#fulldisclosure

From http://www.123rf.com

If this was a Twitter feed, I might try and see if that hash tag could get any worldwide attention.  I am not "on" Twitter, but I have been looking into it more recently (#fledglingnovice).

I saw some posts and twitter feeds recently on the subject of a 2/20/13 online JAMA Surgery article regarding the cost effectiveness of Gastric Bypass on health care costs for obese individuals over a 6 year period.

In "Impact of Health Care Costs of Obese Persons, A 6 Year Follow up of Surgical and Comparison Cohorts Using Health Plan Data", over 29,000 obese patients were followed for up to 6 years, and their health care costs were monitored.  Half the group were surgical patients, and the other half were medically managed.  The results implied that there was no real health care cost savings realized over that time, which refuted the well-accepted findings of a previous study in 2011 demonstrating the converse.

As we are always quick to do, especially when a result doesn't jibe with what you expect to see, looking more in depth at the study does point out some flaws that need to be taken into consideration.  And, in further #fulldisclosure, I have personally not read the full article to gather these points, just reporting and commenting on them from some authorities that have reflected on the article,  its research methodology, and its relative impact as a whole.

The patients studied were mostly Veteran males, average age 50 and above.  As a contrast to our experiences, in our high volume center's office,  the demographic we serve has an average age around 35,  and 80-20 favoring females.  I am not sure what the national demographics are for Bariatric Surgery as a whole, but I'd be surprised if this studied group was closely representative in their age, gender, and degree of overall health,  as they embarked on weight loss surgery.

The surgery patients were followed from 2000-2006, and their caseload is significantly more laden with open Bypass as opposed to laparoscopic cases, the latter of which is much more commonplace and safer in the present day.  for example, nearly all of our 700 cases last year were laparoscopic, and the average length of stay was 2 days or less.  Therefore, The laparoscopic approach to surgery would decrease length of stay after surgery, as well as decrease the likelihood of some post op complications, such as ventral hernias, which results in readmission or further surgery and therefore increased cost over the studied 6 year period.

Cost is the only studied measure as an index created by the authors, an Obesity Propensity Score, yet there is no measure or index for a 'benefit score'.  I realize that is beyond the scope of this article, but not having a cost vs benefit discussion as far as the insurance reimbursement for weight loss surgery makes the argument against surgery based on cost alone, and practically incomplete.

Furthermore, as a takeaway point, Dr. Robin Blackstone from the ASMBS stated that this study may actually argue for further studies regarding earlier intervention for obese patients, so as to shift the cost effectiveness curve  to a more measure, as earlier intervention could positively effect comorbidities dramatically from a monetary and resolution standpoint.

And finally, there was a mention in one article I read about the study that stated the actual results of their 6 year followup was lacking, as data for followup dropped off for most patients at much shorter that the 6 years, the time when the curve should favor benefit and reduced cost owing to the procedure. We keep track longitudinally in our office of all patients who are seen, as is required by our Centers of Excellence standards.  We, as most high volume center, have found it difficult to get follow up for a long period of time after surgery, base on a number of factors, so it is labor intensive and understandable.

All that glitters is not Gold, for those who have issues with Bariatric surgery, and are staunch against it.  I understand that position on weight loss surgery to a degree, but looking into the results of this most recent study, in association with our experiences at our Bariatric Care Center, shows that further studies need to be done.  Isn't that the result of most studies? :)