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Association of Roux-en-Y Gastric Bypass With Postoperative Health Care Use and Expenditures in Canada

Educational Objective To examine the preoperative and 5-year postoperative financial implications of a publicly funded surgical bariatric procedure.

1 Credit CME

JAMA Surgery

Published Online: July 22, 2020

Original Investigation

Article Information and Disclosures

Jean-Eric Tarride, MA, PhD^1,2,3;

Aristithes G. Doumouras, MD, MPH^4,5,6;

Dennis Hong, MD, MSc^4,5,6;

et al

J. Michael Paterson, MSc^6,7,8;

Semra Tibebu, MPH⁶;

Richard Perez, MSc⁶;

Julia Ma, MPH⁶;

Valerie H. Taylor, MD, PhD⁹;

Feng Xie, MSc, PhD^1,2;

Vanessa Boudreau, MD^4,5,6;

Eleanor Pullenayegum, MA, PhD^10,11;

David R. Urbach, MSc, MD¹²;

Mehran Anvari, MD, PhD^4,5,6

Author Affiliations

¹Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
²Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
³Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe’s Hamilton, St. Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
⁴Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
⁵Centre for Minimal Access Surgery, St Joseph’s Healthcare, McMaster University, Hamilton, Ontario, Canada
⁶ICES, Toronto, Ontario, Canada
⁷Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
⁸Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
⁹Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
¹⁰Dalla Lana School of Public Health, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
¹¹Hospital for Sick Children, Toronto, Ontario, Canada
¹²Women’s College Hospital Research Institute, Departments of Surgery and Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

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Key Points

Question Is a Roux-en-Y gastric bypass procedure associated with higher health care spending 5 years after the procedure compared with a matched control group in Ontario, Canada?

Findings In this population-based cohort study of 1587 patients who underwent a Roux-en-Y gastric bypass and 1587 control individuals, the net health care expenditures associated with the procedure were CAD $10 831 (2017 Canadian dollars) (US $8341) over 5 years, excluding the costs associated with the date of the procedure. Health care expenditures were statistically significantly higher during the 3 years after the procedure but were similar thereafter to spending in the control group.

Meaning These findings suggest that in a setting with a public health care system, Roux-en-Y gastric bypass is associated with increased health care costs in the short term.

Abstract

Importance Results of previous studies are mixed regarding the economic implications of a Roux-en-Y gastric bypass (RYGB).

Objective To assess the 5-year incremental health care use and expenditures after RYGB.

Design, Setting, and Participants This population-based cohort study conducted in Ontario, Canada, used a difference-in-differences approach to compare health care use and expenditures between patients who underwent a publicly funded RYGB from March 1, 2010, to March 31, 2013, and propensity score–matched control individuals who did not undergo a surgical bariatric procedure. The study period allowed for a minimum 60 months of follow-up because, at that time, the most recent date for which administrative data on health care and expenditures were available was March 31, 2018. Data sources included the Ontario Bariatric Registry linked to several Ontario health administrative databases and the Electronic Medical Record Administrative Data Linked Database. Health care use and expenditures data for 5 years before and 5 years after the index date (procedure date for RYGB group; random date for controls) were analyzed. Data analyses were performed March 12, 2019, to March 10, 2020.

Intervention RYGB procedure.

Main Outcomes and Measures The primary outcome was total health care expenditures.

Results The final propensity score–matched cohorts comprised 1587 individuals in the RYGB group (mean [SD] age, 47 [10.2] years) and 1587 controls (mean [SD] age, 47 [12.2] years); each group had 1228 women (77.4%) and a mean body mass index (calculated as weight in kilograms divided by height in meters squared) of 46. Mean total health care expenditures (2017 Canadian dollars) per patient in the RYGB group increased from CAD $15 594 (95% CI, CAD $14 743 to CAD $16 614) (US $12 008 [95% CI, US $11 353 to US $12 794]) in the 5 years before the procedure to CAD $30 389 (95% CI, CAD $28 789 to CAD $32 232) (US $23 401 [95% CI, US $22 169 to US $24 821]) over the 5 years after the procedure, a difference of CAD $14 795 (95% CI, CAD $13 172 to CAD $16 480) (US $11 393 [95% CI, US $10 143 to US $12 691]). For the control group, mean total health care expenditures per individual increased from CAD $16 109 (95% CI, CAD $14 727 to CAD $17 591) (US $12 405 [95% CI, US $11 341 to US $13 546]) 5 years before the index date to CAD $20 073 (95% CI, CAD $18 147 to CAD $22 169) (US $15 457 [95% CI, US $13 974 to US $17 071]) 5 years after the date, a difference of CAD $3964 (95% CI, CAD $2250 to CAD $5875) (US $3053 [95% CI, US $1733 to US $4524]). Overall, the difference-in-differences estimate of the net cost of RYGB was CAD $10 831 (95% CI, CAD $8252 to CAD $13 283) (US $8341 [95% CI, $6355 to $10 229]) over the 5-year period. This amount excluded the mean (SD) cost associated with the index date: CAD $6501 (CAD $1087) (US $5006 [US $837]) for the RYGB cohort and CAD $9 (CAD $72) (US $7 [US $55]) for the controls. The cost differential was primarily associated with increased hospitalizations in the first months immediately after RYGB. Expenditures leveled off in year 3 after the index date; differences in total expenditures between the RYGB and control cohorts were not statistically significantly different in years 4 and 5.

Conclusions and Relevance Health care expenditures in the 3 years after publicly funded RYGB were higher in patients who underwent the procedure than in control individuals, but the costs were similar thereafter. This finding suggests the need to decrease hospital and emergency department readmissions after surgical bariatric procedures because such use is associated with increased spending.

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Article Information

Accepted for Publication: April 7, 2020.

Corresponding Author: Jean-Eric Tarride, MA, PhD, Centre for Health Economics and Policy Analysis, McMaster University, 1280 Main St W, Communications Research Laboratory (CRL) 227, Hamilton, ON L8S 4K1, Canada (tarride@mcmaster.ca).

Published Online: July 22, 2020. doi:10.1001/jamasurg.2020.1985

Author Contributions: Ms Tibebu had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Tarride, Doumouras, Paterson, Perez, Taylor, Xie, Urbach, Anvari.

Acquisition, analysis, or interpretation of data: Tarride, Doumouras, Hong, Paterson, Tibebu, Perez, Ma, Taylor, Xie, Boudreau, Pullenayegum, Anvari.

Drafting of the manuscript: Tarride, Doumouras, Taylor, Xie.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Tarride, Doumouras, Tibebu, Ma, Xie, Pullenayegum, Urbach.

Obtained funding: Tarride, Paterson, Taylor, Anvari.

Administrative, technical, or material support: Hong, Perez, Taylor, Anvari.

Supervision: Paterson, Perez, Boudreau, Pullenayegum, Anvari.

Conflict of Interest Disclosures: Dr Tarride reported receiving grants from the Canadian Institutes of Health Research (CIHR) during the conduct of the study. Mr Paterson reported receiving grants from CIHR during the conduct of the study and being an employee of ICES (formerly the Institute for Clinical Evaluative Sciences), which is funded by the Ontario Ministry of Health. Ms Tibebu reported receiving grants from CIHR and being an employee of ICES during the conduct of the study. Ms Ma reported receiving grants from CIHR during the conduct of the study. No other disclosures were reported.

Funding/Support: This study was funded by grants from CIHR and the Ontario Bariatric Network and was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The analyses, conclusions, opinions, and statements expressed herein are those of the authors and do not reflect the official policy or position of the funders or data sources; no endorsement is intended or should be inferred.

Additional Information: Parts of this article are based on data and information compiled and provided by the Ontario Ministry of Health, CIHR, and the Ontario Bariatric Registry.

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Association of Roux-en-Y Gastric Bypass With Postoperative Health Care Use and Expenditures in Canada

The Need for an Improved Evidence Base to Inform the Health Care Decision-making Process

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