Cost-Effectiveness of Bariatric Surgery Prior to Posterior Lumbar Decompression and Fusion in an Obese Population with Degenerative Spondylolisthesis

Abstract

Study Design. Cost-effectiveness analysis. Objective. To determine if bariatric surgery prior to posterior lumbar decompression and fusion (PLDF) for degenerative spondylolisthesis (DS) is a cost-effective strategy. Summary of Background Data. Obesity poses significant perioperative challenges for DS. Treated operatively, obese patients achieve worse outcomes relative to non-obese peers. Concomitantly, they fare better with surgery than with nonoperative measures. These competing facts create uncertainty in determining optimal treatment algorithms for obese patients with DS. The role of bariatric surgery merits investigation as a potentially cost-effective optimization strategy prior to PLDF. Methods. We simulated a Markov model with two cohorts of obese individuals with DS. 10,000 patients with body mass index (BMI) more than or equal to 30 in both arms were candidates for both bariatric surgery and PLDF. Subjects were assigned either to (1) no weight loss intervention with immediate operative or nonoperative management (''traditional arm'') or (2) bariatric surgery 2 years prior to entering the same management options (''combined protocol''). Published costs, utilities, and transition probabilities from the literature were applied. A willingness to pay threshold of $100,000/QALY was used. Sensitivity analyses were run for all variables to assess the robustness of the model. Results. Over a 10-year horizon, the combined protocol was dominant ($13,500 cheaper, 1.15 QALY more effective). Changes in utilities of operative and nonoperative treatments in non-obese patients, the obesity cost-multiplier, cost of bariatric surgery, and the probability of success of nonoperative treatment in obese patients led to decision changes. However, all thresholds occurred outside published bounds for these variables. Conclusion. The combined protocol was less costly and more effective than the traditional protocol. Results were robust with thresholds occurring outside published ranges. Bariatric surgery is a viable, cost-effective preoperative strategy in obese patients considering elective PLDF for DS.

Obesity and Spine Surgery: A Qualitative Review About Outcomes and Complications. Is It Time for New Perspectives on Future Researches?

“…Multivariate regression analyzes revealed that undergoing BS before an elective ACDF was associated with a significantly reduced risk of pulmonary, renal and cardiac complications, sepsis and 90-day readmissions. 68 Other papers supported these results 58 , 91 , 180 although some results questioned the real measured effect of a proper weight loss. 71 , 96 These results, together with the presented literature, suggest that a multidisciplinary strategy could play a key role in obese patients.…”

Cost‐Effectiveness of Surgical Weight‐Loss Interventions for Patients With Knee Osteoarthritis and Class III Obesity

“…Our findings are consistent with prior literature suggesting that bariatric surgery is cost‐effective in various other patient populations (46). Bariatric surgery has previously been shown to be cost‐effective or cost saving for patients who have a BMI ≥40 kg/m 2 and degenerative spondylolisthesis or hip OA (40,47,48). Alsumali et al reported RYGB as preferred over LSG for populations with a BMI >40 kg/m 2 , while LSG is preferred when the initial BMI is <40 kg/m 2 (40).…”