Rivaroxaban versus warfarin treatment among morbidly obese patients with venous thromboembolism: Comparative effectiveness, safety, and costs.

INTRODUCTION: Limited data exist on direct-acting oral anticoagulants in morbidly obese patients with venous thromboembolism (VTE). We compared clinical and health/economic outcomes with rivaroxaban versus warfarin for VTE treatment in morbidly obese patients. MATERIALS AND METHODS: This retrospective 1:1 propensity score matched cohort study analyzed data from 2 US claims databases. VTE patients initiating rivaroxaban or warfarin were identified who had diagnosis codes for morbid obesity (ICD-9:278.01,V85.4; ICD-10:E66.01,E66.2,Z68.4) 12 months pre- or 3 months post-initiation and followed ≥3 months. Intent-to-treat (ITT) and on-treatment (OT) analyses were conducted using conditional logistic regression and generalized linear models to compare recurrent VTE and major bleeding risks, healthcare resource utilization (HRU), and per patient per year (PPPY) costs. RESULTS: In total, 2890 matched pairs of morbidly obese VTE patients initiating rivaroxaban or warfarin were identified. Risks of recurrent VTE (ITT: OR: 0.99; 95% CI: 0.85-1.14) and major bleeding (OT: OR: 0.75; 95% CI: 0.47-1.19) were similar for cohorts. Anti-Factor Xa laboratory measurement was performed on <1% of rivaroxaban cohort. Hospitalizations (OR: 0.86; 95% CI: 0.77-0.96) and outpatient visits (OR: 0.23; 95% CI: 0.10-0.56), were lower with rivaroxaban versus warfarin (ITT analysis). Average total medical costs PPPY were $2829 lower with rivaroxaban versus warfarin ($34,824 vs $37,653), mainly driven by hospitalization costs. Total healthcare costs (including pharmacy) were similar ($43,034 vs $44,565). CONCLUSIONS: Morbidly obese VTE patients receiving rivaroxaban had similar risks of recurrent VTE and major bleeding versus warfarin. Rivaroxaban treatment yielded significantly less HRU and total medical costs, with similar total healthcare costs between groups.

[Cost and Revenue Relationship in Orthopaedic and Trauma Surgery Patients in Relation to Body Mass Index]. / Kosten-Erlös-Verhältnis orthopädisch-unfallchirurgischer Patienten in Abhängigkeit vom Body-Mass-Index.

BACKGROUND: Growing numbers of patients in orthopaedic and trauma surgery are obese. The risks involved are e.g. surgical complications, higher costs for longer hospital stays or special operating tables. It is a moot point whether revenues in the German DRG system cover the individual costs in relation to patients' body mass index (BMI) and in which area of hospital care potentially higher costs occur. MATERIAL AND METHODS: Data related to BMI, individual costs and revenues were extracted from the hospital information system for 13,833 patients of a large hospital who were operated in 2007 to 2010 on their upper or lower extremities. We analysed differences in cost revenue relations dependent on patients' BMI and surgical site, and differences in the distribution of hospital cost areas in relation to patients' BMI by t and U tests. RESULTS: Individual costs of morbidly obese (BMI ≥ 40) and underweight patients (BMI < 18.5) significantly (p < 0.05) exceeded individual DRG revenues. Significantly higher cost revenue relations were detected for all operations on the lower and upper extremities except for ankle joint surgeries in which arthroscopical procedures predominate. Most of the incremental costs resulted from higher spending for nursing care, medication and special appliances. Costs for doctors and medical ancillary staff did not increase in relation to patients' BMI. CONCLUSION: To avoid BMI related patient discrimination, supplementary fees to cover extra costs for morbidly obese or underweight patients with upper or lower extremities operations should raise DRG revenues. Moreover, hospitals should be organisationally prepared for these patients.

Trends in socioeconomic costs of morbid obesity among Korean adults, 2009-2013: Data from National Health Insurance Service.

As the prevalence of morbid obesity increased in Korea, the estimation of the accurate socioeconomic costs by morbid obesity was required; we analysed national medical costs through the big data. From 2009 year to 2013 year, Direct Costs (DC) for medical costs, transit costs and nursing costs and Indirect Costs (IC) for Future Income Loss (FIL) and Productivity Loss (PL) of morbid obesity (BMI≥30) were calculated, and socioeconomic costs were estimated by applying Population Attributable Risk (PAR) proportion according to obesity related diseases. From 10 year follow up research, Relative risk (RR) for morbid obesity related disease was analysed in comparison with control group. The high RR disease were congestive heart failure (RR 3.204 CI 2.421-3.987), hypertension (RR 3.13 CI 3.058-3.202), type 2 DM (RR 3.112 CI 2.973-3.251), pulmonary embolism (RR 2.969 CI 1.812-4.126), dyslipidemia (RR 2.283 CI 2.221-2.345) and ischaemic heart disease (RR 2.187 CI 2.068-2.306) in order. The socioeconomic costs by morbid obesity tended to increase 1.47 times from 2009 year (492 billion KRW) to 2013 year (726.2 billion KRW). The growth of the prevalence and the socioeconomic costs by morbid obesity in Korea are required not only the personal care issue but also social and national strategies for the future morbid obesity control.

Robotic Gastric Bypass Surgery in the Swiss Health Care System: Analysis of Hospital Costs and Reimbursement.

BACKGROUND: Robotic technology shows some promising early outcomes indicating potentially improved outcomes particularly for challenging bariatric procedures. Still, health care providers face significant clinical and economic challenges when introducing innovations. METHODS: Prospectively derived administrative cost data of patients who were coded with a primary diagnosis of obesity (ICD-10 code E.66.X), a procedure of gastric bypass surgery (CHOP code 44.3), and a robotic identifier (CHOP codes 00.90.50 or 00.39) during the years 2012 to 2015 was analyzed and compared to the triggered reimbursement for this patient cohort. RESULTS: A total of 348 patients were identified. The mean number of diagnoses was 2.7 and the mean length of stay was 5.9 days. The overall mean cost per patients was Swiss Francs (CHF) from 2012 to 2014 that was 21,527, with a mean reimbursement of CHF 24,917. Cost of the surgery in 2015 was comparable to the previous years with CHF 22,550.0 (p = 0.6618), but reimbursement decreased significantly to CHF 20,499.0 (0.0001). CONCLUSIONS: The average cost for robotic gastric bypass surgery fell well below the average reimbursement within the Swiss DRG system between 2012 and 2014, and this robotic procedure was a DRG winner for that period. However, the Swiss DRG system has matured over the years with a significant decrease resulting in a deficit for robotic gastric bypass surgery in 2015. This stipulates a discussion as to how health care providers should continue offering robotic gastric bypass surgery, particularly in the light of developing clinical evidence.

Bariatric surgery for the treatment of severely obese patients in South Korea--is it cost effective?

BACKGROUND: In South Korea, the number of severely obese patients has increased. An economic study comparing bariatric surgery with nonsurgical interventions has not been published for Asia. OBJECTIVES: This study was conducted to evaluate the cost effectiveness of bariatric surgery as compared to nonsurgical interventions for severe obese Korean people. METHODS: We used the Markov model to compare the lifetime expected costs and quality-adjusted life years (QALYs) between bariatric surgery and nonsurgical interventions from Korean Healthcare system perspectives. Our target cohort consisted of severe obese people defined as having a body mass index of 30-<40 kg/m(2) in South Korea. The starting age of the cohort was 30 years old, and the cycle length was 1 year. Nonsurgical interventions included a physician visit, exercise, diet, and pharmacotherapy. A discount of 5 % was applied in cost and QALY. The incremental cost-effectiveness ratio (ICER) of bariatric surgery compared to nonsurgery interventions was calculated. RESULTS: The cost-utility analysis study indicated that bariatric surgery had US$1,522 incremental costs and 0.86 incremental QALYs as compared to nonsurgical interventions. Through the base case analysis, ICER was US$1,771/QALY. The sensitivity analyses were performed using a variety of assumptions, and the robustness of the study results was also demonstrated. CONCLUSION: The study indicated that bariatric surgery was a cost-effective alternative to nonsurgical interventions over a lifetime, providing substantial lifetime benefits for severely obese Korean people.

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.

Prescription drug cost reduction in Native Hawaiians after laparoscopic Roux-en-y gastric bypass.

OBJECTIVE: Native Hawaiians (NH) represent a unique population where socioeconomic factors have contributed to higher incidence rates of obesity and related comorbidities than in the general population resulting in substantial prescription medication costs. Studies demonstrate that laparoscopic Roux-en-y gastric bypass (LRYGB) surgery results in significant weight loss, improvement of comorbidities, and decreased costs for prescription medications in Caucasians. This study aimed to analyze the effects of LRYGB surgery on Native Hawaiians and their prescription drug costs. METHODS: Demographics, baseline body mass index (BMI), comorbidities, preoperative, and postoperative data were analyzed for NH patients who underwent LRYGB between January 2004 and April 2009. Medication costs were determined using the online pharmacy . Generic drugs were selected when appropriate, while vitamins and nutritional supplements were not included in this study. RESULTS: Fifty (14 Men, 36 women) NH patients had sufficient data and follow-up for analysis. Average preoperative BMI was 49 kg/m(2), while at one year follow-up it decreased to 33 kg/m(2) (P<.001). This correlates to an average of 61% excess body weight lost (P<.001). The average number of prescription medications decreased from 3.5/patient preoperatively to 1.1/patient at one year (P<.001), equating to a monthly cost savings of US $195.8/patient (P<.001). CONCLUSIONS: LRYGB provided substantial weight loss for morbidly obese NH patients, resulting in significantly less prescription medication use and substantial cost savings. Thus, bariatric surgery for weight management has the potential to improve the overall well-being and lower the financial burden of medical care in socioeconomically disadvantaged communities such as the NH.

[TRAMOMTANA (Multidisciplinary treatment of morbid obesity: medication, behavioral therapy, nutritional support, and physical activity). From question to reality in an investigator-initiated clinical trial (II)]. / TRAMOMTANA (Tratamiento Multidisciplinar de la Obesidad Mórbida: Medicamentos, Terapia de comportamiento, Apoyo Nutricional y Actividad física). De la pregunta a la realidad de un ensayo clínico investigador iniciado (II).

Implementation of an intensive, multidisciplinary weight loss program in patients with morbid obesity is reported. This program is based on behavioral changes, lifestyle intervention, medication, and group therapy sessions. Our objective is to show that the results achieved with this two-year weight loss program will be at least similar to those achieved with bariatric surgery in patients with morbid obesity. We also intend to show that this multidisciplinary treatment induces an improvement in the comorbidity rate associated to smaller costs for our national health system.

Laparoscopic gastric bypass results in decreased prescription medication costs within 6 months.

The prevalence of obesity has reached epidemic proportions. The treatment of obesity-related health conditions is costly. Although laparoscopic gastric bypass is expensive, health care costs in obese patients should decrease with subsequent weight loss and overall improved health. Specifically, monthly prescription medication costs should decrease quickly after surgery. Fifty consecutive laparoscopic gastric bypass patients at a university-based bariatric surgery program were enrolled in the study. Medication consumption was prospectively recorded in a database. Patients' monthly prescription (not over-the-counter) medication costs before surgery and 6 months postoperatively were calculated. Retail costs were determined by a query to drugstore.com, an online pharmacy. Generic drugs were selected when appropriate. Costs for diabetic supplies and monitoring were not included in this analysis. Patients were mostly female (86%). Mean body mass index preoperatively was 51 kg/m2. Mean excess weight loss at 6 months was 52%. Patients took an average of 3.7 prescription medications before surgery compared with 1.7 after surgery (P < 0.05). All patients took nonprescription nutritional supplements, including multivitamins, oral vitamin B12, and calcium postoperatively. Laparoscopic gastric bypass resulted in a significant improvement in comorbid health conditions as early as 6 months after surgery. In an unselected group of patients, this led to a substantial overall mean monthly prescription medication cost savings, especially in those with gastroesophageal reflux disease, hypertension, diabetes, and hypercholesterolemia.