Évaluation médicoéconomique du traitement de l'obésité morbide par anneau gastrique ajustable suédois (SAGB)

Budget Impact Analysis of Surgical Treatment for Obesity in Sweden

Background:

The recent substantial increase in the number of obese surgeries performed in Sweden has raised concerns about the budget impact.

Objective:

Our aim in this paper is to present an assessment of the budgetary impact of different policies for surgical intervention for obese and overweight subjects from a healthcare perspective in Sweden.

Methods:

The model simulates the annual expected treatment costs of obesity related diseases and surgery in patients of different sex, age and Body Mass Index (BMIMI). Costs evaluated are costs of surgery plus the excess treatment costs that an obese patient has over and above the treatment costs of a normal-weight patient. The diagnoses that are included for costs assessment are diabetes and cardiovascular disease since these diagnoses are the principal diagnoses associated with obesity. Four different scenarios over the number of surgical operations performed each year are simulated and compared: (1) no surgical operation, (2) 3 000 surgical operations in persons with BMI > 40, (3) 4000 (BMI > 40), and (4) 5000 (expanded to BMI > 38).

Results:

Comparing Scenario 2 with Scenario 1 results in a net budget impact of on average SEK 121 million per annum or SEK 40 000 per patient. This implies that 55 percent of the cost of surgery, set equal to SEK 90 000 for each patient, has been offset by a reduction in the excess treatment costs of obesity related diseases. Expanding annual surgery from 3000 to 4000 the cost-offset increased to 58%. By expanding annual surgery further from 4000 to 5000 and at the same time expanding the indication for surgery from BMI > 40 to BMI > 38, no cost-offset is obtained.

Conclusion:

A cost-minimization strategy for bariatric surgery in Sweden should not expand indication, but rather increase the number of surgeries within the currently accepted indication.

Cost-utility of bariatric surgery for morbid obesity in Finland

BACKGROUND

The aim of this study was to evaluate the cost-utility of bariatric surgery (gastric bypass, sleeve gastrectomy and gastric banding) compared with ordinary treatment in the Finnish healthcare system.

METHODS

Analysis was done from a healthcare provider's perspective using a combination of a decision tree and a Markov model, with a time horizon of 10 years. Health-related quality of life was estimated from a representative population survey, and other parameter values were based on registers, systematic reviews, controlled studies and expert opinion.

RESULTS

In the base-case analysis, bariatric surgery was both more effective and less costly than the ordinary treatment. The mean costs were €33,870 and €50,495, and the mean number of quality-adjusted life-years 7·63 and 7·05, for bariatric surgery and ordinary treatment respectively. Uncertainty around the parameter values was tested comprehensively in sensitivity analyses, and the results were robust.

CONCLUSION

Surgery for morbid obesity increases health-related quality of life, and reduces the need for further treatments and total healthcare costs. According to this analysis, non-operative care would be more costly for the Finnish healthcare system on average after 5 years following surgery.

Pre-Lap-Band group education in Medicaid population: does it really make a difference?

BACKGROUND

The effect of group education classes before a Lap-Band procedure has not been well defined. We hypothesized that in a Medicaid population, the completion of a standardized 12-week multidisciplinary preoperative program (SMPP) would significantly improve the preoperative and early postoperative weight loss. All procedures were performed at a University-affiliated community hospital from 2006 to 2007.

METHODS

A prospectively collected database of 292 patients who underwent Lap-Band placement was retrospectively reviewed. All patients in the study cohort were encouraged to participate in the SMPP, which included medical, psychological, and nutritional interventions. The patients were divided into 2 groups according to their participation in the SMPP program: SMPP compliant and non-SMPP compliant. The postoperative weight loss of these 2 groups was then compared using the general linear models for repeated measures statistical analysis.

RESULTS

No significant difference was found in the mean baseline excess body weight between the 2 groups (74 +/- 20 kg in the SMPP-compliant and 76 +/- 20 kg in the non-SMPP-compliant participants). The mean baseline body mass index (47 +/- 7 versus 48 +/- 72 kg/m(2) for the SMPP-compliant and non-SMPP-compliant participants) was also similar in the 2 groups. The postoperative follow-up rate was 94.5% at 1 month, 72.3% at 6 months, and 52.7% at 12 months. The excess weight loss was significantly greater in the SMPP compliant group than in the noncompliant group during the observed 12-month follow-up period (P = .04, by general linear models for repeated measures).

CONCLUSION

In a Medicaid population, implementation of an intensive preoperative SMPP resulted in a significant improvement in the short-term weight loss after Lap-Band placement.

Comparison of three instruments assessing the quality of economic evaluations: A practical exercise on economic evaluations of the surgical treatment of obesity

Objectives:The increasing use of full economic evaluations has led to the development of various instruments to assess their quality. The purpose of this study was to compare the frequently usedBritish Medical Journal(BMJ) check-list and two new instruments: the Consensus Health Economic Criteria (CHEC) list and the Quality of Health Economic Studies (QHES) instrument. The analysis was based on a practical exercise on economic evaluations of the surgical treatment of obesity.

Methods:The quality of nine selected studies was assessed independently by two health economists. To compare instruments, the Spearman rank correlation coefficient was calculated for each assessor. Moreover, the test–retest reliability for each instrument was assessed with the intraclass correlation coefficient (ICC) (3,1). Finally, the inter-rater agreement for each instrument was estimated at two levels: comparison of the total score of each article by the ICC(2,1) and comparison of results per item by kappa values.

Results:The Spearman's rank correlation coefficient between instruments was usually high (rho > 0.70). Furthermore, test–retest reliability was good for every instruments, that is, 0.98 (95 percent CI, 0.86–0.99) for the BMJ check-list, 0.97 (95 percent CI, 0.73–0.98) for the CHEC list, and 0.95 (95 percent CI, 0.75–0.99) for the QHES instrument. However, inter-rater agreement was poor (kappa < 0.40 for most items and ICC(2,1) ≤ 0.5).

Conclusions:The study shows that the results of the quality assessment of economic evaluations are not so much influenced by the instrument used but more by the assessor. Therefore, quality assessments should be performed by at least two independent experts and final scoring based on consensus.