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Surgical considerations

Cost and weight-loss greatest consideration for bariatric surgery

The study identified three unobserved subgroups: cost-sensitive, benefit-focused and procedure-focused

Patients are likely to base their weight loss surgery choice on expected out-of-pocket costs and how much weight they can lose but not the risk of complications or recovery time, according to a study by researchers from the University of Michigan.

In the study, ‘Patient Preferences for Bariatric Surgery: Findings From a Survey Using Discrete Choice Experiment Methodology’, published in JAMA Surgery, Michigan Medicine researchers used a methodology that helps understand consumer preferences before products hit the market to explore how bariatric surgery recipients make decisions and process complex information.

"Instead of asking patients about the reasons for or against particular procedures, we asked patients to tell us what procedure characteristics mattered to them the most," explained lead author, Dr Michael Rozier, who studied health care management and policy at the University of Michigan. Rozier partnered with senior author, Dr Lisa Prosser, professor of pediatrics at the U-M Medical School and member of U-M Institute for Healthcare Policy and Innovation, on the study of 800 adults who were pursuing bariatric surgery.

The study methodology, called conjoint analysis, has been used to gain insight on how people decide on vaccinations, new born screenings and other health choices. In this case, it helped researchers learn what aspects of bariatric surgery patients’ value.

Surgical options for weight loss vary considerably in risks and benefits, but the relative importance of procedure-associated characteristics in patient decision making is largely unknown. This study was undertaken in order to identify patient preferences for risks, benefits, and other attributes of treatment options available to individuals who are candidates for bariatric surgery.

The researchers surveyed the patients via an internet-based survey administered to patients recruited from bariatric surgery information sessions in the State of Michigan. Each procedure was described by the following set of attributes: (1) treatment method, (2) recovery and reversibility, (3) time that treatment has been available, (4) expected weight loss, (5) effect on other medical conditions, (6) risk of complication, (7) adverse effects, (8) changes to diet, and (9) out-of-pocket costs. Participants chose between surgical profiles by comparing attributes. Survey data were collected from May 2015 to January 2016 and analysed from February to June 2016.

From the 815 respondents (79.9% women; mean [SD] age, 44.5 [12.0] years), profiles of hypothetical procedures that included resolution of medical conditions (coefficient for full resolution, 0.229 [95% CI, 0.177 to 0.280; p<0.001]; coefficient for no resolution, −0.207 [95% CI, −0.254 to −0.159; p< 0.001]), higher total weight loss (coefficient for each additional 20% loss, 0.185 [95% CI, 0.166 to 0.205; p<0.001]) and lower out-of-pocket costs (coefficient for each additional $1000, −0.034 [95% CI, −0.042 to −0.025; p<0.001]) were most likely to be selected.

Younger respondents were more likely than older respondents to choose treatments with higher weight loss (coefficient for loss of 80% excess weight 0.543 [95% CI, 0.435-0.651] vs 0.397 [95% CI, 0.315-0.482]) and were more sensitive to out-of-pocket costs (coefficient for US$100 out-of-pocket costs, 0.346 [95% CI, 0.221-0.470] vs 0.262 [95% CI, 0.174 to 0.350]; coefficient for US$15,000 in out-of-pocket costs, −0.768 [95% CI, −0.938 to −0.598] vs −0.384 [95% CI, −0.500 to −0.268]). Marginal willingness to pay indicated respondents would pay US$5470 for losing each additional 20% of excess body weight and US$12,843 for resolution of existing medical conditions, the most desired procedure attributes.

Latent class analysis identified the following three unobserved subgroups: cost-sensitive (most concerned with costs); benefit-focused (most concerned with excess weight loss and resolution of medical conditions); and procedure-focused (most concerned with how the treatment itself worked, including recovery and reversibility).

The most commonly performed bariatric surgery, sleeve gastrectomy, did not fit the top qualities that surveyed patients waned from their surgery - compared to gastric bypass, patients who have sleeve gastrectomy lose less weight, on average during the first year.

"We know there may be slightly better weight loss and increased comorbidity resolution with bypass, so recommending sleeve gastrectomy may be somewhat different than what patients in this study valued," said study co-author, Dr Amir Ghaferi, a bariatric surgeon at Michigan Medicine and director of the Michigan Bariatric Surgery Collaborative. This unique data is important in guiding conversations and expectations, added Ghaferi who carries out health services research as a member of U-M IHPI. Those discussions may include coming to terms with the potential for weight regain in the years after bariatric surgery.

The team is set to embark on an additional study to gain surgeon responses to the same survey.

"The new data may help providers understand where their intuition might be different from what patients want," said Prosser, director of the U-M's Child Health Evaluation and Research Center

The survey's findings on financial concerns underscore an existing gap: health care providers are rarely trained how to discuss the out-of-pocket costs of given procedures with their patients.

"In fact, we often discourage providers from entering into that area of conversation because we don't want money to influence the relationship between providers and patients," saud Rozier, now an assistant professor of health management and policy at the Saint Louis University College for Public Health and Social Justice. But it matters, he added, especially among patients ages 18 to 44. "Our results show it matters a great deal to patients. So we probably need to figure out an appropriate way to incorporate cost into conversations providers have with their patients."

“The decision to choose one weight loss method over another is complex and relies on factors related to the procedures, patient preferences, and how physicians frame choices. This study provides information on which characteristics are most important from a patient perspective and that patients demonstrate heterogeneity in preferences,” the authors concluded. “We often know why patients select one procedure over another, but the hypothetical trade-offs in this study give us the relative importance of these attributes. Recognising that patients will understand these trade-offs differently can improve the discussion between patient and physician on the risks and benefits of various weight loss options.”

To access this paper, please click here

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