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Weight Loss Surgery in UK: Cost Effectiveness Report

British Bariatric Report

Weight Loss Surgery Procedures - Research Into Gastric Reduction Surgery

Weight Loss Surgery in UK: Cost Effectiveness

Obesity in England

In 1998, amongst adults in England, 17.3% of men and 21.2% of women were obese (body mass index (BMI) > 30), and 0.6% of men and 1.9% of women were morbidly obese (BMI > 40). The prevalence of obesity in England has been increasing. Obesity is associated with increased morbidity and mortality, and is a recognised risk factor for cardiovascular disease, type 2 diabetes, cancer, degenerative diseases of the musculo-skeletal system, reproductive disorders and respiratory disorders. Weight loss has beneficial effects on co-morbidities and long-term survival.

Obesity Management Including Bariatric Surgery

Currently, obesity tends to be managed by the NHS within primary care. Other interventions may be considered. Provision of specialist obesity clinics is limited in England and Wales. Gastric surgery is considered when all other measures have failed. It is not a common procedure; around 200 gastric operations are carried out annually in England and Wales, with a large proportion funded privately.

Cost Effectiveness of Bariatric Surgery

This report aims to systematically review the clinical effectiveness and cost-effectiveness of surgery for the management of morbid obesity and to develop a cost-effectiveness model using the best available evidence to determine cost-effectiveness in a UK setting.

Results

In all, 17 randomised clinical trials (RCTs) and one non-randomised clinical trial were included in the systematic review. Two RCTs and the non-randomised clinical trial compared surgical interventions with conventional treatment. The remaining 15 RCTs compared different types of surgery. The methodological quality of the included studies varied. Surgery was more effective than conventional treatment in achieving long-term weight loss and improving QoL and co-morbidities. Gastric bypass surgery was more beneficial than gastroplasty or jejunoileal bypass, with laparoscopic placement producing fewer complications than open procedures.

Economic Assessment

Searching revealed four economic evaluations: two were from the USA, one from The Netherlands and one from Sweden. When assessed on recognised criteria of internal and external validity, all four economic evaluations were considered of poor quality. Surgery was shown to be cost-effective or cost-saving compared with non-surgical treatment or no treatment.

Summary of Benefits of Bariatrics

When compared with conventional treatment, surgery resulted in a significantly greater loss of weight (23–37 kg more weight), which was maintained at 8 years. As a consequence, there were improvements in QoL and co-morbidities associated with the loss of weight from surgery. Comparison of the different types of surgery showed that gastric bypass appeared more beneficial, with a greater weight loss (6–14 kg more weight) and/or improvements in co-morbidities and complications than either gastroplasty or jejunoileal bypass. Assessment of open versus laparoscopic gastric bypass and adjustable silicone gastric banding showed fewer serious complications with laparoscopic placement. Laparoscopic surgery had a longer operative time compared with open surgery, but resulted in reduced blood loss, proportion of patients requiring intensive care unit stay, length of hospital stay, days to return to activities of daily living and days to return to work.

Costs of Surgery

The costs of the different interventions varied from £336 for usual care to £3223 for vertical banded gastroplasty, to £3333 and £3392 for open and laparoscopic gastric bypass, and £4450 and £4753 for laparoscopic and open silicone adjustable gastric banding. The total net costs of treating morbid obesity (over 20 years) through surgical procedures varied from £9626.90 for vertical banded gastroplasty to £10,795.16 for silicone adjustable gastric banding. All surgical procedures were more costly than treatment through usual care, with total net costs of £6964.15 over 20 years. These costs are based on several assumptions concerning models of treatment.

Cost/Quality-Adjusted Life-Year (QALY)

The economic evaluation considered three types of surgical procedure specifically: gastric bypass (Roux-en-Y), vertical banded gastroplasty and adjustable gastric banding, and non-surgical management. Comparison of surgery with non-surgical management over a 20-year period showed that surgery offered additional QALYs at an additional cost. When compared with non-surgical management, gastric bypass had a net cost per QALY of £6289 while vertical banded gastroplasty and silicone adjustable gastric banding had a net cost per QALY of £10,237 and £8527, respectively. Comparison of the different procedures suggests that the difference in cost per QALY is less clear. Gastric bypass appears to have a very modest net cost per QALY gained compared to vertical banded gastroplasty (£742/QALY). In contrast, silicone adjustable gastric banding has a large net cost per QALY gained compared to gastric bypass (£256,856/QALY).

Conclusions

Currently, limited numbers of morbidly obese people receive surgery in England and Wales. A constraint upon the development of any service would need to ensure there are adequately trained multi-disciplinary teams to operate and provide long-term support to patients. Given the proportions of patients who may benefit from surgery and the need for experienced teams with appropriate facilities, it would seem appropriate that any service should be provided within specialist facilities.

If implemented, the additional total cost to the NHS in England and Wales may be £136.5 million over the 20-year life-expectancies of the 50,000 patients who are thought to be morbidly obese and who may meet the criteria for surgery. The impact on the annual budget of the NHS is difficult to assess given the limited information on the incidence of morbid obesity. Expert opinion suggests that some 800 morbidly obese people may meet the criteria for surgery each year at an additional total cost of £2.2 million over their 20-year life-expectancies. Any savings would depend on the non-financial constraints of any increase in surgery over the next few years, such as staffing, as well as the number of patients choosing to have surgery and the future costs of surgery that may change as the service develops.

Recommendations for Future Research

Although surgery appears effective in terms of weight change, there is limited evidence addressing the long-term consequences and its influence on the QoL of patients. In addition, there have been few economic evaluations comparing the different surgical interventions, and the availability of costing and resource use data appears limited. It would be beneficial if these could be addressed through good quality research.

Source:
NHS Health Technology Assessment Programme
Clegg AJ, Colquitt J, Sidhu MK, Royle P, Loveman E, Walker A. The clinical effectiveness and cost-effectiveness of surgery for people with morbid obesity: a systematic review and economic evaluation. Health Technol Assess 2002;6(12).

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Laparoscopic or open bariatric surgery, such as gastric banding or bypass is not an easy solution to morbid obesity and weight loss. It is a serious surgical procedure, involving health risks. To produce lasting weight loss it requires a long-term patient commitment to eating a healthy diet and following a regular program of physical exercise. Life-long use of nutritional supplements may also be necessary. So, before deciding, discuss your options fully with your doctor. © 2003-2017 Bariatric-Surgery.Info - Terms - Contact - Information - Resources