Cirurgia bariátrica: mortalidade, utilização de serviços e custos. Estudo de caso em uma grande operadora do sistema de saúde suplementar no Brasil

Abstract

Introduction: Morbid obesity has been identified as a major epidemic in developed countries. In Brazil, the numbers are alarming, mainly due to the growth of cases in just a few years. At present, it affects 0.64% of people aged 20 years and more, totaling more than 600 thousand individuals. Once morbidly obese, the individual has little chance of success undergoing conservative treatment including diet, exercise,change of life style and medication. Bariatric surgery takes place as an attractive and unique resolution for both morbid obesity itself and related comorbidities, such as hypertension and diabetes. In Brazil, the Unified Health System (SUS) provides full coverage for bariatric surgery for all who meet the criteria for designation. However, with a few operational capacity and reduced budget, only a small number of individuals have been operated on so far. The private supplementary health in Brazil,with some 40 million Brazilians insured, has, over the years, achieved a much greater number of individuals. Purposes: The objectives of this dissertation were to assess the 30-day mortality rate after bariatric surgery and hospital length of stay and identify associated variables for all patients operated between 2004 and 2007. In a cohort of patients operated on in 2005, we analyzed the use of health services by type and its costs, one year before and after bariatric surgery. Method: Firstly, the 30-day mortality rate after the surgery, length stay and the associated variables were calculated and compared with national and international data on the same subject. Factors associated with mortality and longer length stays were investigated using multiple logistic regression. The second study evaluated healthcare utilization and associated costs of patients assisted by a large health maintenance organization (HMO), one year before and one year after surgery. Multiple logistic regressionmodels were developed to identify factors associated with high use and high cost profiles. Results: In the first study, 2,167 patients were followed up. The mortality rate up to the 30th day after the surgery for this group was 0.64%. Mortality was highly related to age > 50 years, BMI > 50kg/m² and surgeons experience of less than 20 bariatric surgeries/per year. Longer hospital stay was associated with the same factors plus the presence of hypertension before surgery. In the second study, the costs associated with healthcare utilization were significantly higher in thepostoperative period, with twice the number of hospitalizations, more medical consultations and exams. These findings did not consider corrective plastic surgeries which are only available after one year of the bariatric surgery and stabilized weight loss. Conclusions: The mortality and length stay for bariatric surgery are consistent with data from international studies, and much lower than the rates obtained frompatients operated on by the public health system in Brazil. The greater use of medical services in the postoperative period and higher associated costs are worrying as bariatric surgery is currently the only alternative treatment for the over 600 thousand morbid obese Brazilians. New alternatives must be developed and prevention reinforced in order to reverse the current trend of increasing obesity in the country.