Short- and long-term outcomes after bariatric surgery in the Medicare population

Treatments for severe obesity include lifestyle modifications (exercise, diet), use of medications (e.g., orlistat, phentermine), endoscopically placed devices (e.g., gastric balloons), and bariatric surgery. Most nonsurgical treatments fail to achieve long-term weight control, reports the Centers for Medicare and Medicaid Services (CMS).

In contrast, bariatric surgery is perceived to be an effective obesity treatment, especially in the long term, and reduces morbidities. It has become the preferred therapy for persons with severe obesity refractory to medical therapy.

Many Medicare-eligible people in the U.S. likely meet NIH indications for either surgical or endoscopic bariatric therapy.

According to a National Institutes of Health (NIH) Panel, bariatric surgery is indicated for patients with a body mass index (BMI) of 40 Kg/m2 or more (obesity grade 3), or a BMI of 35 Kg/m2 or more (obesity grades 2 or 3) with an obesity-related comorbidity who have not responded to lifestyle modification therapy. Bariatric surgery also has been evaluated in adults with moderate obesity (obesity grade 1, BMI 30-34.9 Kg/m2).

Bariatric surgical procedures result in anatomic manipulations of the gastrointestinal tract; and more recently similar anatomic modifications have been achieved through the use of endoscopic technologies. Many adults age 65 and older meet indications for bariatric treatment, but the utilization of these procedures remains low.

Based on the U.S. National Health and Nutrition Examination Survey (NHANES), in 2012 35 percent of people 60 years and older had a BMI of 30 Kg/m2 or more, 14 percent had a BMI of 35 Kg/m2 or more, and six percent had a BMI of 40 Kg/m2 or more, with a women-to-men ratio of almost 2:1 within each category. Thus, a large number of Medicare-eligible people in the U.S. likely meet NIH indications for either surgical or endoscopic bariatric therapy.

A technology assessment was conducted to objectively summarize and appraise the current evidence regarding the effectiveness and safety of bariatric therapies in the Medicare-eligible population. Key findings include:

Among patients who are eligible for Medicare:

• There are no randomized trials evaluating the effectiveness and safety of bariatric surgical or endoscopic procedures; there are few direct (head-to-head) comparisons between different surgical procedures with sufficient evidence in nonrandomized studies and none for endoscopic procedures.
• Bariatric surgery overall, and in particular the procedures of Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding, leads to improvements in weight loss outcomes beyond one year after surgery.
• Roux-en-Y gastric bypass performs better compared to sleeve gastrectomy or adjustable gastric banding for metabolic, cardiovascular outcomes, renal function outcomes and for postoperative complications; Roux-en-Y gastric bypass also performs better for weight loss outcomes.