Cost-Effectiveness of Bariatric Surgery for the Treatment of Obesity: A Cost-Utility Analysis at International Metabolic and Bariatric Centre

By Mushtaq Ahmad, Maria Alamgir, Waqar Ahmad, Mah Noor Dad Khan, Abdul Haseeb Sahibzada

Affiliations

1. Department of Bariatric Surgery, International Metabolic and Bariatric Centre, Afridi Medical Complex, Peshawar, Pakistan

doi: 10.29271/jcpsp.2025.07.917

ABSTRACT
Objective: To determine the cost-effectiveness of bariatric surgery in comparison to conservative treatment options in managing obesity and its secondary complications.
Study Design: A cross-sectional survey.
Place and Duration of the Study: Department of Bariatric Surgery, International Metabolic and Bariatric Centre, Afridi Medical Complex, Peshawar, Pakistan, from August 2019 to June 2024.
Methodology: Patients undergoing bariatric surgeries including gastric bypass or sleeve gastrectomy were included in the surgical group; those getting routine medical care for obesity during the same time period were included in the non-surgical group. Data on preoperative and postoperative medical expenses for the surgery cohort was taken from medical records and hospital billing systems during a five-year period. Frequencies and percentages for categorical variables and mean ± standard deviation for continuous variables in both groups were calculated as part of the descriptive analysis.
Results: A total of 5,743 patients who underwent bariatric surgery were included in the study. The average cost of bariatric surgery, including preoperative treatment and postoperative follow-up, was PKR 670,000 per person. Over a five-year period, this cost increased to PKR 904,290. On the other hand, the non-surgical group's average five-year total cost for managing obesity-related comorbidities was PKR 1,797,988.
Conclusion: Bariatric surgery is a cost-effective intervention in managing obesity and its associated complications in the long term as compared to conventional treatment options and provides an increase in the healthcare cost reduction and enhances health status, higher quality of life, and increased QALYs.

Key Words: Bariatric surgery, Cost-effectiveness, Cost-utility analysis.

INTRODUCTION

Globally, the overweight and obesity epidemic has grown into a major public health issue. According to World Health Organisation (WHO) estimates there were over 1.5 billion overweight adults in 2008.¹ Over 500 million people aged ≥20 years were obese. WHO projects that more than 700 million adults will be obese and that there will be 2.3 billion overweight adults by 2045.² Obesity significantly increases the risk of cancer, respiratory conditions, cardiovascular disease, and stroke, all of which significantly reduce life expectancy and quality along and is associated with increased economic burden and expenditure.^3,4

In addition to its immediate health effects, obesity places a crippling financial strain on people and healthcare systems due to rising medical expenses for treatments, hospital stays, prescription medicines, and long-term illness management.⁵ According to an analysis of 33 U.S. studies, the direct medical expenditures of obesity were more than six times higher per person than those of overweight, with an estimated total cost of around $114 billion.⁶

Despite being regarded as the cornerstone of obesity mana-gement, lifestyle interventions including diet, exercise, and behavioural therapy are mostly ineffective at helping morbidly obese people lose weight and maintain in long term.⁷ Bariatric surgery has been the most effective and sustainable intervention in this population. As well as promoting significant changes in weight loss, key bariatric surgeries such as adjustable gastric banding (AGB), sleeve gastrectomy (SG), and gastric bypass (GB) contribute to significant changes in or remission of comorbidities of obesity. For instance, several patients recover cardiovascular function and mobility after some months of surgery and stabilise their blood glucose levels.⁸

Despite the available evidence suggesting that bariatric surgery is effective in both the treatment of obesity and the amelioration of obesity-related complications, surgery continues to be underutilised. As it has been shown, only 1% of the population which is now considered eligible for bariatric surgery, actually go for an operation and among various factors that may constitute an influence, the question concerning its financial characteristics might be mentioned.⁹ This view, however, ignores the larger financial picture: Although surgical intervention may initially seem costly, its value becomes evident when compared to the significantly higher expenditure incurred in managing obesity-related diseases. For example, managing type 2 Diabetes only in terms of medicine including insulin, visits to the doctor and complications such as retinopathy or nephropathy can cost tens of thousands of dollars per patient per year. Whereas Bariatric surgery is a one-time extensive cost throughout the treatment process, which minimises or eliminates such recurrent costs.^10,11 Moreover, bariatric surgery has financial advantages other than its immediate medical expenses. Patients frequently report higher quality of life, decreased absenteeism, and increased productivity, all of which support economic stability for both individuals and society.¹²

This study aimed to determine the cost-effectiveness of bariatric surgery in comparison to conservative treatment options in managing obesity and its secondary complications.

METHODOLOGY

This retrospective economic analysis, which examined data from 2019 to 2024, was carried out at the Department of Bariatric Surgery, International Metabolic and Bariatric Centre, Afridi Medical Complex, Peshawar, Pakistan, over a five-year period. The study received ethical approval from the Institutional Review Board (Ref. No: 653/DME/AMC). Prior to data inclusion, all participants provided written informed consent.

Patients with a body mass index (BMI) of 40 kg/m² or higher without any comorbidity, or with a BMI of 35 kg/m² or higher with at least one obesity-related comorbidity, such as type 2 Diabetes, hypertension, or obstructive sleep apnoea, were included in the study. The patients had to be between the ages of 18 and 65 years. Patients undergoing bariatric surgeries, such as gastric bypass or sleeve gastrectomy, were included in the surgical group; those getting routine medical care for obesity during the same time period were included in the non- surgical group. Individuals with a history of previous bariatric or revision surgery, inadequate follow-up data, or incomplete medical records were not included.

Clinical and economic factors were considered in the data collection procedure. Data on preoperative and postoperative medical expenses for the surgery cohort was taken from medical records and hospital billing systems during a five-year period. The expenditure on treating obesity-related comor-bidities, such as prescription medicines, diagnostic tests, hospital stays, and outpatient visits, was also examined for the same period for the non-surgical group.

Total cost was defined as direct and indirect healthcare costs in this study. The hospitalisation, outpatient services, surgical operations, laboratory tests, and prescribed medications constituted the direct healthcare cost while productivity loss, number of absences from work, and disability costs composed the indirect healthcare cost. Therefore, by using the total healthcare cost and the qulaity-adjusted life years (QALYs) which were achieved, the cost-utility ratio of a more comprehensive measure of the value of the intervention was calculated to determine the cost-effectiveness of bariatric surgery.

Data were analysed by using IBM SPSS Statistics version 26. As for the checking of differences in expenses and outcomes between the groups, statistical analysis was conducted. Frequencies and percentages for categorical variables and mean ± standard deviation (SD) for continuous variables in both groups were calculated as a part of the descriptive analysis.

RESULTS

Out of 5,743 patients included in the study, 3,576 (62%) of the patients in the surgical group were females. The average age was 40 ± 8.12 years. This group's baseline BMI was 46 ± 6 kg/m². Comorbidities associated with obesity, including type 2 Diabetes 3,389 (59%), hypertension 3,025 (53%), and obstructive sleep apnoea 2,323 (40%), were similar in both groups at baseline (Table I).

Table  I:   Baseline  characteristics  of  patients.

Variables	Frequencies (%)
Total patients	5,743 (100%)
Gender distribution
Female	3,576 (62%)
Male	2,167 (38%)
Average age (years)	40 ± 8.12
Baseline BMI (kg/m2)	46 ± 6.05
Comorbidities
Type 2 Diabetes	3,389 (59%)
Hypertension	3,025 (53%)
Obstructive sleep apnoea	2,323 (40%)

Table  II:  QALYs  and  cost  per  QALY  for  surgical  vs. non-surgical  groups.

Groups	Average QALYs (mean ± SD)	Cost per QALY (PKR)
Surgical group	3.8 ± 0.14	236,842
Non-surgical group	2.5 ± 0.17	720,000

The average cost of bariatric surgery, including preoperative treatment and postoperative follow-up, was PKR 670,000 per person. Over a five-year period, this cost increased to PKR 904,290. On the other hand, the non-surgical group's average five-year total cost for managing obesity-related comorbi- dities was PKR 1,797,988. This amount covered medical costs associated  with  comorbidities  as  shown  in  Figure  1.

A total of 4,135 (72%) of patients experienced type 2 Diabetes remission five years following surgery, compared to 1,149 (20%) in the group that did not undergo surgery. Similarly, 861 (15%) of patients in the non-surgical group experienced a resolution of hypertension, while 3,733 (65%) of patients in the surgical group had a resolution. Only 574 (10%) of patients in the non-surgical group showed improvement in their obstructive sleep apnoea symptoms, compared to 3,331 (58%) of surgery patients as shown in Figure 2.

The average QALYs obtained during a five-year period were 2.5 ± 0.4 for the non-surgical group and 3.8 ± 0.5 for the surgery group. The surgical group's average cost per QALY was PKR 236,842, which was substantially less than the non-surgical group's cost per QALY of PKR 720,000 (Table II).

Figure 1:  Five-year cost breakdown of non-surgical management of obesity-related  comorbidities.

Figure 2: Comparison of clinical outcomes between surgical and non- surgical  groups.

DISCUSSION

This study provides a comprehensive comparison of the healthcare costs, comorbidities, and quality of life between obese patients who underwent bariatric surgery and those who did not, over a five-year period. The findings of this study emphasise the substantial cost savings and health benefits associated with bariatric surgery compared to non-surgical management of obesity and its related comorbidities.

According to the results of this study, patients in the bariatric surgery group had an average expense of 904,290 PKR for their medical expenses during five years while the patients in the non-surgical group spent 179,7988 PKR. These findings are in line with the extensive literature that has indicated that bariatric surgery makes long-term savings on the costs of healthcare since there is likely to be a less frequent demand for other medical treatments in future. For example, Terranova et al. showed that bariatric surgery reduced both the frequency of utilisation of overall healthcare and the costs associated with comorbidities mainly due to type 2 Diabetes and hyper- tension.¹³ This reduction in hospitalisations as well as medication cost stated in the study is consistent with the systematic review study of Lopes et al. that revealed a reduction in hospital admission and long-term pharmacological therapy among bariatric surgery patients.¹⁴

One of the main reasons for increased costs in the non-surgical group was the treatment of obesity-related diseases in the individuals’ lifetime. Accordingly, cost shares of the major diseases were Diabetes, hypertension, and fatty liver disease. However, the results of Jacobsen et al. suggest that the non-surgical treatment of these conditions forms part of a long cycle of medications, regular check-ups, and sometimes hospitalisations, thus making it expensive. That is why, it is necessary to develop a better and long-term treatment approach for obesity itself and for the diseases with which it is associated, including bariatric surgery.¹⁵

Bariatric surgery significantly improved the symptoms of obesity-associated diseases, including type 2 Diabetes, hypertension, and obstructive sleep apnoea in 4,135 (72%) of patients who experienced Diabetes remission and 3,733 (65%) of patients who had hypertension resolved. These figures are in concordance with another systematic review done by Sheng et al. showing that the remission of type 2 Diabetes post-bariatric surgery lies in 30 to 90% depending on the surgery type. Likewise, the enhancement in obstructive sleep apnoea as shown in the present study with an increase of 58% is also efficiently supported by Al Oweidat et al. which reveal bariatric surgery with an improvement rate of 65% of the same affliction, marking it as a solution to the concurrent condition of obesity.^16,17 However, the non-surgical group only gained these very small improvements in these conditions, specifically 1,149 (20%) of the patients had a change of any kind in type 2 Diabetes and 574 (10%) experienced improvement in sleep apnoea. This discrepancy also facilitates the assertion made herein that non-surgical weight loss interventions for managing obesity- associated complications provide poor outcomes in the long-term weight loss and amelioration of obesity-mediated diseases. Rees et al. have found out that comorbidities can be controlled by lifestyle modifications and medications, but what bariatric surgery has for long term effects and remission is incomparable.¹⁸

Overall, this study established that the bariatric surgery group experienced a significant improvement in quality of life with an average gain of 3.8 QALYs, within the five-year study period while the non-surgical group had an average gain of 2.5 QALYs. This increase in QALYs shown for the surgical group can be explained by a number of other studies such as the one by Hachem et al. For instance, they found out that bariatric surgery enhances the combined physical and mental health which enhances the quality of life.¹⁹ Earlier studies, such as that conducted by Pyykko et al., have indicated such post-surgical improvements experienced by bariatric surgery patients, including enhancements to psychological health, where patients have reduced prejudice, better self-regard, and social adjustment.²⁰

This study was performed in a single tertiary care hospital in Pakistan that has its own resource constraints which may make this study’s finding less generalisable to other zones or other healthcare settings with better resources. Potential future research should be conducted on a larger number of centres, with a more heterogeneous patient population, over a longer time horizon and with a wider range of indirect costs to offer a more realistic idea of the advantages of bariatric surgery in the long  term.

CONCLUSION

The results of this study concluded that bariatric surgery is a cost-effective intervention in managing obesity and its asso-ciated complications in the long term as compared to conventional treatment options and also provides an increase in healthcare cost reduction and enhances health status, higher quality of life, and increased QALYs.

ETHICAL  APPROVAL:
The ethical approval was obtained prior to the commencement of research from the Institutional Review Board of Afridi Medical Complex, Peshawar, Pakistan (Ref No: 653/DME/AMC).

PATIENTS’  CONSENT:
Informed consent was obtained from all participants before enrolment in the study.

COMPETING  INTEREST:
The  authors  declared  no  conflict  of  interest.

AUTHORS’  CONTRIBUTION:
MA: Conception, design, manuscript writing, and critical review.
MA: Analysis, interpretation of data, and manuscript writing.
WA: Conception, design acquisition, and critical review.
MNDK: Data collection and statistical analysis.
AHS: Analysis and interpretation of data, manuscript writing, and critical review.
All authors approved the final version of the manuscript to be published.

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