Gastric Bypass Compared To Sleeve Gastrectomy In Diabetic Patients
Overview
This retrospective cohort study aimed to compare the effects of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on overall and diabetes-specific healthcare costs among patients with type 2 diabetes. The study analyzed data from Optum’s deidentified Clinformatics® Data Mart database, focusing on 9608 matched patients who underwent either SG or RYGB between 2007 and 2019.
The findings revealed a significant decline in healthcare costs related to type 2 diabetes in the initial years following both SG and RYGB procedures. However, RYGB was associated with a more substantial decrease in pharmacy costs, as well as in type 2 diabetes-specific office and laboratory expenses. On the other hand, SG was linked to lower total healthcare costs during the first three follow-up periods and reduced acute care costs in the initial two years post-surgery.
Despite the observed reductions in ambulatory type 2 diabetes monitoring and antidiabetes medication requirements following RYGB, patients did not experience an overall medical cost-benefit in the early years compared to SG. These findings underscore the need for comprehensive evaluation and consideration of various factors when determining the most suitable surgical approach for patients with type 2 diabetes.
Introduction
Type 2 diabetes presents a significant economic challenge in the United States, not only in terms of direct medical costs but also due to its associated morbidity and mortality rates. With an estimated prevalence of 11.3% among the population, type 2 diabetes accounts for a substantial portion of the nation’s healthcare expenditure. Among the various expenses incurred, prescription medications for glycemic control constitute a major component, amounting to billions of dollars annually. This financial burden underscores the urgent need for effective management strategies to mitigate both the health and economic impacts of the disease.
Obesity is a primary driver of type 2 diabetes, with more than half of individuals diagnosed with the condition having a body mass index (BMI) of 40 kg/m² or higher. Bariatric surgery, particularly procedures like sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), has emerged as a highly effective intervention for severe obesity. Beyond weight loss, bariatric surgery has been shown to improve overall quality of life and lead to substantial improvements in type 2 diabetes, including remission rates of up to 50% over a five-year period post-surgery.
However, despite the proven efficacy of bariatric surgery, there remains a lack of comprehensive data comparing the long-term outcomes and associated healthcare costs between different surgical procedures, particularly SG and RYGB. Previous studies have often been limited by small sample sizes, inadequate follow-up periods, or the absence of robust control groups. Consequently, there is a critical need for large-scale analyses that can provide more definitive insights into the comparative effectiveness and cost implications of these procedures.
The present study seeks to address this gap by leveraging a nationwide insurance claims database to evaluate the impact of SG versus RYGB on both type 2 diabetes-specific and overall healthcare costs over a four-year period following the index procedure. By examining real-world data from a diverse patient population, the study aims to determine whether RYGB offers greater cost savings and healthcare utilization benefits compared to SG among individuals with type 2 diabetes. These findings have the potential to inform clinical decision-making and healthcare policy, ultimately optimizing the allocation of resources and improving outcomes for patients with type 2 diabetes undergoing bariatric surgery.
Method
In this retrospective cohort study, data from Optum’s deidentified Clinformatics® Data Mart database were meticulously analyzed, covering a period from 2007 to 2019. The study focused on a specific demographic: adults aged 18 to 70 who underwent primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) surgeries between 2010 and 2019. To ensure robust analysis, only patients with at least 6 months of enrollment data both before and after their bariatric surgery were included in the study cohort.
Identifying patients with type 2 diabetes within this cohort was a crucial aspect of the study. To achieve this, a validated claims-based algorithm was employed. This algorithm not only identified patients with type 2 diabetes but also differentiated between those with active prescriptions for antidiabetes agents at baseline and those without. This differentiation allowed for a nuanced understanding of the population and its healthcare needs.
The study tracked each patient from 6 months before their surgery up to 48 months post-surgery. Various outcome measures were considered, with a primary focus on overall and type 2 diabetes-specific healthcare costs. These costs were further broken down into different categories such as pharmacy, ambulatory care, acute care, and total healthcare costs. By dissecting the costs in this manner, the researchers aimed to gain insights into the specific areas where healthcare resources were allocated post-bariatric surgery.
To ensure the validity of the findings, numerous covariates were taken into account. These included demographic factors such as age, sex, and region of residence, as well as clinical factors like preoperative BMI, type 2 diabetes medication use patterns, and evidence of complications. Matching strategies were employed to minimize bias, particularly confounding by indication, which could skew the results if not properly addressed.
Analytically, interrupted time series plots and differences-in-differences (DiD) analysis were utilized to compare outcomes between patients who underwent SG versus RYGB procedures. By examining trends over time and comparing outcomes between the two surgical approaches, the researchers were able to draw meaningful conclusions about the relative effectiveness and cost-effectiveness of each procedure.
Furthermore, sensitivity analysis was conducted to explore how the findings might differ when focusing on a subset of patients with more severe type 2 diabetes. This subset analysis provided additional insights into the potential impact of bariatric surgery on patients with more advanced disease.
Overall, this study contributes valuable insights into the healthcare utilization and costs associated with SG and RYGB procedures among patients with type 2 diabetes. The comprehensive methodology and rigorous analysis employed in this study enhance our understanding of the real-world outcomes of bariatric surgery and provide valuable information for clinicians, researchers, and policymakers alike.
Result
The study aimed to assess the healthcare costs associated with two common bariatric surgical procedures, sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), among a cohort of patients aged 18 to 70 years. The analysis focused on patients with continuous enrollment in either commercial or Medicare Advantage plans, ensuring a robust dataset for evaluating long-term cost implications.
After applying exclusion criteria, the study cohort comprised 10,851 patients, with 4,804 individuals undergoing SG and an equal number undergoing RYGB. The demographic characteristics of the matched SG and RYGB groups were well-balanced, ensuring a fair comparison between the two procedures.
The median post-surgical follow-up period was 2.2 years, with approximately one-fifth of patients having a complete four-year follow-up. This extensive follow-up duration allowed for a comprehensive assessment of healthcare costs over time.
The analysis revealed immediate and substantial reductions in total type 2 diabetes-specific healthcare costs following both SG and RYGB surgeries. These reductions were consistent across various cost categories, including pharmacy, ambulatory care, and acute care. However, while both procedures led to similar initial decreases in type 2 diabetes-specific costs, differences between SG and RYGB emerged during later follow-up periods.
Interestingly, the study found that SG patients incurred significantly higher type 2 diabetes-specific pharmacy costs compared to RYGB patients throughout the entire follow-up period. This finding suggests potential differences in medication utilization or effectiveness between the two procedures, warranting further investigation into the underlying factors driving these cost disparities.
Additionally, while total healthcare costs, including those unrelated to type 2 diabetes, were initially lower for SG compared to RYGB, the differences were not consistently significant over time. This indicates that while SG may offer some cost advantages in the short term, these benefits may diminish over the long term, highlighting the importance of considering both immediate and long-term cost implications when evaluating bariatric surgery options.
Furthermore, the study conducted sensitivity analyses to validate the robustness of the findings, which confirmed the overall trends observed in the main analysis. This further strengthens the reliability and generalizability of the study results.
In conclusion, the study provides valuable insights into the healthcare costs associated with SG and RYGB surgeries, emphasizing the importance of considering both short-term and long-term cost implications when making treatment decisions for patients with obesity and type 2 diabetes.
Conclusion
In this nationwide cohort study, the impact of two common bariatric surgery procedures, sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), on healthcare costs specifically related to type 2 diabetes was examined. While both surgeries led to substantial declines in type 2 diabetes-specific costs in the initial years following the procedures, RYGB was associated with larger reductions in total and type 2 diabetes-specific pharmacy costs, as well as type 2 diabetes-specific office and laboratory costs over a four-year period. However, SG was linked to lower acute care costs and total healthcare costs in the first one to two years post-surgery. By the end of the study period, there were no significant differences between the two procedures in acute care or total healthcare costs.
Prior clinical studies had suggested that RYGB might result in greater reductions in total healthcare costs among patients with type 2 diabetes compared to SG. While RYGB did show a larger impact on decreasing outpatient care costs associated with type 2 diabetes, the early postoperative period for RYGB also involved higher acute care costs, offsetting some of the potential benefits. This finding aligns with previous research indicating a higher rate of surgical complications and reoperations following RYGB compared to SG, potentially due to severe hypoglycemic episodes.
Despite the significant impact of RYGB on reducing type 2 diabetes medication costs, particularly among patients using antidiabetes medication at baseline, there was no clear advantage of RYGB over SG in overall ambulatory visits, laboratory costs, acute care, or total costs. Additionally, the study did not consider the cost implications of new American Diabetes Association guidelines favoring more expensive medications, which could influence future cost-benefit analyses.
The flattening of overall total healthcare cost trajectories following both RYGB and SG underscores the potential economic benefits of bariatric surgery for patients with type 2 diabetes. However, limitations of the study include its observational nature, loss to follow-up over time, and inability to measure the duration of type 2 diabetes. Further research, including randomized trials with longer follow-up periods, is needed to better understand the economic impact and clinical outcomes associated with these surgical interventions.
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