What is the impact on the healthcare system if access to bariatric surgery is delayed?

Abstract

Background: Bariatric surgery has been available as part of the Brazilian Public Health System for patients with body mass index>40 kg/m² (or>35 kg/m² with co-morbidities) since 1999. However, access to surgery is challenging, with eligible patients waiting up to 7 years before surgery.

Objective: Our objective was to compare costs and effectiveness of different waiting times before surgery versus prompt surgery.

Settings: Public practice.

Methods: A Markov microsimulation model compared 5 different strategies: no surgery, prompt surgery, and delaying surgery for 1, 2, 4, and 7 years. Markov tracker variables and states reflected changes in body mass index, type 2 diabetes status (including remission and relapse), and cardiovascular events. Time horizon was 20 years; discount rate, 5%; and the perspective of the Brazilian Public Health System. Effectiveness was calculated as quality adjusted life years.

Results: Prompt surgery was the least costly and most effective strategy compared with any delay. Costs increased and effectiveness diminished progressively with the length of delays. Waiting 7 years for surgery was the most expensive and least effective strategy. Prompt surgery maintained dominance in 99.9%, 90.7%, 96.1%, and 94.2% of simulations in probabilistic sensitivity analyses versus 1-, 2-, 4-, and 7-year delays, respectively. Immediate surgery was very cost effective compared with no surgery in the case base. In the scenario with all patients having type 2 diabetes, immediate surgery was dominant to any strategy, including the no surgery group.

Conclusions: Delaying bariatric operations is more expensive and less effective compared with prompt surgery and very cost effective compared with no surgery. Public health systems should pursue strategies to accelerate access to surgery to decrease obesity related complications and mortality of patients, but also to improve cost effectiveness.

Keywords: Bariatric surgery; Cost effectiveness; Delay access.