Long-term cost-effectiveness of interventions for obesity: A mendelian randomisation study

Abstract

Background

The prevalence of obesity has increased in the United Kingdom, and reliably measuring the impact on quality of life and the total healthcare cost from obesity is key to informing the cost-effectiveness of interventions that target obesity, and determining healthcare funding. Current methods for estimating cost-effectiveness of interventions for obesity may be subject to confounding and reverse causation. The aim of this study is to apply a new approach using mendelian randomisation for estimating the cost-effectiveness of interventions that target body mass index (BMI), which may be less affected by confounding and reverse causation than previous approaches.

Methods and findings

We estimated health-related quality-adjusted life years (QALYs) and both primary and secondary healthcare costs for 310,913 men and women of white British ancestry aged between 39 and 72 years in UK Biobank between recruitment (2006 to 2010) and 31 March 2017. We then estimated the causal effect of differences in BMI on QALYs and total healthcare costs using mendelian randomisation. For this, we used instrumental variable regression with a polygenic risk score (PRS) for BMI, derived using a genome-wide association study (GWAS) of BMI, with age, sex, recruitment centre, and 40 genetic principal components as covariables to estimate the effect of a unit increase in BMI on QALYs and total healthcare costs. Finally, we used simulations to estimate the likely effect on BMI of policy relevant interventions for BMI, then used the mendelian randomisation estimates to estimate the cost-effectiveness of these interventions.

A unit increase in BMI decreased QALYs by 0.65% of a QALY (95% confidence interval [CI]: 0.49% to 0.81%) per year and increased annual total healthcare costs by £42.23 (95% CI: £32.95 to £51.51) per person. When considering only health conditions usually considered in previous cost-effectiveness modelling studies (cancer, cardiovascular disease, cerebrovascular disease, and type 2 diabetes), we estimated that a unit increase in BMI decreased QALYs by only 0.16% of a QALY (95% CI: 0.10% to 0.22%) per year.

We estimated that both laparoscopic bariatric surgery among individuals with BMI greater than 35 kg/m ², and restricting volume promotions for high fat, salt, and sugar products, would increase QALYs and decrease total healthcare costs, with net monetary benefits (at £20,000 per QALY) of £13,936 (95% CI: £8,112 to £20,658) per person over 20 years, and £546 million (95% CI: £435 million to £671 million) in total per year, respectively.

The main limitations of this approach are that mendelian randomisation relies on assumptions that cannot be proven, including the absence of directional pleiotropy, and that genotypes are independent of confounders.

Conclusions

Mendelian randomisation can be used to estimate the impact of interventions on quality of life and healthcare costs. We observed that the effect of increasing BMI on health-related quality of life is much larger when accounting for 240 chronic health conditions, compared with only a limited selection. This means that previous cost-effectiveness studies have likely underestimated the effect of BMI on quality of life and, therefore, the potential cost-effectiveness of interventions to reduce BMI.

Abstract

Sean Harrison and colleagues use Mendelian randomization techniques to estimate the cost effectiveness of interventions targeting body mass index.

Author summary

Why was this study done?

• The prevalence of obesity has increased in the United Kingdom, and reliably measuring the impact on quality of life and the total healthcare cost from obesity is key to informing the cost-effectiveness of interventions that target obesity, and determining how much additional healthcare funding may be required should the trend of increasing obesity continue.

• Current methods of examining cost-effectiveness of interventions for obesity may be subject to confounding and reverse causation, and previous studies also typically only use a limited number of health conditions to estimate the effects of BMI on quality of life, potentially underestimating the effects of BMI.

• The aim of this study is to elucidate a new approach using mendelian randomisation for estimating the cost-effectiveness of interventions that target body mass index (BMI), which may be less affected by confounding and reverse causation than previous approaches.

What did the researchers do and find?

• Using mendelian randomisation, we estimated that a unit increase in BMI decreased quality-adjusted life years (QALYs) by 0.65% of a QALY per year and increased annual total healthcare costs by £42.23 per person.

• Using these results and simulations, we estimated that, compared to no intervention and over 20 years, people aged 40 to 69 years in England or Wales with a BMI over 35 kg/m ² receiving laparoscopic bariatric surgery would have, on average, an increase of 0.92 QALYs and a decrease in total healthcare costs of £5,096 per person.

• We also estimated that restricting volume promotions for high fat, salt and sugar products would, across the 21.7 million adults aged 40 to 69 years in England and Wales, increase QALYs by 20,551 per year and decrease total healthcare costs by £137 million per year, and that between 1993 and 2017 in England and Wales, the increase in BMI of people aged 40 to 69 years led to a decrease of 1.13% of a QALY per year and an increase in annual healthcare costs of £69 per person.

What do these findings mean?

• Mendelian randomisation can be used to estimate the impact of interventions on quality of life and healthcare costs and is likely less biased than existing observational methods.

• Interventions for BMI are likely to be cost-effective, possibly more so than previously anticipated using simulation methods that restrict the effect of changes in BMI on health conditions to cancer, cardiovascular disease, cerebrovascular disease, and type 2 diabetes.