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      Costs and Outcomes of Increasing Access to Bariatric Surgery: Cohort Study and Cost-Effectiveness Analysis Using Electronic Health Records

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          Abstract

          Objectives

          To estimate costs and outcomes of increasing access to bariatric surgery in obese adults and in population subgroups of age, sex, deprivation, comorbidity, and obesity category.

          Methods

          A cohort study was conducted using primary care electronic health records, with linked hospital utilization data, for 3,045 participants who underwent bariatric surgery and 247,537 participants who did not undergo bariatric surgery. Epidemiological analyses informed a probabilistic Markov model to compare bariatric surgery, including equal proportions with adjustable gastric banding, gastric bypass, and sleeve gastrectomy, with standard nonsurgical management of obesity. Outcomes were quality-adjusted life-years (QALYs) and net monetary benefits at a threshold of £30,000 per QALY.

          Results

          In a UK population of 250,000 adults, there may be 7,163 people with morbid obesity including 1,406 with diabetes. The immediate cost of 1,000 bariatric surgical procedures is £9.16 million, with incremental discounted lifetime health care costs of £15.26 million (95% confidence interval £15.18–£15.36 million). Patient-years with diabetes mellitus will decrease by 8,320 (range 8,123–8,502). Incremental QALYs will increase by 2,142 (range 2,032–2,256). The estimated cost per QALY gained is £7,129 (range £6,775–£7,506). Net monetary benefits will be £49.02 million (range £45.72–£52.41 million). Estimates are similar for subgroups of age, sex, and deprivation. Bariatric surgery remains cost-effective if the procedure is twice as costly, or if intervention effect declines over time.

          Conclusions

          Diverse obese individuals may benefit from bariatric surgery at acceptable cost. Bariatric surgery is not cost-saving, but increased health care costs are exceeded by health benefits to obese individuals.

          Related collections

          Most cited references 19

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          Effects of bariatric surgery on cancer incidence in obese patients in Sweden (Swedish Obese Subjects Study): a prospective, controlled intervention trial.

          Obesity is a risk factor for cancer. Intentional weight loss in the obese might protect against malignancy, but evidence is limited. To our knowledge, the Swedish Obese Subjects (SOS) study is the first intervention trial in the obese population to provide prospective, controlled cancer-incidence data. The SOS study started in 1987 and involved 2010 obese patients (body-mass index [BMI] >or=34 kg/m(2) in men, and >or=38 kg/m(2) in women) who underwent bariatric surgery and 2037 contemporaneously matched obese controls, who received conventional treatment. While the main endpoint of SOS was overall mortality, the main outcome of this exploratory report was cancer incidence until Dec 31, 2005. Cancer follow-up rate was 99.9% and the median follow-up time was 10.9 years (range 0-18.1 years). Bariatric surgery resulted in a sustained mean weight reduction of 19.9 kg (SD 15.6 kg) over 10 years, whereas the mean weight change in controls was a gain of 1.3 kg (SD 13.7 kg). The number of first-time cancers after inclusion was lower in the surgery group (n=117) than in the control group (n=169; HR 0.67, 95% CI 0.53-0.85, p=0.0009). The sex-treatment interaction p value was 0.054. In women, the number of first-time cancers after inclusion was lower in the surgery group (n=79) than in the control group (n=130; HR 0.58, 0.44-0.77; p=0.0001), whereas there was no effect of surgery in men (38 in the surgery group vs 39 in the control group; HR 0.97, 0.62-1.52; p=0.90). Similar results were obtained after exclusion of all cancer cases during the first 3 years of the intervention. Bariatric surgery was associated with reduced cancer incidence in obese women but not in obese men. Swedish Research Council, Swedish Foundation for Strategic Research, Swedish Federal Government under the LUA/ALF agreement, Hoffmann La Roche, Cederoths, AstraZeneca, Sanofi-Aventis, Ethicon Endosurgery.
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            Catalogue of EQ-5D scores for the United Kingdom.

            The National Institute for Health and Clinical Excellence (NICE) has issued guidance on cost-effectiveness analyses, suggesting that preference-based health-related quality of life (HRQL) weights or utilities be based on UK community preferences, preferably using the EQ-5D; ideally all analyses would use the same system for deriving HRQL weights, to encourage consistency and comparability across analyses. Development of a catalogue of EQ-5D scores for a range of health conditions based on UK preferences would help achieve many of these goals. . To provide a UK-based catalogue of EQ-5D index scores. . s were consistent with the previously published catalogue of EQ-5D scores for the US. Community-based UK preferences were applied to EQ-5D descriptive questionnaire responses in the US-based Medical Expenditure Panel Survey (MEPS). Ordinary least squares (OLS), Tobit, and censored least absolute deviations (CLAD) regression methods were used to estimate the 'marginal disutility' of each condition controlling for covariates. . Pooled MEPS files (2000-2003) resulted in 79,522 individuals with complete EQ-5D scores. Marginal disutilities for 135 chronic ICD-9 and 100 CCC codes are provided. Unadjusted descriptive statistics including mean, median, 25th and 75th percentiles are also reported. . This research provides community-based EQ-5D index scores for a wide variety of chronic conditions that can be used to estimate QALYs in cost-effectiveness analyses in the UK. Although using EQ-5D questionnaire responses from the US-based MEPS is less than ideal, the estimates approximate HRQL guidelines by NICE and provide an easily accessible"off-the-shelf" resource for cost-effectiveness and public-health applications.
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              Association between bariatric surgery and long-term survival.

              Accumulating evidence suggests that bariatric surgery improves survival among patients with severe obesity, but research among veterans has shown no evidence of benefit.
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                Author and article information

                Contributors
                Journal
                Value Health
                Value Health
                Value in Health
                Elsevier
                1098-3015
                1524-4733
                1 January 2017
                January 2017
                : 20
                : 1
                : 85-92
                Affiliations
                [1 ]Department of Primary Care and Public Health Sciences, King’s College London, London, UK
                [2 ]National Institutes for Health Research Biomedical Research Centre at Guy’s and St Thomas’ National Health Service Foundation Trust, London, UK
                [3 ]Department of Surgery, St George’s University Hospital National Health Service Foundation Trust, London, UK
                [4 ]Department of Social Policy, London School of Economics and Political Science, London, UK
                Author notes
                [* ] Address correspondence to: Martin C. Gulliford, Department of Primary Care and Public Health Sciences, King’s College London, Addison House, Guy’s Campus, London SE1 1UL, UK.Department of Primary Care and Public Health Sciences, King’s College London, Addison House, Guy’s CampusLondonSE1 1ULUK martin.gulliford@ 123456kcl.ac.uk
                Article
                S1098-3015(16)30102-4
                10.1016/j.jval.2016.08.734
                5338873
                28212974
                © 2017 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Elsevier Inc. All rights reserved.

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

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