main Outcomes and Measures  The study measured total, outpatient, inpatient, and outpatient pharmacy expenditures from 3 years before surgery to 10 years after surgery, excluding expenditures associated with the initial bariatric surgical procedure.

Results  Among 9954 veterans with severe obesity, 7387 (74.2%) were men; the mean (SD) age was 52.3 (8.8) years for the surgery cohort and 52.5 (8.7) years for the nonsurgery cohort. Mean total expenditures for the surgery cohort were $5093 (95% CI, $4811-$5391) at 7 to 12 months before surgery, which increased to $7448 (95% CI, $6989-$7936) at 6 months after surgery. Postsurgical expenditures decreased to $6692 (95% CI, $6197-$7226) at 5 years after surgery, followed by a gradual increase to $8495 (95% CI, $7609-$9484) at 10 years after surgery. Total expenditures were higher in the surgery cohort than in the nonsurgery cohort during the 3 years before surgery and in the first 2 years after surgery. The expenditures of the 2 cohorts converged 5 to 10 years after surgery. Outpatient pharmacy expenditures were significantly lower among the surgery cohort in all years of follow-up ($509 lower at 3 years before surgery and $461 lower at 7 to 12 months before surgery), but these cost reductions were offset by higher inpatient and outpatient (nonpharmacy) expenditures.

Conclusions and Relevance  In this cohort study of 9954 predominantly older male veterans with severe obesity, total health care expenditures increased immediately after patients underwent bariatric surgery but converged with those of patients who had not undergone surgery at 10 years after surgery. This finding suggests that the value of bariatric surgery lies primarily in its associations with improvements in health and not in its potential to decrease health care costs.

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