Bariatric Surgery Cost-Effective for Patients with Obesity, Cirrhosis

Bariatric surgery may be cost-effective for improving survival in patients with obesity and cirrhosis, according to findings from a recent study.1

Leveraging US Veterans Health Administration (VHA) data for patients from 128 VHA medical centers, the retrospective cohort economic evaluation study found sleeve gastrectomy and Roux-en-Y gastric bypass were associated with an increase in expected survival versus lifestyle modification alone. Additionally, both interventions were cost-effective within a 10-year horizon at a willingness-to-pay threshold of $100,000 per quality adjusted life-year (QALY).1

Obesity is estimated to affect >40% of US adults, most of whom also have metabolic dysfunction-associated steatotic liver disease (MASLD) or metabolic dysfunction-associated steatohepatitis (MASH) and are therefore at risk of developing cirrhosis. Historically, weight loss has served as the mainstay of treatment. Even with the availability of pharmacologic treatment following the accelerated approval of Madrigal Pharmaceuticals’ resmetirom (Rezdiffra) in 2024, lifestyle interventions continue to play a critical role in disease management.2,3

“While lifestyle interventions are critical for facilitating weight loss, potentially augmented by weight loss pharmacotherapy, bariatric surgery has the strongest long-term data supporting clinically significant and sustained weight loss, as well as improvements in obesity-related comorbidities and overall survival,” David Kaplan, MD, MSc, a professor of medicine and section chief of hepatology at the Hospital of the University of Pennsylvania, and colleagues wrote.1 “Despite its proven effectiveness, uptake remains low, in part because of patient-related factors, including a lack of awareness of the benefits and patient preference for nonsurgical management.”

To evaluate the impact of bariatric surgery on outcomes and cost-effectiveness among patients with obesity, investigators retrospectively examined VHA data for a cohort of patients who were referred to the US Department of Veterans Affairs lifestyle modification program, MOVE!, and completed ≥2 visits, or who underwent bariatric surgery between September 2008 and September 2020.1

For inclusion, patients were required to be ≥18 years of age with a body mass index (BMI) >35 or with a BMI >30 and ≥1 major metabolic comorbidity. Risk set matching was used to match bariatric surgery cases in a 1:5 ratio with nonsurgical controls.1

The primary outcome was the incremental cost-effectiveness ratio (ICER) of bariatric surgery vs MOVE! over the course of 10 years, with a willingness-to-pay threshold of $100,000 per QALY gained considered cost-effective based on prior literature.1

The final cohort included 4301 sleeve gastrectomy, 1906 Roux-en-Y gastric bypass, and 31,055 MOVE! participants, among whom 64, 8, and 354, respectively, had cirrhosis. Among the cohort, the median age was 52 (interquartile range [IQR], 44 to 59) years and the majority of participants were male (68.7%).1

For the entire cohort, peri-interventional year 0 costs were approximately $83,528 greater among patients undergoing surgical treatment for weight loss relative to nonsurgical controls. Over 10 years, the cumulative cost modeled for surgery patients was $263,487 (95% CI, $247,246 to $279,727) compared with $179,262 (95% CI, $167,435 to $191,089) for controls. Among patients with cirrhosis, investigators noted costs were increased but with a smaller differential in peri-intervention costs ($69,847).1

Additionally, they pointed out bariatric surgery was cost-effective at a willingness-to-pay threshold of $100,000 per QALY among patients with cirrhosis.1

Further analysis revealed bariatric surgery was associated with longer observed survival (9.67 years; 95% CI, 9.64 to 9.71) than participation in the MOVE! program (9.46 years; 95% CI, 9.44 to 9.48) (P <.001). Although the observed increase in survival was more pronounced among patients with cirrhosis, investigators noted this trend did not meet statistic significance (9.09 years; 95% CI, 8.53 to 9.57 vs 8.23 years; 95% CI, 7.91 to 8.55; P = .08).1

Accounting for costs borne within either the perioperative year or the perioperative year plus the following year, the ICER for surgery was $159,813 for the overall cohort. However, investigators pointed out surgery was cost-saving among patients with cirrhosis (ICER, −$13,395).1

“Bariatric surgery is associated with improved survival and is cost-effective up to 10 years after surgery in the VA population, including patients with cirrhosis,” investigators concluded.1 “Despite higher costs observed over 10 years, the benefits in terms of survival and quality of life may justify the investment, particularly when considering the long-term health improvements and potential reductions in obesity-related comorbidities.”

References

1. Bansal S, Bader A, Mahmud N, et al. Survival and Cost-Effectiveness of Bariatric Surgery Among Patients With Obesity and Cirrhosis. JAMA Surg. doi:10.1001/jamasurg.2025.0490

2. National Center for Health Statistics. Obesity and Severe Obesity Prevalence in Adults: United States, August 2021–August 2023. September 2024. Accessed April 1, 2025. https://www.cdc.gov/nchs/products/databriefs/db508.htm

3. Brooks A. Resmetirom (Rezdiffra) Receives Historic FDA Approval for Noncirrhotic NASH. HCPLive. March 14, 2024. Accessed April 1, 2025. https://www.hcplive.com/view/resmetirom-rezdiffra-receives-historic-fda-approval-for-noncirrhotic-nash