Weight Loss, is it Worth the Cost?

Meron Mezgebe, Mercer University College of Pharmacy

The estimated global incidence of diabetes is predicted to increase to 439 million adults by 2030 partially due to increasing prevalence of obesity and sedentary lifestyle. Diabetes may lead to premature death and complications such as blindness, amputations, renal disease, and cardiovascular diseases. [1] In the U.S., Type 2 Diabetes (T2D) costs the economy over $245 billion yearly. [2] Gastric band (GB) surgery for obese people with T2D was previously found to be cost-effective and clinically effective compared with non-surgical interventions. [3]

Cost-effectiveness of gastric band surgery for overweight but not obese adults with type 2 diabetes in the US [4]
Design Microsimulation model; N= 302
Objective To determine the cost-effectiveness of gastric band surgery in overweight but not obese people who receive standard diabetes care
Study Groups Australian RCT (n= 48); U.S. National Health and Nutrition Examination Survey (NHANES) (n= 254)
Methods Participants were eligible if they were between 18 and 65 years, with T2D of less than 5 years’ duration and a BMI between 25 and 30 kg/m2. Eligible participants from an Australian RCT and U.S. adults with self-reported diabetes from the NHANES were included.

All Australian costs were recorded at the time they were incurred and inflated to 2015 U.S. dollar value (AU$1 = US$0.78). All U.S. costs were inflated to 2015 U.S. dollar values with unit costs derived from RedBook and from relevant peer-reviewed literature.

The United Kingdom Prospective Diabetes Study (UKPDS) outcomes model used in this study, is a stochastic microsimulation model that projects rates of death and diabetes complication and their associated quality of life and direct health cost implications based on key risk factors.

Duration NHANES 1999-2011; Australian RCT 2009-2013.
Primary Outcome Measure The incremental cost-effectiveness ratio for GB surgery
Baseline Characteristics
RCT NHANES
Age, years ± SD 52.2 ± 6.7 53 ± 9.4
Diabetes duration, years ± SD 2.3 ± 1.9 2.4 +/-1.7
Male, % 48 38
White, % 88 72
Non-smokers 46 28
Prior ischemic heart disease/stroke, % 8 12
Weight, kg ± SD 82 ± 11.4 79 ± 11.1
Height, m ± SD 1.7 ± 0.1 1.68 ± 0.11
BMI, kg/m2 ± SD 28.9 ± 1.1 27.8 ± 1.4
Systolic blood pressure, mmHg ± SD 130.9 ± 15.4 130.8 ± 20
HbA1c, % ± SD 7.1 ± 1.2 7.4 ± 2.1
Total cholesterol, mmol/L ± SD 5 ± 1.2 5.2 ± 1.2
HDL cholesterol, mmol/L ± SD 1.2 ± 0.3 1.2 ± 0.3
Results
GB

dollars ± SD

Control

dollars ± SD

Difference

(95% CI)

p-value
LAGB surgery 8,377 ± 2,108 0 ± 0 8,377 (7,529 to 9,225) <0.0001
Total hospital costs 10,899 ± 7,118 3161 ± 6136 7,737 (3,797 to 11,677) 0.0003
Total outpatient costs 4,806 ± 1,626 3,443 ± 1,043 1,363 (564 to 2,161) 0.0013
Total diabetes-related medication costs 693 ± 653 2,287 ± 1,747 -1,593 (-2,373 to -814) 0.0002
Total health costs 16,398 ±8,258 8,848 ±6,348 7,551 (3,292 to 11,810) 0.0009
Incremental Cost Effectiveness Ratio (ICER) 94,387
Adverse Events N/A
Study Author Conclusions If weight loss endures for more than five years, GB surgery for overweight but not obese people with T2D is cost-effective in the US setting.

The Australian & U.S. population had different baseline BMI, ethnic, and unmeasured cultural differences; potentially limiting the applicability of the results to the U.S. population. The analysis assumed weight loss observed at two years endured for at least five years, the cost-effectiveness of GB surgery is overestimated if the weight loss is not sustained. Finally, the findings of this report only apply to overweight individuals with T2D for less than five years. Since longer disease duration in obese people with T2D is associated with lower rates of diabetes remission and lesser protection from diabetes complications is noted after bariatric surgery.

References

[1] Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010 Jan;87(1):4-14.

[2] American Diabetes A. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013;36:1033-46.

[3] Keating CL, Dixon JB, Moodie ML, et al. Cost effectiveness of surgically induced weight loss for the management of type 2 diabetes: modeled lifetime analysis. Diabetes Care. 2009 Apr;32(4):567-74.

[4] Wentworth JM, Dalziel KM, O’Brien PE, et al. Cost-effectiveness of gastric band surgery for overweight but not obese adults with type 2 diabetes in the U.S. J Diabetes Complications. 2017 Jul;31(7):1139-1144.

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