OBJECTIVES : Obesity is a health problem with major economic consequences. Demand for bariatric surgery far outstrips supply, and public/private insurance coverage is limited. This study aims to (1) perform a quantitative meta-analysis of health economic evidence regarding bariatric surgery from 1995, and (2) update our narrative synthesis and quality appraisal regarding the health economics reporting of bariatric surgery since September 2015.

METHODS : Validated guidelines informed systematic screening, data extraction, content and meta-analyses. Meta-analyses were conducted regarding annual cost changes ‘before’ versus ‘after’ surgery, and cumulative cost differences between surgical and non-surgical groups. Sensitivity and subgroup analyses were also performed. A narrative review that summarized full and partial health economic evaluations regarding bariatric surgery was conducted to update our previous review that covered 1995-2015.

RESULTS : N=101 studies were eligible for the qualitative analyses of health economic evaluations in bariatric surgery from 1995-December 2018, with 24 studies published after September 2015. Quality of health economic reporting increased to high from our previous review and the inclusion of complications/reoperations were predominantly contained in the full health economic evaluations that rated as high quality. Health economics studies also reflected technical changes in bariatric surgery. Sixty-one out of N=101 studies were eligible for the quantitative meta-analyses. Bariatric surgery was cost-saving over a lifetime scenario (inclusive of the costs of complications/reoperations from 84% of studies eligible for our novel meta-analytical model). Additionally, consideration of indirect costs through sensitivity analyses increased cost savings. Medication cost savings were predominant in the ‘before’ versus ‘after’ meta-analysis.

CONCLUSIONS : Bariatric surgery is cost-saving over a lifetime course. A broader perspective inclusive of indirect costs would drive further evidence of cost-savings. Health economists are hearing the call to present higher quality studies and include the costs of complications/reoperations; however, indirect costs and body contouring surgery have not attracted enough attention to date.