Long-term Costs and Return on Investment for Bariatric Surgery

摘要 减肥手术是最有效的治疗严重肥胖症，但只有1-2%的合格患者 每年做手术。尽管有强有力的证据表明， 严重肥胖的成本和减肥手术在诱导临床显著和持续的 体重减轻、生存期延长和肥胖相关健康状况的重大改善[即，2型 糖尿病（T2 DM）]与常规医疗护理相比。使用减肥手术的障碍包括患者和 医生对这些手术的知识和态度;缺乏非手术治疗的资源， 严重肥胖症;以及因保险覆盖范围不足而导致的高额患者费用。覆盖面不足， 尽管医疗保险提供全面覆盖，但在私营保险公司中，重要的术前要求很普遍 用于减肥手术超过20年，有证据表明减肥手术的成本效益<50，000美元/QALY。 减肥手术覆盖率的持续差距似乎是由于对长期成本的担忧 并发症和手术的巨大潜在预算影响，因为约15%的美国成年人有资格进行减肥 外科手术和每个程序的成本很高（20 - 30，000美元/程序）。因此，付款人可能需要证据 减肥手术在提供更广泛的覆盖面之前是节省成本的。 经济证据中有四个主要差距是私人保险扩展的障碍 减肥手术的保险我们建议通过比较5年和10年的数据来解决这些证据缺口。 约30，000例既往接受过两种最常见的减肥手术（SG和 RYGB）和一个大型队列（约90，000名）严格匹配的非手术重度肥胖患者， 2005-2019年，后续行动至2021年。超过5，000名手术患者和15，000名非手术患者 2012年之前的日期将有10年或更长时间的数据，这是迄今为止最大的经济研究， 随访时间最长的研究。我们建议实现三个目标： 目的1：比较接受SG和RYGB的患者的5年和10年医疗保健总成本变化 与匹配的非手术重度肥胖患者进行比较。 目的2：检查手术对成本影响的异质性，以了解是否存在临床 具有更有利的手术后成本轨迹的严重肥胖患者亚组。 目标2a：我们将检查所有手术患者和匹配的非手术患者之间的异质性。 ·目标2b：我们将检查T2 DM手术患者及其匹配患者之间的异质性。 目标3：估计目标2中确定的每个分组达到收支平衡的时间，以确定投资回报 在5到10年的时间内，在考虑手术的初始费用后。

ABSTRACT Bariatric surgery is the most effective treatment for severe obesity, yet only 1-2% of eligible patients undergo surgery annually. This low rate of bariatric surgery uptake persists despite strong evidence of the high cost of severe obesity and the superiority of bariatric procedures in inducing clinically significant and sustained weight loss, prolonged survival, and major improvements in obesity-related health conditions [i.e., type 2 diabetes (T2DM)] when compared to usual medical care. Barriers to use of bariatric surgery include patient and physician knowledge and attitudes towards these procedures; lack of resources for non-surgical treatment of severe obesity; and high patient costs arising from inadequate insurance coverage. Inadequate coverage and significant pre-surgical requirements is common among private insurers despite Medicare providing full coverage for bariatric procedures for >20 years and evidence that bariatric surgery is cost-effective at <$50,000/QALY. This continued gap in coverage of bariatric surgery appears to be driven by concerns about the long-term costs of complications and surgery’s large potential budget impact, since ~15% of U.S. adults are eligible for bariatric surgery and the cost per procedure is high ($20-30,000/procedure). As a result, payers may require evidence that bariatric surgery is cost-saving before providing broader coverage. There are four major gaps in the economic evidence that are barriers to expansion of private insurance coverage for bariatric surgery. We propose to address these evidence gaps by comparing the 5- and 10-year expenditures of ~30,000 patients who previously underwent the two most common bariatric procedures (SG and RYGB) and a large cohort (~90,000) of rigorously matched non-surgical patients with severe obesity from years 2005-2019 with follow-up through 2021. Over 5,000 surgical patients and 15,000 nonsurgical patients with index dates before 2012 will have data at 10 years or beyond, making this the largest economic study to date and the study with the longest follow-up. We propose to address three aims: Aim 1: Compare 5- and 10-year changes in total costs of health care among patients undergoing SG and RYGB versus matched non-surgical patients with severe obesity. Aim 2: Examine heterogeneity of the effect of surgery on costs to understand whether there are clinical subgroups of patients with severe obesity who have more favorable post-surgical cost trajectories. • Aim 2a: We will examine heterogeneity among all surgical patients and matched nonsurgical patients. • Aim 2b: We will examine heterogeneity among surgical patients with T2DM and their matches. Aim 3: Estimate time to break-even for each subgroup identified in aim 2 to identify the return-on-investment over a 5- to 10-year time frame after accounting for the initial costs of surgery.