For overweight and obese patients with nonalcoholic steatohepatitis (NASH) cirrhosis, bariatric surgery was a cost-effective treatment in a modeling study.
Looking at three obesity treatment options compared with usual care — laparoscopic sleeve gastrectomy (SG), laparoscopy Roux-en-Y gastric bypass (GB), and intensive lifestyle intervention (ILI) — sleeve gastrectomy was the most cost-effective option for patients with NASH cirrhosis across all weight categories, Jagpreet Chhatwal, PhD, of Massachusetts General Hospital in Boston, and colleagues, wrote in JAMA Network Open.
For all weight categories ranging from overweight to severe obesity, the analysis yielded incremental cost-effectiveness estimates for sleeve gastrectomy (per quality-adjusted life-year or QALY) as follows:
- Overweight: $66,119
- Mild obesity: $18,716
- Moderate obesity: $10,274
- Severe obesity: $6,563
“Our results projected that surgery would outperform usual care and ILI across all weight classes assessed, including overweight, in terms of life expectancy and QALY,” Chhatwal’s group concluded.
On the other hand, although Roux-en-Y gastric bypass yielded a greater amount of quality-adjusted life years for these patients compared with the sleeve procedure, it wasn’t quite as cost-effective. Instead, the cost of the gastric bypass procedure would need to be slashed by several thousand across all categories of obesity, and wasn’t anywhere near cost-effective for overweight patients.
Specifically, the average cost of gastric bypass is estimated at around $28,734. Would the following cost reductions be considered a cost-effective obesity treatment for patients with NASH cirrhosis:
- Mild obesity: Decrease of $4,889
- Moderate obesity: Decrease of $3,189
- Severe obesity: Decrease of $2,289
“Our findings suggest that the slightly superior weight loss attributable to GB might not be worth the higher cost of the procedure,” the group wrote. Bypass not only incurs an extra up-front surgical cost, “it also entails a higher risk of complications, which may limit its cost-effectiveness.”
As for the third treatment option assessed — intensive lifestyle intervention — this strategy didn’t prove cost-effective across any of the weight categories included. Compared with surgery, intensive lifestyle intervention also added the smallest QALY increment, though slightly more than usual care (defined as no weight loss intervention, with liver disease progression “according to probabilities derived from the literature”).
The analysis, which included patient characteristics on 161 participants from a previously published prospective study, also took into account the risks of mortality and complications with surgeries, transition probabilities, treatment efficacy, and quality-of-life weights taken from several other published studies, which were all incorporated into a Markov-based state-transition model developed by the researchers.
“This article adds momentum to growing literature by suggesting that bariatric surgery in patients with NASH is safe, beneficial, and now cost-effective,” wrote Seth Waits, MD, of the University of Michigan in Ann Arbor, and colleagues, in an accompanying commentary.
Typically, they said, patients with cirrhosis are written off as poor candidates for elective surgical interventions because of the increased risks.
“Increasingly, with the advent of the model for end-stage liver disease score, a more granular risk profile can be delineated, and patients at lower risk can be identified,” Waits and colleagues wrote, adding that patients with well-compensated cirrhosis will likely get the most benefit from bariatric surgery.
The benefits “are too great and the patients are too sick to throw the opportunity away because the risks are ‘too high,'” they concluded.
Chhatwal reported receiving research grants from and serving of advisory panels of Merck and Gilead. Other study authors also reported disclosures.
Commentary author Ghaferi reported receiving grants from Blue Cross/Blue Shield of Michigan, the Agency for Healthcare Research and Quality, and the Patient-Centered Outcomes Research Institute.