Treatments for severe obesity include lifestyle modifications (exercise, diet), use of medications (e.g., orlistat, phentermine), endoscopically-placed devices (e.g. gastric balloons), and bariatric surgery. Most nonsurgical treatments fail to achieve long-term weight control.1 In contrast, bariatric surgery is perceived to be an effective obesity treatment, especially in the long term, and reduces morbidities.2-4 It has become the preferred therapy for persons with severe obesity refractory to medical therapy.5 According to a National Institutes of Health (NIH) Panel, bariatric surgery is indicated for patients with a body mass index (BMI) of 40 Kg/m2 or more (obesity grade 3), or a BMI of 35 Kg/m2 or more (obesity grades 2 or 3) with an obesity-related comorbidity who have not responded to lifestyle modification therapy.6 Bariatric surgery also has been evaluated in adults with moderate obesity (obesity grade 1, BMI 30-34.9 Kg/m2).7
Bariatric surgical procedures result in anatomic manipulations of the gastrointestinal tract; and more recently similar anatomic modifications have been achieved through the use of endoscopic technologies. Many adults age 65 and older meet indications for bariatric treatment, but the utilization of these procedures remains low.8, 9 Based on the U.S. National Health and Nutrition Examination Survey (NHANES), in 2012 35 percent of people 60 years and older had a BMI of 30 Kg/m2 or more, 14 percent had a BMI of 35 Kg/m2 or more, and six percent had a BMI of 40 Kg/m2 or more, with a women-to-men ratio of almost 2:1 within each category.10 Thus, a large number of Medicare-eligible people in the U.S. likely meet NIH indications for either surgical or endoscopic bariatric therapy.
We conducted a technology assessment to objectively summarize and appraise the current evidence regarding the effectiveness and safety of bariatric therapies in the Medicare-eligible population.