Cost-Effective Bariatric Surgery in Germany Today

Obesity Surgery, 10, 549-552 Cost-Effective Bariatric Surgery in Germany Today Hans Werner Kuhlmann, MD; Rainer Andrea Falcone, MD; Anna Maria Wolf, MD Evangelisches und Johanniter Klinikum, Duisburg/Dinslaken/Oberhausen gGmbH, Germany Background: The reason for this inquiry was to assess the actual state of Bariatric Surgery in Germany, especially relating to the much discussed economic aspect. Method: A questionnaire was sent to those hospitals in Germany in which we knew that obesity surgery was performed, concerning the year 1997. Results: To our regret, the feedback was only 37%, although this must be considered an adequate response for Germany. Nevertheless, some interesting trends are easily seen. Conclusion: Bariatric Surgery in Germany could pay for itself by saving the costs associated with conservative therapy and preventing co-morbidities in patients with morbid obesity. Key words: Cost-effectiveness, morbid obesity, bariatric surgery, co-morbidities Introduction Unfortunately, nobody knows exactly what is happening at the present time in Germany in the field of bariatric surgery. As others before us, we did not find any real economic impact data on the question “Is bariatric surgery worth its costs?”1 There are no exact figures for the direct and indirect costs of obesity in Germany. Estimates range between 4-5.5 billion USD per year, taking into account all attributable co-morbidities.2 By comparison, analogous figures for Canada have been estimated at between 829 million and 3.5 billion USD in 1999,3 and at between 729 million and 1.6 billion USD in France for the direct costs in 1992.4 When considered as a Reprint requests to: Hans Werner Kuhlmann, MD, General Surgery, Evangelisches und Johanniter Klinikum, Duisburg/Dinslaken/Oberhausen gGmbH, Kreuzstrasse 28, 46535 Dinslaken, Germany. Tel: +49 2064 422301; fax +49 2064 42 2302; e-mail: [email protected] © FD-Communications Inc. proportion of health-care expenditures, these sums are similar to those found in New Zealand,5 Australia6 and France,7 with all of them ranging between 2-2.5% of total health-care costs. Somewhat higher estimates are given for the Netherlands with 4%,8 and the United States with between 5.5-6.8%.9,10 To throw some light on this unsatisfactory situation, in September 1998 we sent a questionnaire to those hospitals in Germany in which we knew that obesity surgery was performed. The questions asked concerned the year 1997. Most authors11,12 chose to transfer the model described by Colditz for the U.S.10 In 1997 a total of 300 billion USD was spent in the German public health system. By this model, a large part of this sum — carefully estimated to be about 17 billion USD — are the direct and indirect costs of conservative treatment of obesity in Germany.13 Out of this total sum for the treatment of obesity, only 5 million USD were spent on bariatric surgery in our country in 1997— and this is a very conservative estimate. This corresponds to less than 0.03% of the “total costs”. The obesity-related diseases with a high incidence include diabetes,12,14,15 cardiovascular and pulmonary diseases, 8,14,16-19 leading to chronic disability,12 early mortality, and not least notably impaired quality of life. 14,20-22 The only possible treatment at the moment which is both effective and cost-efficient in morbidly obese patients is obesity surgery. However, this treatment is not held in high enough esteem by politicians, the health insurance companies and by our conservatively minded medical colleagues. The conservative treatment of morbid obesity has a failure rate of 96-98%, effectiveness and costefficiency therefore being about 2% — a rate Obesity Surgery, 10, 2000 549 Kuhlmann et al which would nowhere in the world be accepted for a surgical procedure. Hence, trying to treat morbid obesity conservatively is a mere waste of money. As can be seen in Table 1, the potential health benefits for patients with morbid obesity and co-morbidities have an early onset after reducing weight by only 5-10%, this already lowering the overall mortality by 20%; 10 kg less weight reduces the diabetes-associated mortality by up to 30%. A patient with a well-controlled treated diabetes costs about 750 USD per year, and a patient not treated that way up to 7,500 USD per year. The other health benefits described after successful bariatric surgery are equally impressive. 22 Materials and Methods The questions asked are set out in Table 2. To our regret the feedback was only 37%, although we would have surmized that all hospitals addressed would have had a high interest in answering the questions of the survey. Nevertheless, this must be considered a fair enough result. At the annual meeting of the German Obesity Society in September 1999, we heard that at present about 75 hospitals are performing obesity surgery (presumably only a few cases per year and only gastric banding). Results Figure 1 depicts the distribution of the operations reported for the year 1997. The trend towards laparoscopic procedures is obvious. This would confirm our above-mentioned information that there is an increasing number of hospitals performing gastric banding on a small scale of a few cases per year. Combined procedures such as biliopancreatic diversion (BPD) or gastric bypass (GBP) seem to be unusual. In Table 3 we present a synopsis of the costs in Germany. These include the actual costs of the operation, the personnel, instruments, materials and anesthesia. The small remaining sum in US $ in no way reflects the margin for the hospital, for there still remain all further expenses to be subtracted, such as accommodation for the patient, medical and nursing care, physiotherapy and necessary drugs. It is easy to realize that bariatric surgery cannot be performed cost-effectively in Table 1. Potential health benefits of weight reduction of 5-10% in morbidly obese patients with comorbidities Feature Mortality Hypertension Diabetes Dyslipidemia Result 20-25% 30-40% 40-50% in in in overall mortality diabetes-related deaths deaths from obesity-related malignancy 10 mmHg in systolic and diastolic blood pressure 50% 30-50% 15% in in in developing diabetes Type II (NIDDM) fasting blood glucose levels HbA1C 10% 15% 30% 8% in in in in cholesterol LDL triglycerides HDL á Table 2. 1999 Survey Questions • How many primary operations in obesity surgery were performed in your clinic in 1997? • Which procedure(s) have been performed? • What were the average costs of the operation billed by the hospital? 550 Obesity Surgery, 10, 2000 Bariatric Surgery in Germany Today SRVG (Eckhout) VBG (Mason) BPD (Scopinaro) Gastric banding laparoscopic Gastric banding conventional Figure 1. Methods of operation reported for 1997 (17 Clinics). SRVG=silastic ring vertical gastroplasty; VBG= vertical banded gastroplasty; BPD=biliopancreatic diversion. Germany under the present conditions. Discussion An increasing number of German hospitals are performing operations in obesity surgery, although often on a small scale not exceeding a few patients per year. There is a distinct trend towards laparoscopic gastric banding, possibly related to the assumption of greater simplicity in surgical technique and post-operative patient management. Malabsorption-based techniques, such as GBP or BPD, are rarely employed and probably limited to hospitals with a broader experience and larger patient number. Bariatric surgery is an effective therapy for morbid obesity. The concern expressed by health insurers that bariatric surgery would set off a new explosion in costs is baseless. Bariatric surgery can well fund itself through the saving of the costs associated with conservative therapy and preventing co-morbidities in patients with morbid obesity. From a point of view of society, the gains both in added life years as well as in quality of life, and the avoidance of costs associated with obesityrelated disease, already have been ascertained. 23,24 Unfortunately there is an increasing number of patients for whom bariatric surgery is rejected because of insufficient costs coverage. Bariatric surgery at the present time is the only sensible option for the treatment of morbid obesity, and a similarly favorable cost-performance ratio is found nowhere else in medicine. Nevertheless, obesity surgery will only be possible in the long term in Germany if adequate funding is provided. It is strongly hoped that the consequences of giving up such operations altogether will not have to be experienced. References 1. Hauri P, Horber FF, Sendi P. Is bariatric surgery worth its costs? Obes Surg 1999; 9: 480-3. 2. Kurscheid T, Lauterbach K. The cost implications of obesity for health care and society. Int J Obes 1998; 22 (Suppl 1): S3-5; discussion S6. 3. Birmingham CL, Muller JL, Palepu A et al. The cost of obesity in Canada. CMAJ 1999; 160: 483-8. Table 3. Costs and income Operations in Bariatric Surgery, conventional technique. EVK Dinslaken 1997 10 days hospital stay without consideration of classic hospital costs (e.g. drugs, nursing, boarding costs, etc.) SRVG Eckhout In USD ASGB Kuzmak In USD BPD Scopinaro In USD 1,261.37 991.67 2,140.68 0 1527.77 0 Hospital allowance 2,940.00 2,940.00 2,940.00 Remaining after deduction of costs of operation 1,678.63 420.56 799.32 Costs of operation Cost of band, payment by health insurance USD = US dollars Obesity Surgery, 10, 2000 551 Kuhlmann et al 4. Detournay B, Fagnani F, Phillippo M et al. Obesity morbidity and health care costs in France: an analysis of the 1991-1992 Medical Care Household Survey. Int J Obes 2000; 24: 151-5. 5. Swinburn B, Ashton T, Gillespie J et al. Health care costs of obesity in New Zealand. Int J Obes 1997; 21: 891-6. 6. Segal L, Carter R, Zimmet P. The cost of obesity: the Australian perspective. Pharmacoeconomics 1994; 5: 45-52. 7. Levy E, Levy P, Le Pen C et al. The economic cost of obesity: the French situation. Int J Obes 1995; 19: 788-92. 8. Seidell JC, Deerenberg I. Obesity in Europe: prevalence and consequences for use of medical care. Pharmacoeconomics 1994; 5(Suppl 1): 38-44. 9. Wolf AM, Colditz GA. The cost of obesity: the US perspective. Pharmacoeconomics 1994; 5: 34-7. 10.Colditz GA. Economic costs of obesity. Am J Clin Nutr 1992; 55(Suppl 2): 503S-7S. 11.Wirth A. Adipositasfibel. Berlin: Springer 1998. 12.Wirth A. Adipositas. Epidemiologie, Ätiologie, Folgekrankheiten, Therapie. Berlin: Springer 1997. 13.Ernährungsabhängige Krankheiten und ihre Kosten, Schriftenreihe des Bundesministeriums für Gesundheit (German Health Ministry), Band 27, 1993. 14.Colditz GA. Economic costs of obesity and inactivity. Med Sci Sports Exerc 1999; 31(No 11 Suppl): 663S-7S. 15.Colditz GA, Willett WC, Rotnitzky A et al. Weight 552 Obesity Surgery, 10, 2000 gain as a risk factor for clinical diabetes mellitus in women. Ann Intern Med 1995; 122: 481-6. 16.Bray AB. Complications of obesity. Ann Intern Med 1985; 103: 1052-62. 17.Kral JG. Morbid obesity and related health risks. Ann Intern Med 1985; 103: 1043-7. 18.Willett WC, Manson JE, Stampfer MJ et al. Weight, weight change, and coronary heart disease in women: risk within the “normal” weight range. JAMA 1995; 273: 461-5. 19.Rexrode KM, Hennekens CH, Willett WC et al. A prospective study of body mass index, weight change, and risk of stroke in women. JAMA 1997; 277: 1539-45. 20.Gorstein J, Grosse RN. The indirect costs of obesity to society. Pharmacoeconomics 1994; 5: 58-61. 21.Van Gemert WG, Adang EMM, Greve JWM et al. Quality of life assessment of morbidly obese patients: effect of weight-reducing surgery. Am J Clin Nutr 1998; 67: 197-201. 22.Kral JG, Sjöström LV, Sullivan MBE. Assessment of quality of life before and after surgery for severe obesity. Am J Clin Nutr 1992; 55: 611S-4S. 23.Van Gemert WG, Adang EMM, Kop M et al. A prospective cost-effectiveness analysis of vertical banded gastroplasty for the treatment of morbid obesity. Obes Surg 1999; 9: 484-91. 24.Oria HE, Moorehead MK. Bariatric analysis and reporting outcome system. Obes Surg 1998; 8: 48799. (Received May 31, 2000; accepted August 30, 2000)