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Native Hawaiians (NH) represent a unique population where socioeconomic factors have contributed to higher incidence rates of obesity and related comorbidities than in the general population resulting in substantial prescription medication costs. Studies demonstrate that laparoscopic Roux-en-y gastric bypass (LRYGB) surgery results in significant weight loss, improvement of comorbidities, and decreased costs for prescription medications in Caucasians. This study aimed to analyze the effects of LRYGB surgery on Native Hawaiians and their prescription drug costs.
Demographics, baseline body mass index (BMI), comorbidities, preoperative, and postoperative data were analyzed for NH patients who underwent LRYGB between January 2004 and April 2009. Medication costs were determined using the online pharmacy <http://www.drugstore.com>. Generic drugs were selected when appropriate, while vitamins and nutritional supplements were not included in this study.
Fifty (14 Men, 36 women) NH patients had sufficient data and follow-up for analysis. Average preoperative BMI was 49 kg/m2, while at one year follow-up it decreased to 33 kg/m2 (P<.001). This correlates to an average of 61% excess body weight lost (P<.001). The average number of prescription medications decreased from 3.5/patient preoperatively to 1.1/patient at one year (P<.001), equating to a monthly cost savings of US $195.8/patient (P<.001).
LRYGB provided substantial weight loss for morbidly obese NH patients, resulting in significantly less prescription medication use and substantial cost savings. Thus, bariatric surgery for weight management has the potential to improve the overall well-being and lower the financial burden of medical care in socioeconomically disadvantaged communities such as the NH.
Obesity is a growing epidemic across the nation. According to the Centers for Disease Control's 2010 Behavioral Risk Factor Surveillance System Report 36.2% of adults in the United States are classified as overweight (BMI ≥25) and 27.6% as obese (BMI ≥ 30).1,2 In 2006, obese individuals spent an average of USD 1,400 more annually on medical care costs than non-obese people, while in 2008 obesity-associated medical care costs in the United States were estimated to be as high as USD 147 billion annually.1 This epidemic has not spared the state of Hawai‘i; furthermore, it has also been distributed unevenly in terms of ethnicity. According to the 2010 United States Census, out of 1,360,301 people in Hawai‘i, 26% of the total population identified as either partially or solely Native Hawaiian (NH).2 Although only 23% of Hawai‘i's total adult population is obese, over 44% of Native Hawaiians are classified as obese.1,3 Consequently, the obesity epidemic also disproportionately impacts Native Hawaiian patients financially as the burden of their prescription drug costs are higher. Native Hawaiians increasingly have sought bariatric surgery as means of weight loss and comorbidity reduction per the Queen's Medical Center's unpublished data on bariatric surgery utilization in the Native Hawaiian community.
Unfortunately, like other indigenous peoples in the United States, Native Hawaiians suffer from some of the worst health. According to the US Department of Health and Human Services Office of Minority Health, Native Hawaiians have more than twice the prevalence of diabetes and are more than 5.7 times as likely as Caucasians to die from diabetes. Native Hawaiians are also 30% more likely to be diagnosed with hypertension than Caucasians.4 This is compounded by the fact that Native Hawaiians are socioeconomically disadvantaged compared to other ethnicities and have a more difficult time accessing adequate healthcare. According to the 2010 Census Bureau data, Native Hawaiian and Pacific Islander family median income was more than USD 9,800 lower than the median income for non-Hispanic Caucasian families; furthermore, 16% of Native Hawaiian and Pacific Islander families were living at the poverty level compared to only 10% of non-Hispanic Caucasian families.4,5
Laparoscopic Roux-en-y gastric bypass (LRYGB) surgery has proven to result in substantial weight loss and comorbidity improvement or resolution. Studies examining the effects of bariatric surgery have demonstrated concomitant reduction in prescription medication use and cost.6–9 One such study, involving 77 morbidly obese patients, reported a decrease from 2.4 unique prescriptions treating gastroesophageal reflux disease, diabetes mellitus, hypertension, and/or hyperlipidemia to 0.2 unique prescriptions at one year postoperatively. This represented a mean monthly medication cost decrease from USD 196 preoperatively to USD 28 at one year postoperatively.8 Another study on 78 patients showed a reduction from 4.2 to 1.4 unique prescription medications per month per patient for obesity-associated comorbidities at one year after laparoscopic Roux-en-y gastric bypass, equating to a monthly drug cost reduction from USD 368.6 to USD 118.7 per patient, a 68% reduction.9
Overall, Native Hawaiians represent a unique population within the United States which is plagued with high rates of obesity and obesity-associated comorbidities and is at increased risk for negative outcomes due to socioeconomic factors that render them least able to cope with the economic burden of prescription drug costs. No studies as of yet have determined if the effect of laparoscopic Roux-en-y gastric bypass surgery on prescription drug costs can be reproduced in a minority population. This study seeks to determine whether a population like the Native Hawaiians that suffers from higher obesity rates, obesity-associated comorbidities and detrimental socioeconomic factors compared to Caucasians can successfully benefit from laparoscopic Roux-en-y gastric bypass surgery as evidenced by postoperative prescription drug cost reduction.
A retrospective chart review was conducted on Native Hawaiian patients over the age of 18 years undergoing laparoscopic Roux-en-y gastric bypass surgery at a tertiary medical center with a comprehensive, multi-disciplinary surgical weight program between January 2004 and April 2009. Only patients with postoperative follow-up for at least one year were included. Medical records were reviewed for demographic data, height, weight, preoperative comorbidities, medication prescriptions, BMI, and excess body weight (EBW). Native Hawaiian ethnicity was determined by a self-reported questionnaire. Medication prescribed to patients before and after bariatric surgery was documented by nursing staff at the medical center. This study included patients who identified themselves as either part or full Native Hawaiian. Outcome measures included amount of weight lost, changes in the number of prescription medications, and prescription drug cost changes postoperatively. Weight loss was reported as the percentage of excess body weight loss (EWL), which is standard in the bariatric surgery nomenclature. Percent EWL was calculated in the following manner:
% EWL = (preoperative weight − postoperative weight) /(preoperative weight − ideal weight) × 100
Successful weight loss after laparoscopic Roux-en-y gastric bypass was defined as a patient achieving greater than 50% of excess body weight lost (>50% EBW) at one year postoperatively.
Medication costs were determined using the online pharmacy (http://www.drugstore.com) and costs were determined for a 30-day supply of all medications each patient was prescribed. Generic versions of medications were substituted for their name-brand counterparts whenever generics were available in both preoperative and postoperative medication cost calculations in order to ensure the estimated cost savings were truly attributable to the experimental factors of laparoscopic Roux-en-y gastric bypass surgery. Vitamins and nutritional supplements were not included in this study. Statistical analysis was performed using IBM SPSS 16.0 (Somers, NY). Chi-squared test analysis was used for independent variables and Student's T-test analysis was performed for continuous variables, with criteria for statistical significance set as P<.05. This study protocol had been reviewed and approved by the Queen's Medical Center's institutional review board.
Out of 105 Native Hawaiian patients receiving weight loss surgery during the study period, 50 (14 men, 36 women) had sufficient one-year follow up data for analysis. The average preoperative BMI was 49 kg/m2 (±7.3), while average BMI at one-year follow-up was 32.6 kg/m2 (±5.6; P<.001), (Figure 1). The average percentage of preoperative EWL was 61.5% (P<.001). Most of the prescription medications were for, but not limited to, obesity-associated comorbidities such as hypertension, diabetes mellitus, gastroesophageal reflux disease, and polyarthralgia and numbered 3.5 (±2.5) unique prescriptions per patient. At one-year postoperatively, the average number of all prescription medications decreased to 1.1 (±1.1) per patient representing a 67% reduction (P<.001; Figure 2). The average preoperative monthly prescription drug cost was USD 263.1 per patient, while the average cost one year after surgery decreased to USD 67.3 per patient, representing a 74% reduction in prescription drug costs (P<.001) and a calculated annualized cost-savings of USD 2,349.6 per patient (Figure 3). No statistically significant differences between male and female patients were found in terms of their preoperative BMI, postoperative weight loss, or reduction in prescription medication costs.
Native Hawaiians are burdened by the highest rates of obesity and obesity-associated comorbidities in Hawai‘i, compounded by poor socioeconomic factors. Complications of obesity-associated comorbidities in Native Hawaiians are also significantly higher when compared to the Caucasian population, resulting in disproportionately higher morbidity and mortality. This health burden is superimposed on a population that is less able to compensate for this significant disease burden. Native Hawaiians have less access to higher education and are more likely to suffer from poverty when compared to the general population. The Native Hawaiian population as a whole has less income than the general population, and are thus less able to afford health care or address the fiscal consequences of obesity-associated comorbidities.4,5 The high prevalence of morbid obesity coupled with high rates of impoverishment generates high morbidity and mortality that not only diminishes the quality of life for a disproportionately higher number of Native Hawaiians but also underscores the importance of any health cost savings the medical community can provide.
Definitive treatment, rather than long-term management, is a better way to reduce the negative impact of the factors listed above on a population's health while simultaneously lessening their financial burden. Reviews and meta-analyses on bariatric surgery have found Roux-en-y gastric bypass surgery to be effective in inducing weight loss in obese patients, with the mean percentage of excess weight loss for patients to be at approximately 61.6% at one year.6 Concurrently, a substantial majority of patients with diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea experience either significant improvement or complete resolution of the listed comorbidities following surgery.7 Similar studies have shown that this reduction in weight results in substantial prescription drug cost reductions as these comorbidities resolve. Prescription drug cost-savings of 57% to 85% have been demonstrated at one-year follow-up after laparoscopic Roux-en-y gastric bypass surgery.7–9
These studies, however, were conducted on an undifferentiated obese population with no consideration for the degree of socioeconomic impoverishment and ethnicity. This is a significant shortcoming as socioeconomically disadvantaged populations would most stand to benefit from any measure that reduces the health and financial burden of obesity. Thus, our study provides a unique opportunity to observe how laparoscopic Roux-en-y gastric bypass surgery can positively impact the health and economic well-being of a socioeconomically disadvantaged group like the Native Hawaiian population.
With an average excess weight loss percentage of 61% and a 74% reduction in prescription drug costs, our study reveals that Native Hawaiians stand to substantially benefit from laparoscopic Roux-en-y gastric bypass surgery in a manner equal to that of Caucasians (Table 1). This finding suggests that while disadvantaged ethnic populations may be disproportionately at risk for obesity and its comorbidities, they may stand to benefit more from laparoscopic Roux-en-y gastric bypass surgery as the savings represent a larger portion of their income.
A few limitations must be noted. We did not compare the drug cost reduction in Native Hawaiians to patients of other ethnicities who underwent bariatric surgery. This drawback extends beyond the scope of this current study which focuses solely on the expenditure for prescription medications by Native Hawaiians. Secondly, we did not compare the cost/savings ratio for the price of bariatric surgery to the financial benefit from the reduction in medication. However, the price for surgery varies widely from patient to patient, as well as by location and physician experience. Therefore, this latter issue would be poorly generalizable to a larger population, even within the same institution. Third, the analysis conducted in this study was limited to patients who had sufficient one-year follow up data. A lack of follow up may be related to suboptimal compliance with recommendations, thereby correlating with poorer outcomes.
Our study demonstrates that laparoscopic Roux-en-y gastric bypass surgery is a very effective way to treat obesity in Native Hawaiians while simultaneously relieving them of the financial burden of prescription drug costs. Prescription drug cost savings achieved by Native Hawaiians were comparable to those achieved by Caucasian counterparts in other studies. Furthermore, if current trends in obesity for the general population continue unabated, the increased disease burden of obesity will no longer be limited to minorities but will represent the general condition of the population as a whole. It is likely that the disease and socioeconomic burden that Native Hawaiians face today will be the exact same burdens that the general population will have to face in the future. Our disadvantaged communities may act as a leading indicator of the health and socioeconomic concerns of the nation as a whole, especially in a challenging economic climate where an increasingly larger percentage of the general population is becoming unable to manage the high costs of healthcare in America. As such, the more we understand and learn from the Native Hawaiian population, the better prepared we will be to deal with and intervene to reduce obesity and obesity-associated comorbidities. Our study demonstrates that although underserved populations may be at greater risk of obesity and its associated comorbidities, they in fact stand to benefit equally from laparoscopic Roux-en-y gastric bypass surgery.
The authors do not have any conflicts of interest to report.