By Anne Harding
NEW YORK (Reuters Health) - 1/3/2019
Bariatric surgery could extend life expectancy and quality-adjusted life-years (QALY) cost-effectively in overweight and obese patients with nonalcoholic steatohepatitis (NASH), a new modeling study suggests.
"Our study provides strong evidence that bariatric surgery could be a promising option and we need more studies in this area, especially ones that can provide direct evidence about the effectiveness of this intervention," Dr. Jagpreet Chhatwal of the Massachusetts General Hospital Institute for Technology Assessment in Boston told Reuters Health by phone. "This will be an important population to consider."
Bariatric surgery is riskier for patients with cirrhosis, Dr. Chhatwal and his team note in JAMA Network Open, online February 22, and insurers typically do not cover it for individuals with BMIs below 35. Weight loss with diet and exercise can improve outcomes in NASH, they add, but is difficult to maintain.
The authors used a Markov-based state-transition model to conduct a virtual trial comparing laparoscopic sleeve gastrectomy (SG), Roux-en-Y gastric bypass (GB) and intensive lifestyle intervention (ILI) to standard care for overweight and obese patients with NASH and compensated cirrhosis.
SG increased QALYs by 0.263 to 1.180, depending on a patient's baseline weight. QALYs rose from 0.263 to 1.207 with GB versus usual care, and from 0.004 to 0.216 with ILI.
Life years increased 0.693 to 1.930 with SG, 0.694 to 1.947 with GB, and 0.012 to 0.114 with ILI.
Expected life years with usual care were 12.9 for overweight patients, 11.9 with mild obesity, 11.0 with moderate obesity and 10.1 with severe obesity, while QALYs were 6.4, 5.8, 5.2 and 4.6, respectively.
SG was cost-effective at any level of overweight or obesity, the authors found, with an incremental cost-effectiveness ratio (ICER) of $66,119 per QALY for overweight patients, $18,716 per QALY in mildly obese patients, $10,274 in moderately obese patients, and $6,563 per QALY in severely obese patients.
In order for GB to be cost-effective, the $28,734 cost of the procedure would need to be reduced by $4,889 in mildly obese patients, $3,189 in moderately obese patients, and $2,289 in severely obese patients. There were fewer QALYs with GB than SG in overweight patients, so lowering the cost of the surgery would not make it cost-effective, the researchers say.
Bariatric surgery in NASH patients would likely be more cost-effective than the study estimates, Dr. Chhatwal noted, given that weight loss can reduce other comorbidities such as diabetes and hypertension.
"With modern-day bariatric surgery's exceedingly favorable safety profile, NASH cirrhosis should not preclude an evaluation for surgery," Dr. Seth A. Waits and colleagues at the University of Michigan, Ann Arbor, write in an editorial accompanying the study. "The effects are too great and the patients are too sick to throw the opportunity away because the risks are 'too high.'"
SOURCE: [https://bit.ly/2NAjeKZ and https://bit.ly/2Uh1DdC](https://bit.ly/2NAjeKZ and https://bit.ly/2Uh1DdC)
*JAMA Netw Open *2019.
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