Bariatric Surgery's Return on Investment for Veterans and VHA
Matthew L. Maciejewski PhD
Durham VA Medical Center, Durham, NC
Durham, NC
Funding Period: September 2011 - August 2014

BACKGROUND/RATIONALE:
More than 10 million U.S. adults, including 165,000 veterans who use Veterans Affairs (VA) medical facilities, have class III obesity [body mass index (BMI) 40 kg/m2]. The impact of this epidemic is substantial; in 2000, class III obesity was associated with 82,066 deaths and over $11 billion in direct U.S. health care expenditures. Over the past decade, VHA has provided bariatric surgery to over 1000 severely obese veterans in 12 approved VHA Medical Centers in the hopes of improving their body weight, health, longevity, and potentially also reducing their health care expenditures. The proposed study builds on our prior work by addressing several novel research questions after bariatric surgery was integrated into the MOVE! program.


OBJECTIVE(S):
The immediate objective of the proposed study is to expand our prior work by increasing our cohort size and observing them for a greater duration of time to allow examinations of ten-year survival, health care use, and expenditures and the long-term durability of changes in weight and resolution of comorbidities. The longer-term objective of the proposed study is learn to better identify which veterans are a good candidates for bariatric surgery as well as predict those who are not. Using new clinical and laboratory data and expanding our prior datasets farther in time, the proposed study will build on our prior work in three primary aims:

1) Compare weight change and resolution of diabetes, hypertension, and hyperlipidemia between veterans who had bariatric surgery and a matched cohort of severely obese veterans who did not have bariatric surgery in 2000-2010, and examine the durability of weight change and disease resolution among surgical cases.

2) Compare long-term survival between veterans who had bariatric surgery and a matched cohort of severely obese veterans who did not have bariatric surgery in 2000-2010, and examine trends in major surgical complications among surgical cases.

3) Compare long-term trends in VA health care utilization and VA expenditures between veterans who had bariatric surgery and a matched cohort of severely obese veterans who did not have bariatric surgery in 2000-2010.

METHODS:
First, our study will address the rate of resolution of diabetes, hypertension, and hyperlipidemia. Prior studies of this question have had many limitations, including a lack of a non-surgical control group, a lack of laboratory and blood pressure data to confirm resolution of comorbidities, and a focus on out-dated bariatric procedures. Second, it will follow patients over an entire decade of care (2000-2010) to establish the long-term durability of these health improvements, including the durability of weight loss, which has been poorly characterized in the literature. Third, our study will seek to identify patient-level characteristics that are associated with failures - failures to lose weight, failures to resolve comorbidities, and failures to achieve long-term weight maintenance - in an explicit attempt to identify important factors associated with less desirable health and economic outcomes.

FINDINGS/RESULTS:
None to date, but have drafted a memo to SQDUG and VASQIP outlining our process of identifying veterans who had bariatric surgery in 2000-2011 for their use (if they so choose).

IMPACT:
The proposed study is highly responsive to the HSR&D Priority Area of Health Care Access/Rural Health. We expect these results to inform VA's bariatric surgery program development.

PUBLICATIONS:

Journal Articles

1. Maciejewski ML, Livingston EH, Smith VA, Kahwati LC, Henderson WG, Arterburn DE. Health expenditures among high-risk patients after gastric bypass and matched controls. Archives of surgery (Chicago, Ill. : 1960). 2012 Jul 1; 147(7):633-40.

Conference Presentations

1. Maciejewski ML, Livingston E, Smith V, Kahwati L, Henderson W, Arterburn D. Impact of Bariatric Surgery on Survival in a Cohor of Predominantly Older Men. Paper presented at: AcademyHealth Annual Research Meeting; 2011 Jun 12; Seattle, WA.

DRA: Health Systems, Diabetes and Related Disorders
DRE: Treatment - Observational
Keywords: Cardiovascular Disease, Comparative Effectiveness, Cost-Effectiveness, Outcomes - Patient, Utilization
MeSH Terms: none