Randomized Controlled Trial Based US Commercial Payor Cost-Effectiveness Analysis of Endoscopic Sleeve Gastroplasty Versus Lifestyle Modification Alone for Adults With Class I/II Obesity.

PURPOSE: Endoscopic sleeve gastroplasty (ESG) is a minimally invasive day procedure that the MERIT randomized controlled trial (RCT) has demonstrated to be an effective and safe method of weight loss versus lifestyle modification alone. We sought to evaluate the cost-effectiveness of ESG from the perspective of a US commercial payer in a cohort of adults with class II and class I obesity with diabetes based on this RCT. MATERIALS: We used a Markov modelling approach with BMI group health states and an absorbing death state. Baseline characteristics, utilities, BMI group transition probabilities, and adverse events (AEs) were informed by patient-level data from the MERIT RCT. Mortality was estimated by applying BMI-specific hazard ratios to US general population mortality rates. We used BMI-based health state utilities to reflect the impact of obesity comorbidities and applied disutilities due to ESG AEs. Costs included intervention costs, AE costs, and BMI-based annual direct healthcare costs to account for costs associated with obesity comorbidities. A willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY) was assumed. RESULTS: In our base-case analysis over a 5-year time horizon, ESG was cost-effective versus lifestyle modification alone with an incremental cost-effectiveness ratio of $23,432/QALY. ESG remained cost-effective in all sensitivity analyses we conducted and was dominant in analyses with longer time horizons. CONCLUSION: ESG is a cost-effective treatment option for people living with obesity and should be considered in commercial health plans as an additional treatment option for clinically eligible patients.

Pharmaceutical utilisation and costs before and after bariatric surgery.

OBJECTIVE: To determine whether pharmaceutical utilisation and costs change after bariatric surgery. SUBJECTS: Total population of Australians receiving Medicare-subsidised laparoscopic adjustable gastric banding (LAGB) in 2007 (n=9542). DESIGN: Computerised data linkage with Medicare, Australia's universal tax-funded health insurance scheme. Pharmaceuticals relating to obesity-related disease and postsurgical management were assigned to therapeutic categories and analysed. The mean annual numbers of pharmaceutical prescriptions for each category were compared over the 4-year period from the year before LAGB (2006) to 2 years after LAGB (2009) using utilisation incidence rate ratios (IRRs). RESULTS: The population was mainly female (77.7%) and age was normally distributed with the majority (60.7%) of subjects aged between 35-54 years. Utilisation rates decreased significantly after LAGB in the following therapeutic categories: diabetes (IRR 0.51, IRR 95% CI 0.50-0.53, mean annual cost differences per person $30), cardiovascular (0.81, 0.80-0.82, $29), psychiatric (0.95, 0.93-0.97, $13), rheumatic and inflammatory disorders (0.51, 0.49-0.53, $10) and asthma (0.78, 0.75-0.81, $9). In contrast, significantly greater utilisation was observed in the pain (1.28, 1.23-1.32, $12), gastrointestinal tract disorder (1.04, 1.02-1.07, $5) and anaemia/vitamins (2.34, 2.01-2.73, $4) therapeutic categories. When the defined categories were combined, a net reduction in pharmaceutical utilisation was observed, from 10.5 to 9.6 pharmaceuticals prescribed per person/year, and costs decreased from $AUD517 to $AUD435 per year in 2009 prices. CONCLUSION: Relative to the year before LAGB, overall pharmaceutical utilisation was reduced in the 2 years after the year of LAGB surgery, demonstrating that bariatric surgery can lead to reductions in pharmaceutical utilisation in the 'real world' setting. The greatest absolute cost reductions were observed in the therapies to treat diabetes and cardiovascular disease.

Evaluating the cost-effectiveness of laparoscopic adjustable gastric banding versus standard medical management in obese patients with type 2 diabetes in the UK.

AIM: To evaluate the cost-effectiveness of laparoscopic adjustable gastric banding (LAGB) versus standard medical management (SMM) in obese patients with type 2 diabetes from a UK healthcare payer perspective. METHODS: A validated computer model of diabetes was used to project outcomes reported from a randomized clinical trial of LAGB versus SMM in obese patients with type 2 diabetes. Two-year follow-up data from the trial were projected over a 40-year time horizon and cost-effectiveness was assessed from the perspective of the National Health Service. Future costs and clinical outcomes were discounted at 3.5% annually and all costs were reported in 2010 pounds sterling. A series of sensitivity analyses were performed. RESULTS: LAGB was associated with benefits in HbA1c, systolic blood pressure, body mass index and serum lipid concentrations, which led to significant increases in discounted life expectancy (an increase of 0.64 years) and quality-adjusted life expectancy (an increase of 0.92 quality-adjusted life years, QALYs) and reduced incidence of diabetes complications relative to SMM. Treatment costs in the LAGB arm increased by 4552 Great British Pounds (GBP), but this was partially offset by cost savings resulting from a reduction in the incidence of all modelled diabetes complications. The incremental cost-effectiveness ratio of GBP 3602 per QALY in the base case fell well below commonly quoted willingness-to-pay thresholds in the UK setting. CONCLUSIONS: On the basis of data from a recent randomized controlled trial, LAGB is likely to be considered cost-effective from the healthcare payer perspective when compared with SMM of obesity in patients with type 2 diabetes in the UK setting.

Effect of source of funding on weight loss up to 3 years after gastric banding.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is a popular choice for patients seeking weight loss surgery. Since behavioural change appears to play a role in weight loss outcomes we postulated that publicly funded patients might not do as well as self-payers. This series examines the effect of public funding versus self-pay on patients undergoing LAGB over 1, 2 and 3 years. METHODS: Consecutive non-randomised cohort series of patient undergoing LAGB over 5 years (September 2003 to December 2008) in a single unit. Age, sex, funding route, body mass index (BMI) and complications were recorded. Per cent excess weight loss (EWL) and the Reinhold criterion for success (proportion achieving 50 % EWL) were assessed. RESULTS: Ninety-nine patients were publicly funded, and 250 patients were self-payers. Initial BMI was significantly higher in publicly funded patients (46.6 vs. 42.3 kg/m(2), p < 0.001) with a higher proportion of males (22.2 vs. 6.0 %, p < 0.001). Mean % EWL was significantly less for publicly funded patients at 1 year (38.1 vs. 53.5 %, p < 0.001) and 2 years (49.6 vs. 64.1 %, p < 0.001), but not at 3 years (59.7 vs. 61.8 %, p = 0.784). Fewer publicly funded patients achieved 50 % EWL at 1 year (24.5 vs. 50.2 %, p < 0.001), but with no significant difference at 2 years (54.8 vs. 67.0 %, p = 0.140) or 3 years (55.2 vs. 66.0 %, p = 0.349). CONCLUSIONS: Self-pay patients initially achieved more % EWL and greater success in reaching 50 % EWL after LAGB, but this difference was not maintained. The results suggest that patient motivation, using self-pay as a surrogate marker, may affect early results, but the operation itself is the main determinant of weight loss at 3 years.

Outcomes of the adjustable gastric band in a publicly funded obesity program.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is considered a safe and effective treatment for severe obesity and obesity-related comorbidities. We sought to examine the outcome of LAGB delivered through a Canadian publicly funded obesity program. METHODS: We retrospectively analysed the cases of patients who underwent LAGB within a comprehensive, multidisciplinary, publically funded obesity program. RESULTS: A total of 178 patients underwent LAGB. Mean percentage total body weight loss at 1, 2 and 3 years was 15.8%, 20.7% and 20.3%, respectively. The most common short-term complication was postoperative nausea (19%). The medium-term complications included band migration (5.6%) and port site complications, band leakage and incisional hernia at 1% each. The reoperation rate was 4.5%. The mean surgery duration was 56 minutes and the mean length of stay was 1.4 days. The average numbers of clinic visits and band adjustments were highest in the first year. The most common investigation for postoperative symptoms was fluoroscopy (86%). An outcome comparison between the 2 generations of the REALIZE gastric band was inconclusive, requiring further data collection. CONCLUSION: Publicly funded LAGB results in effective weight loss and acceptable safety over the short term. Our patients may represent a distinct population that differs from that in the private system. Long-term data are necessary to determine the cost-effectiveness of this important surgical option for severe obesity.

CONTEXTE: L'anneau gastrique ajustable posé par laparoscopie (AGAL) est considéré comme un traitement sécuritaire et efficace contre l'obésité sévère et les comorbidités connexes. Nous avons cherché à analyser le résultat de la pose d'un AGAL réalisée dans le cadre d'un programme public de lutte contre l'obésité au Canada. MÉTHODES: Nous avons analysé de façon rétrospective les cas de patients qui ont reçu un AGAL dans le contexte d'un programme intégré et multidisciplinaire de lutte contre l'obésité financé par le secteur public. RÉSULTANTS: Au total, 178 patients ont reçu un AGAL. La perte procentuelle moyenne totale de masse corporelle à 1, 2 et 3 ans s'est établie à 15,8 %, 20,7 % et 20,3 % respectivement. Les nausées postopératoires ont constitué la complication à court terme la plus fréquente (19 %). Les complications à moyen terme ont inclus le déplacement de l'anneau (5,6 %) et des complications du côté porte, la fuite au niveau de l'anneau et une hernie à celui de l'incision : elles ont atteint 1 % dans chaque cas. Le taux de répétition de l'intervention a atteint 4,5 %. L'intervention chirurgicale a duré en moyenne 56 minutes et le séjour moyen 1,4 jours. Le nombre moyen de visites à la clinique et celui des rajustements de l'anneau étaient les plus élevés au cours de la première année. Les symptômes postopératoires sont examinés le plus souvent par fluoroscopie (86 %). Une comparaison des résultats entre les 2 générations de l'anneau gastrique REALIZE n'a pas été concluante, ce qui oblige à réunir d'autres données. CONCLUSIONS: La pose d'un AGAL financée par le secteur public entraîne une perte de poids efficace et offre une sécurité acceptable à court terme. Nos patients peuvent représenter une population distincte qui diffère de celle du secteur privé. Il faut des données à long terme pour déterminer la rentabilité de cette option chirurgicale importante en cas d'obésité sévère.

A prospective randomized trial of laparoscopic gastric bypass versus laparoscopic adjustable gastric banding for the treatment of morbid obesity: outcomes, quality of life, and costs.

BACKGROUND: Gastric bypass and adjustable gastric banding are the 2 most commonly performed bariatric procedures for the treatment of morbid obesity. The aim of this study was to compare the outcomes, quality of life, and costs of laparoscopic gastric bypass versus laparoscopic gastric banding. STUDY DESIGN: Between 2002 and 2007, 250 patients with a body mass index of 35 to 60 kg/m2 were randomly assigned to gastric bypass or gastric banding. After exclusion, 111 patients underwent gastric bypass and 86 patients underwent gastric banding. Outcome measures included demographic data, operative time, blood loss, length of hospital stay, morbidity, mortality, early and late reoperation rate, weight loss, changes in quality of life, and cost. Treatment failure was defined as losing less than 20% of excess weight or conversion to another bariatric operation for failure of weight loss. RESULTS: There were no deaths at 90 days in either group. The mean body mass index was higher in the gastric bypass group (47.5 vs. 45.5 kg/m2, respectively, P < 0.01) while the mean age was higher in the gastric band group (45 vs. 41 years, respectively, P < 0.01). Compared with gastric banding, operative blood loss was higher and the mean operative time and length of stay were longer in the gastric bypass group. The 30-day complication rate was higher after gastric bypass (21.6% vs. 7.0% for gastric band); however, there were no life-threatening complications such as leaks or sepsis. The most frequent late complication in the gastric bypass group was stricture (14.3%). The 1-year mortality was 0.9% for the gastric bypass group and 0% for the gastric band group. The percent of excess weight loss at 4 years was higher in the gastric bypass group (68 ± 19% vs. 45 ± 28%, respectively, P < 0.05). Treatment failure occurred in 16.7% of the patients who underwent gastric banding and in 0% of those who underwent gastric bypass, with male gender being a predictive factor for poor weight loss after gastric banding. At 1-year postsurgery, quality of life improved in both groups to that of US norms. The total cost was higher for gastric bypass as compared with gastric banding procedure ($12,310 vs. $10,766, respectively, P < 0.01). CONCLUSIONS: Laparoscopic gastric bypass and gastric banding are both safe and effective approaches for the treatment of morbid obesity. Gastric bypass resulted in better weight loss at medium- and long-term follow-up but was associated with more perioperative and late complications and a higher 30-day readmission rate. There was a wide variation in weight loss after gastric banding with a small proportion of patients considered as treatment failure, and male gender was a predictive factor for poor weight loss.

National trends in use and outcome of laparoscopic adjustable gastric banding.

BACKGROUND: Laparoscopic adjustable gastric banding is gaining popularity in the United States. Our objective was to examine the use and outcomes of laparoscopic adjustable gastric banding at academic medical centers. METHODS: Using the "International Classification of Diseases, Ninth Revision" diagnosis and procedure codes, data were obtained from the University Health System Consortium Clinical Database for all laparoscopic adjustable gastric banding and gastric bypass procedures performed from 2004 to 2007. Quartile trends in the use of all procedures were determined, and a comparison of in-hospital morbidity and mortality between laparoscopic adjustable gastric banding and laparoscopic gastric bypass was performed. RESULTS: A total of 31,333 bariatric surgery procedures were performed from 2004 to 2007. During this period, the use of laparoscopic adjustable gastric banding and gastric bypass procedures increased from 7% to 23% and 53% to 66%, respectively. A concurrent decrease occurred in the use of open gastric bypass procedures from 40% to 11%. Compared with laparoscopic gastric bypass, laparoscopic adjustable gastric banding was associated with a significantly shorter length of stay (1.3 versus 2.7 d, P<.01), lower morbidity (2.8% versus 7.5%, P<.01), lower 30-day readmission rate (.7% versus 2.5%, P<.01), lower in-hospital mortality (.02% versus .08%, P<.01), and lower hospital cost ($8689 versus 14,386, P<.01). CONCLUSION: From 2004 to 2007, significant growth occurred in the number of laparoscopic adjustable gastric banding (+329%) and laparoscopic gastric bypass (+125%) procedures, with a precipitous decrease in the number of open gastric bypass (-73%) procedures. The increasing popularity of the laparoscopic adjustable gastric band procedure could in part be related to the lower cost and lower morbidity compared with laparoscopic gastric bypass.

Cost-effectiveness analysis of laparoscopic gastric bypass, adjustable gastric banding, and nonoperative weight loss interventions.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the two most commonly performed bariatric procedures. Although both procedures likely reduce healthcare expenditures related to the resolution of co-morbid conditions, they have different rates of perioperative risks and different rates of associated weight loss. We designed a model to evaluate the incremental cost-effectiveness of these procedures compared with nonoperative weight loss interventions and with each other. METHODS: We used a deterministic, payer-perspective model comparing the lifetime expected costs and outcomes of LAGB, LRYGB, and nonoperative treatment. The major endpoints were survival, health-related quality of life, and weight loss. Life expectancy and lifetime medical costs were calculated across age, gender, and body mass index (BMI) strata using previously published data. RESULTS: For both men and women, LRYGB and LAGB were cost-effective at <$25,000/quality-adjusted life-year (QALY) even when evaluating the full range of baseline BMI and estimates of adverse outcomes, weight loss, and costs. For base-case scenarios in men (age 35 y, BMI 40 kg/m(2)), the incremental cost-effectiveness was $11,604/QALY for LAGB compared with $18,543/QALY for LRYGB. For base-case scenarios in women (age 35 y, BMI 40 kg/m(2)), the incremental cost-effectiveness was $8878/QALY for LAGB compared with $14,680/QALY for LRYGB. CONCLUSION: The modeled cost-effectiveness analysis showed that both operative interventions for morbid obesity, LAGB and RYGB, were cost-effective at <$25,000 and that LAGB was more cost-effective than RYGB for all base-case scenarios.

Cost-Effectiveness Analysis of Bariatric Surgery for Morbid Obesity.

BACKGROUND: In the USA, three types of bariatric surgeries are widely performed, including laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), and laparoscopic adjustable gastric banding (LAGB). However, few economic evaluations of bariatric surgery are published. There is also scarcity of studies focusing on the LSG alone. Therefore, this study is evaluating the cost-effectiveness of bariatric surgery using LRYGB, LAGB, and LSG as treatment for morbid obesity. METHODS: A microsimulation model was developed over a lifetime horizon to simulate weight change, health consequences, and costs of bariatric surgery for morbid obesity. US health care prospective was used. A model was propagated based on a report from the first report of the American College of Surgeons. Incremental cost-effectiveness ratios (ICERs) in terms of cost per quality-adjusted life-year (QALY) gained were used in the model. Model parameters were estimated from publicly available databases and published literature. RESULTS: LRYGB was cost-effective with higher QALYs (17.07) and cost ($138,632) than LSG (16.56 QALYs; $138,925), LAGB (16.10 QALYs; $135,923), and no surgery (15.17 QALYs; $128,284). Sensitivity analysis showed initial cost of surgery and weight regain assumption were very sensitive to the variation in overall model parameters. Across patient groups, LRYGB remained the optimal bariatric technique, except that with morbid obesity 1 (BMI 35-39.9 kg/m2) patients, LSG was the optimal choice. CONCLUSION: LRYGB is the optimal bariatric technique, being the most cost-effective compared to LSG, LAGB, and no surgery options for most subgroups. However, LSG was the most cost-effective choice when initial BMI ranged between 35 and 39.9 kg/m2.

Bariatric surgery costs and implications for hospital margins: comparing laparoscopic gastric bypass and laparoscopic gastric banding.

BACKGROUND: Effective cost reduction strategies require effective analyses of charges. METHODS: Costs and charges for laparoscopic gastric bypass and laparoscopic gastric banding were compared. Equipment costs, both disposable and reusable, were obtained. Data on the total charges, anesthesiology charges, and hospital charges were obtained; univariate and multivariate analyses were performed. RESULTS: Disposable equipment costs for laparoscopic gastric bypass totaled $3516.23, for laparoscopic gastric banding they were $4363; the difference stemmed from the $3195 laparoscopic band. Median total charges for the procedures differed by less than $100 (P=0.81). Hospital charges for gastric bypass were about $275 (P=0.087) more for bypass than for banding. CONCLUSIONS: Effective cost reduction strategies require cost analyses of each individual procedure; results for one procedure cannot necessarily be generalized to another procedure even if overall costs do not differ.

Reoperation and Medicare Expenditures After Laparoscopic Gastric Band Surgery.

IMPORTANCE: Following the US Food and Drug Administration approval for laparoscopic gastric band surgery in 2001, as many as 96 000 devices have been placed annually. The reported rates of reoperation range from 4% to 60% in short-term studies; however, to our knowledge, few long-term population-level data on outcomes or expenditures are known. OBJECTIVE: To describe the rate of device-related reoperations occurring after laparoscopic gastric band surgery as well as the associated payments in a longitudinal national cohort. DESIGN, SETTINGS, AND PARTICIPANTS: This retrospective review of 25 042 Medicare beneficiaries who underwent gastric band placement between 2006 and 2013 identifies gastric band-related reoperations, including device removal, device replacement, or revision to a different bariatric procedure (eg, a gastric bypass or sleeve gastrectomy). The rates of reoperation were risk adjusted using a multivariable logistic regression model that included patient age, sex, race/ethnicity, Elixhauser comorbidities, and the year that the operation was performed. MAIN OUTCOMES AND MEASURES: Rate of device-related reoperation nationally and across individual hospital referral regions. Thirty-day total episode Medicare payments to hospitals for the index operation and any subsequent reoperations. RESULTS: Of the 25 042 patients who underwent gastric band placement, 20 687 (82.61%) were white, 18 143 (72.45%) were women, and the mean age was 57.56 years. Patients (mean age, 57.5; 76.2% women) requiring reoperation had lower rates of hypertension (64.9% vs 73.4%; P < .001) and diabetes (40.4% vs 44.6%; P < .001) and were more likely to have their index operation at a for-profit hospital (34.6% vs 22.0%; P < .001). With an average of 4.5-year follow-up, 4636 patients (18.5%) underwent 17 539 reoperations (an average of 3.8 procedures/patient). Hospital referral regions demonstrated a 2.9-fold variation in risk- and reliability-adjusted rates of reoperation (lower quartile average, 13.3%; upper quartile average, 39.1%). During the study period, Medicare paid $470 million for laparoscopic gastric band associated procedures, of which $224 million (47.6%) of the payments were for reoperations. From 2006 to 2013, the proportion of payments from Medicare for reoperations increased from 16.4% to 77.3% of their annual spending on the gastric band device. CONCLUSIONS AND RELEVANCE: Among Medicare beneficiaries undergoing gastric band surgery, device-related reoperation was common, costly, and varied widely across hospital referral regions. These findings suggest that payers should reconsider their coverage of the gastric band device.

Cost-Utility Analysis of Bariatric Surgery in Italy: Results of Decision-Analytic Modelling.

OBJECTIVE: To evaluate the cost-effectiveness of bariatric surgery in Italy from a third-party payer perspective over a medium-term (10 years) and a long-term (lifetime) horizon. METHODS: A state-transition Markov model was developed, in which patients may experience surgery, post-surgery complications, diabetes mellitus type 2, cardiovascular diseases or die. Transition probabilities, costs, and utilities were obtained from the Italian and international literature. Three types of surgeries were considered: gastric bypass, sleeve gastrectomy, and adjustable gastric banding. A base-case analysis was performed for the population, the characteristics of which were obtained from surgery candidates in Italy. RESULTS: In the base-case analysis, over 10 years, bariatric surgery led to cost increment of EUR 2,661 and generated additional 1.1 quality-adjusted life years (QALYs). Over a lifetime, surgery led to savings of EUR 8,649, additional 0.5 life years and 3.2 QALYs. Bariatric surgery was cost-effective at 10 years with an incremental cost-effectiveness ratio of EUR 2,412/QALY and dominant over conservative management over a lifetime. CONCLUSION: In a comprehensive decision analytic model, a current mix of surgical methods for bariatric surgery was cost-effective at 10 years and cost-saving over the lifetime of the Italian patient cohort considered in this analysis.

One-year cost-effectiveness of surgical treatment of morbid obesity: vertical banded gastroplasty versus Lap-Band.

BACKGROUND: This study was designed as an economic evaluation alongside a randomized clinical trial. The object of this study was to evaluate the 1-year cost-effectiveness of surgical treatment of morbid obesity comparing two operations. METHODS: 100 patients were assigned randomly to vertical banded gastroplasty (VBG) or Lap-Band surgery. Both medical and non-medical costs were identified and measured. Costs data were combined with percentage Excess Weight Loss (%EWL) and with Quality Adjusted Life Years (QALYs) to obtain cost per %EWL and cost per QALY ratios. RESULTS: At 1 year, the total costs were not significantly different between both groups (95% confidence interval E5,999-E1,765). Also, the QALY gain after surgery was not significantly different between the two groups. However, %EWL was significantly higher in the VBG group compared to the Lap-Band group, P-value .0001. The estimated incremental cost per %EWL was E105.83 (E1,885.91/-17.82). For the costs per QALY, the estimated ratio was dominant. The overall mortality in this study was 2%. 2 patients in the VBG group died within 30 days after surgery; 1 of these deaths was possibly related to the VBG procedure. CONCLUSION: At 1 year after surgery, the costs and QoL of the two treatment modalities were found to be equal. Therefore, the selection of the procedure can be based on the clinical aspects, effectivity and safety at 1 year. In addition, the results of a long-term cost-effectiveness analysis (e.g. with a follow-up of 36 months) planned in the future can also be helpful in the selection of the preferred treatment.

Cost-effectiveness and budget impact of obesity surgery in patients with type-2 diabetes in three European countries.

BACKGROUND: We aimed to establish a payer-perspective cost-effectiveness and budget impact (BI) model of adjustable gastric banding (AGB) and gastric bypass (GBP) vs conventional treatment (CT) in patients with BMI > or =35 kg/m(2) and type-2 diabetes T2DM, in Germany, UK and France. METHODS: Clinical evidence was obtained from literature and patient-reported EQ-5D scores given BMI and T2DM status from HODaR. Resource utilization data in AGB, GBP and CT were obtained from quoted publications so as to reflect practice in 2005. CT in each country was based on descriptions in HTA reports or based on co-authors' experience of current practice. Unit costs were obtained from published sources when available, or from co-authors' institutions. A deterministic algorithm with cost and utility discounting, enabled selection of inputs independently throughout the time scope for each of the 3 treatments, and included mean BMI, amounts of resources and unit costs. RESULTS: The base case time-scope was 5 years, and the annual discount rate for utilities and costs was 3.5%. Compared to CT, GBP yielded +80.8 kg/m(2).years, +2.6 T2DM-free-years and +1.34 QALYs. AGB yielded +57.8 kg/m(2).years, +2.5 T2DM-free-years and +1.03 QALYs. In Germany and France, both GBP and AGB yielded a cost decrease, and were thus dominant in terms of ICER compared to CT. In the UK, GBP and AGB yielded a cost increase, but were cost-effective. CONCLUSION: In patients with T2DM and BMI > or =35 kg/m(2), AGB and GBP are effective at 5-year follow-up in cost-saving in Germany and France, and are cost-effective in the UK with a moderate BI vs CT.

Laparoscopic gastric banding for morbid obesity: outpatient procedure versus overnight stay.

BACKGROUND: In western countries, laparoscopic gastric banding is increasingly used in the surgical treatment of morbid obesity. This study aimed to investigate the feasibility, safety, morbidity, and costs of an outpatient procedure (OP) compared with an overnight stay (OS). METHODS: In a 2-year period, 50 consecutive patients were randomized to an OP group or an OS group. RESULTS: In the OP group, 76% of the patients were successfully discharged the same day, without readmissions. Four procedures were converted, and one complication occurred. The patients in the OP group seemed to experience more pain (p = 0.009). Satisfaction scores were 8.1 (OP) and 8.8 (OS) (p = 0.06). Half of the OP patients and most of the OS patients preferred a clinical admission. The OP treatment cost 600 euros less than OS. CONCLUSION: With proper patient selection, laparoscopic gastric banding can be performed safely and at lower cost as an outpatient procedure.

Band versus bypass: randomization and patients' choices and perceptions.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) are becoming increasingly popular; however, little is understood about patients' motivational factors and reasons for choosing a particular procedure. This investigation explored patient choices and perceptions concerning LRYGB and LAGB. METHODS: A survey was given to 120 consecutive patients who had undergone LRYGB or LAGB 3-24 months earlier. The survey was designed to ascertain why patients chose banding or bypass, and how they rated their surgical outcome. RESULTS: A total of 101 patients responded (84%): 22 had undergone LAGB, 79 LRYGB. The top reason for choosing LRYGB was greater expectation of weight loss, whereas LAGB was chosen for its lower risk. Overall, 21% (18/84) of the patients were willing to be involved in a prospective randomized study of bariatric procedure choice. Six of 19 (32%) patients who underwent LAGB, but only 12 of the 65 (18%) who underwent LRYGB stated that they would be willing to accept randomization between the operations. CONCLUSIONS: Patients expressed varied reasons for choosing their procedure, most related to weight loss or safety profiles. Patients undergoing LAGB would have predicted similar results with either procedure, whereas those undergoing LRYGB showed a trend toward greater overall satisfaction with their operations (p = 0.06) and would have predicted an inferior outcome with the other procedure. Although the overall percentage of patients willing to be randomized is not high, a busy bariatric practice could recruit sufficient numbers of willing patients to undergo a prospective randomized trial of LRYGB and LAGB.

The impact of morbid obesity on the state economy: an initial evaluation.

BACKGROUND: Obesity's impact on a state's economy has not been fully analyzed. This study compared bariatric surgery demographics at a large university hospital to that of a broader region's population statistics. From this comparison, an economic model was derived that evaluated, for the state of New Mexico, the cost of obesity in terms of lost business output, employment, and income. METHODS: Between September 2003 and September 2005, we analyzed the charts of all of our patients from New Mexico who underwent laparoscopic gastric bypass and laparoscopic banding. Input-output analysis estimate margins, the purchase prices for goods and services, and regional purchase coefficients, the percent of spending by local suppliers, were used to model the regional economy. Collected patient data, used in conjunction with IMPLAN model data, were used to estimate, on a regional basis, an industry-by-industry formulation of input-output accounts to calculate multipliers in order to assess the impact of economic costs of the obese on the general economy. RESULTS: Total labor income impacts are nearly 200 million dollars, 1,660 dollars of output income per household and 245 dollars of labor income per household. Obesity cost New Mexico more than 7,300 jobs and cut state and local tax revenues by more than 48 million dollars. CONCLUSION: Obesity's impact of more than 1.3 billion dollars amounts to 2.5% of New Mexico's gross state product. Governmental measures to combat this menace are warranted.

[Medicoeconomic evaluation of the treatment of morbid obesity by Swedish adjustable gastric banding (SAGB)]. / Evaluation médicoéconomique du traitement de l'obésité morbide par anneau gastrique ajustable suédois (SAGB).

INTRODUCTION: Aim of the present study was to analyze the medicoeconomic impact of each treatment for obesity in France, taking into account morbid obesity-associated comorbidities from a health insurance perspective and to calculate the cost-effectiveness ratio of SAGB compared to the non-surgical treatment for various kinds of patients, as well as the budget impact on a given cohort of patients. METHODS: The model studied surgery-eligible patients and compared the effectiveness of the SAGB treatment to the conventional treatment. The follow-up extended from 1 to 5 years. Costs analyzed were treatment-related direct medical costs, as well as potential comorbidities costs. The effectiveness is determined according to the BMI loss and its maintenance over time, together with the level of improved quality of life. RESULTS: An evaluation on a series of 1,000 patients shows that the treatment with SAGB is dominant (less expensive, more effective in terms of loss of BMI and its duration) compared to the conventional treatment for patients suffering from type II diabetes or obstructive sleep apnea. The same evaluation in terms of QALYs shows that the treatment with SAGB is dominant compared to the conventional treatment for patients with a BMI >or= 35 kg/m(2) and a type II diabetes, as well as for patients whose BMI >or= 40 kg/m(2) (with or without type II diabetes mellitus).

Trends in insurance coverage for bariatric surgery and the impact of evidence-based reviews.

The recent increase in demand for bariatric surgery has placed mounting economic pressure on insurance companies and other third-party payers (TPPs). As a result, some of the TPPs have responded by excluding or limiting their coverage of all or certain types of bariatric surgical procedures, and cite as their reason, a lack of evidence that supports the safety and efficacy of such procedures. Over the years, so-called "evidence-based reviews" have been used to back these claims. Some of these reviews have significant flaws and limitations that are discussed.

Childhood obesity: what can be done to help today's youth?

Childhood obesity is at epidemic proportions in the United States today. This epidemic has created a public health crisis. Although several initiatives are under way to address childhood obesity, including legislative bills before Congress and a call by the National Academy of Sciences for society to band together to stop the rise in the rates of childhood obesity, none of these efforts address what can be done today to help those youth that are considered morbidly obese and who have failed to find solutions with the standard medical treatment plan. This article discusses the use of bariatric surgery as a possible solution, presents a case study to illustrate the impact bariatric surgery can have on youth who are morbidly obese, and defines the pediatric nurse's role in helping to assure that youth are included in the current legislative process.