Post on 09-Aug-2020
Surgery – cure of type 2 diabetes?
Lena CarlssonThe Sahlgrenska AcademyGothenburgSweden
Swedish Obese Subjects (SOS) Study
A prospective, controlled intervention trial started in 1987.
Examines the effects of bariatric surgery compared to usual carePrimary endpoint:
Overall mortality
Secondary endpoints:DiabetesMIStroke
Main limitation: The non-randomized design
Surgery groupN=2010343 with diabetes
Control group N=2037260 with diabetes
Banding VBG GBP Usual care
SOS - A prospective, controlled intervention study
Inclusion criteria:37-60 years oldBMI men>34, women>38
Follow up:Up to 32 years, median over 20 years
Wei
ght c
hang
e, %
No. ExaminedControlBandingVBGGBP
2037376
1369265
1490333
1086209
1267284
1007180
55615048937
176508213
Follow-up time, years1242284987184
-35
-30
-25
-20
-15
-10
-5
0
5
0 1 2 3 4 6 8 10 15 20
Control
Banding
VBG
GBP
Long term effects on body weightPercent weight change (95% CI)
From Sjöström, Peltonen, …….Carlsson. JAMA 2012
Diabetes was defined by:
Fasting blood glucose: ≥ 6.1 mmol/L (corresponding to fasting plasma glucose ≥ 7.0 mmol/L or ≥126 mg/dL)
and/or
Glucose lowering medication
Prediabetes was defined by:
Fasting blood glucose: 5.0–6.0 mmol/L (corresponding to fasting plasma glucose 5.6-6.9 mmol/L)
Diabetes and prediabetes in the SOS study
0.00
0.20
0.40
0.60
0.80
1.00
Prop
ortio
n w
ithou
t dia
bete
s (9
5% C
I)
2-year 10-year 15-yearFollow-up time
Control groupSurgery group
Diabetes remission inSOS patients with diabetes at baseline
Sjöström, Peltonen, …..Carlsson. JAMA, June 11, 2014
0.00
0.20
0.40
0.60
0.80
1.00
Prop
ortio
n w
ithou
t dia
bete
s (9
5% C
I)
2-year 10-year 15-yearFollow-up time
Control groupSurgery group
Diabetes remission inSOS patients with diabetes at baseline
72%
Sjöström, Peltonen, …..Carlsson. JAMA, June 11, 2014
Similar to observations in RTCs
0.00
0.20
0.40
0.60
0.80
1.00
Prop
ortio
n w
ithou
t dia
bete
s (9
5% C
I)
2-year 10-year 15-yearFollow-up time
Control groupSurgery group
72%
Sjöström, Peltonen, …..Carlsson. JAMA, June 11, 2014
30%
Diabetes remission inSOS patients with diabetes at baseline
0.00
0.20
0.40
0.60
0.80
1.00
Prop
ortio
n w
ithou
t dia
bete
s (9
5% C
I)
2-year 10-year 15-yearFollow-up time
Control groupSurgery group
72%
Sjöström, Peltonen, …..Carlsson. JAMA, June 11, 2014
30%
Diabetes remission inSOS patients with diabetes at baseline
Which patients stay in remission?
There were no baseline risk factor-treatment interactions(eg. BMI did not influence the results)
Type 2 diabetes is a progressive disease
Beta cells gradually lose the ability to produce insulin
Treatment benefit (remission) may depend on beta cell function
Importance of diabetes duration?
Which subgroups of patients obtain long-term diabetes remission?
Diabetes remission after bariatric surgery stratified by diabetes duration at baseline
Early treatment is important for remission
Sjöström et al, JAMA 2014
11800 patients with diabetes at baseline
The effect of diabetes duration in SOReg(Scandinavian Obesity Surgery Registry)
0
10
20
30
40
50
60
70
80
90Re
miss
ion
(%)
1 år
Diabetes duration at the time of surgery
1-year Remission (%)in relation to diabetes
duration in SOReg
SOReg 2019
0
10
20
30
40
50
60
70
80
90
1 år2 år5 år
1, 2 and 5-year Remission (%)in relation to diabetes
duration in SOReg
SOReg 2019Diabetes duration at the time of surgery
How early should we treat?
Many patients with obesity will develop diabetes.
Should we try to prevent this by bariatric surgery?
In which patients?
Both SOS and SOReg show that early treatment is important for remission
HR=0.22 (0.18-0.27), p<0.001Adj HR=0.17, p<0.001
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
Kapl
an-M
eier
cum
ulat
ive
inci
denc
e
0 2 10 15Follow-up time, years
1658 1561 1225 576Surgery1771 1513 1076 404Control
Number at risk:
Control (392 events)Surgery (110 events)
Bariatric surgery strongly prevents diabetes
Around 80% risk reduction
Carlsson et al, N Engl J Med, Aug 23, 2012
NNT=4.6
0
20
40
60
80
100
120
140
Inci
denc
e ra
te p
er 1
000
p-y
(95%
CI)
Control groupSurgery group
Baseline values, deciles
InteractionP=0.55
BMI
Effects of bariatric surgery on diabetes incidence in sub-groups defined by baseline BMI
0
20
40
60
80
100
120
140
Inci
denc
e ra
te p
er 1
000
p-y
(95%
CI)
0
20
40
60
80
100
120
140
Inci
denc
e ra
te p
er 1
000
p-y
(95%
CI)
0
20
40
60
80
100
120
140
Inci
denc
e ra
te p
er 1
000
p-y
(95%
CI)
Control groupSurgery group
Blood glucose, mg/dl Serum insulin, mU/L
Baseline values, deciles
InteractionP=0.007
InteractionP=0.007
InteractionP=0.55
BMI
Effects of bariatric surgery on diabetes incidence in sub-groups defined by baseline BMI, insulin or glucose
0
20
40
60
80
100
120
140
Inci
denc
e ra
te p
er 1
000
p-y
(95%
CI)
0
20
40
60
80
100
120
140
Inci
denc
e ra
te p
er 1
000
p-y
(95%
CI)
0
20
40
60
80
100
120
140
Inci
denc
e ra
te p
er 1
000
p-y
(95%
CI)
Control groupSurgery group
Blood glucose, mg/dl Serum insulin, mU/L
Baseline values, deciles
InteractionP=0.007
InteractionP=0.007
InteractionP=0.55
BMI
Effects of bariatric surgery on diabetes incidence in sub-groups defined by baseline BMI, insulin or glucose
prediabetes
HR=0.26 (0.20-0.34), p<0.001
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
cum
ulat
ive
inci
denc
e
0 2 10 15
Follow-up time, years
Control (237 events)Surgery (69 events)
Euglycemia
HR=0.17 (0.12-0.22), p<0.001
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
cum
ulat
ive
inci
denc
e
0 2 10 15
Follow-up time, years
Control (155 events)Surgery (41 events)
Prediabetes
Diabetes prevention in patients euglycemia orprediabetes
NNT=7.0 NNT=1.3
Data from Carlsson et al, N Engl J Med, Aug 23, 2012
Sjöström, Peltonen, …..Carlsson. JAMA, June 11, 2014
Retinopathy, nephropathy and neuropathy
56% risk reduction in patients with T2D
Bariatric surgery and prevention of microvascular complications in patients with T2D
Log-rank test P=0.001HR=0.55 (95% CI: 0.38-0.79)
0.00
0.20
0.40
0.60
0.80
1.00
Kapl
an-M
eier
est
imat
e
0 2 4 6 8 10 12 14 16Follow-up time, years
159 153 147 138 132 124 118 104 80Surgery87 81 81 76 69 62 51 38 25Control
Number at risk
Control (51 events)
Surgery (66 events)
Duration <1 yr
Log-rank test P=0.006HR=0.61 (95% CI: 0.42-0.87)
0.00
0.20
0.40
0.60
0.80
1.00
Kapl
an-M
eier
est
imat
e
0 2 4 6 8 10 12 14 16Follow-up time, years
93 90 86 83 74 66 56 36 23Surgery89 83 76 68 57 50 39 21 15Control
Number at risk
Control (65 events)
Surgery (54 events)
Duration 1-3 yrs
Log-rank test P=0.156HR=0.79 (95% CI: 0.56-1.09)
0.00
0.20
0.40
0.60
0.80
1.00
Kapl
an-M
eier
est
imat
e
0 2 4 6 8 10 12 14 16Follow-up time, years
91 84 75 63 49 40 33 23 13Surgery84 71 60 52 42 33 24 15 8Control
Number at risk
Control (69 events)
Surgery (72 events)
Duration ≥4 yrs
Early treatment is important for prevention of complications in T2D
45% risk reduction 39% risk reduction NS
Sjöström, Peltonen, …..Carlsson. JAMA, June 11, 2014
Obesity –> prediabetes –> T2D –> complications
Prevention Remission
How does timing of bariatric surgery affectprevention of microvascular complications?
At which stage is treatment benefit greatest?
What is the long-term effect of bariatric surgery on microvascularcomplications in patients with different baseline glucose status?
SOS study – baseline:Euglycemia: n=2838Prediabetes: n=591Screen detected T2D: n=246Established T2D: n=357
How early should we treat to prevent microvascular complications?
HR=0.63 (0.48-0.81)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
Euglycemia
HR=0.18 (0.11-0.30)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
Prediabetes
HR=0.39 (0.24-0.65)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
ST2D
HR=0.54 (0.40-0.72)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
T2D
Interaction p < 0.001
Effect of bariatric surgery on microvascular events in SOS patients stratified by baseline glucose status (Retinopathy, nephropathy, neuropathy)
From Carlsson et al, Lancet D&E 2017
HR=0.63 (0.48-0.81)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
Euglycemia
HR=0.18 (0.11-0.30)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
Prediabetes
HR=0.39 (0.24-0.65)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
ST2D
HR=0.54 (0.40-0.72)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
T2D
Interaction p < 0.001
Effect of bariatric surgery on microvascular events in SOS patients stratified by baseline glucose status
46%risk reduction
From Carlsson et al, Lancet D&E 2017
HR=0.63 (0.48-0.81)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
Euglycemia
HR=0.18 (0.11-0.30)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
Prediabetes
HR=0.39 (0.24-0.65)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
ST2D
HR=0.54 (0.40-0.72)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
T2D
Interaction p < 0.001
Effect of bariatric surgery on microvascular events in SOS patients stratified by baseline glucose status
46%risk reduction
61%risk reduction
From Carlsson et al, Lancet D&E 2017
HR=0.63 (0.48-0.81)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
Euglycemia
HR=0.18 (0.11-0.30)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
Prediabetes
HR=0.39 (0.24-0.65)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
ST2D
HR=0.54 (0.40-0.72)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
T2D
Interaction p < 0.001
Effect of bariatric surgery on microvascular events in SOS patients stratified by baseline glucose status
82%risk reduction
46%risk reduction
61%risk reduction
From Carlsson et al, Lancet D&E 2017
HR=0.63 (0.48-0.81)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
Euglycemia
HR=0.18 (0.11-0.30)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
Prediabetes
HR=0.39 (0.24-0.65)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
ST2D
HR=0.54 (0.40-0.72)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
T2D
Interaction p < 0.001
Effect of bariatric surgery on microvascular events in SOS patients stratified by baseline glucose status
82%risk reduction
From Carlsson et al, Lancet D&E 2017
HR=0.18 (0.11-0.30)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
Prediabetes
Why are microvascular complications reduced by bariatric surgery in patients that have baseline prediabetes?
82%risk reduction
From Carlsson et al, Lancet D&E 2017
HR=0.18 (0.11-0.30)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
Prediabetes
Why are microvascular complications reduced by bariatric surgery in patients that have baseline prediabetes?
82%risk reduction
Bariatric surgery strongly prevents diabetes.
From Carlsson et al, Lancet D&E 2017
HR=0.18 (0.11-0.30)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
Prediabetes
Why are microvascular complications reduced by bariatric surgery in patients that have baseline prediabetes?
82%risk reduction
Bariatric surgery strongly prevents diabetes.
Is it only because bariatric surgery prevents diabetes?
From Carlsson et al, Lancet D&E 2017
Log-rank test, p<0.001HR=0.22 (0.11-0.44)
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
ControlSurgery
Patients with baseline prediabetes but without diabetes during follow-up
Microvascular complications
78% risk reduction in patients that remain non-diabetic during follow-up
From Carlsson et al, Lancet D&E 2017
Log-rank test, p<0.001HR=0.22 (0.11-0.44)
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
ControlSurgery
Patients with baseline prediabetes but without diabetes during follow-up
Microvascular complications
78% risk reduction in patients that remain non-diabetic during follow-up
Differences in glucose levels between surgery and control patients?
From Carlsson et al, Lancet D&E 2017
Log-rank test, p<0.001HR=0.22 (0.11-0.44)
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
ControlSurgery
Patients with baseline prediabetes but without diabetes during follow-up
Microvascular complications
78% risk reduction in patients that remain non-diabetic during follow-up
Differences in glucose levels between surgery and control patients?
Slightly elevated glucose over long time?
From Carlsson et al, Lancet D&E 2017
Log-rank test, p<0.001HR=0.22 (0.11-0.44)
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
ControlSurgery
Patients with baseline prediabetes but without diabetes during follow-up
Microvascular complications
78% risk reduction in patients that remain non-diabetic during follow-up
Differences in glucose levels between surgery and control patients?
Slightly elevated glucose over long time?
Normalized glucose levels after bariatric surgery?
From Carlsson et al, Lancet D&E 2017
Log-rank test, p<0.001HR=0.22 (0.11-0.44)
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
ControlSurgery
Patients with baseline prediabetes but without diabetes during follow-up
Microvascular complications
(p<0.001)
4.18±0.55 mmol/L
4.86±0.65 mmol/L
Fasting blood glucose at 2-years:
From Carlsson et al, Lancet D&E 2017
Log-rank test, p<0.001HR=0.22 (0.11-0.44)
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
ControlSurgery
Patients with baseline prediabetes but without diabetes during follow-up
Microvascular complications
(p<0.001)
4.18±0.55 mmol/L
4.86±0.65 mmol/L
Fasting blood glucose at 2-years:
Slightly elevated (prediabetic) glucose levels are associated with microvascular disease.
From Carlsson et al, Lancet D&E 2017
Log-rank test, p<0.001HR=0.22 (0.11-0.44)
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
ControlSurgery
Patients with baseline prediabetes but without diabetes during follow-up
Microvascular complications
(p<0.001)
4.18±0.55 mmol/L
4.86±0.65 mmol/L
Fasting blood glucose at 2-years:
Slightly elevated (prediabetic) glucose levels are associated with microvascular disease.
Prediabetes should be treated!
From Carlsson et al, Lancet D&E 2017
HR=0.63 (0.48-0.81)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
Euglycemia
HR=0.18 (0.11-0.30)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
Prediabetes
HR=0.39 (0.24-0.65)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
ST2D
HR=0.54 (0.40-0.72)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
Kapl
an-M
eier
est
imat
e
0 5 10 15 20Follow-up time, years
Control
Surgery
T2D
Interaction p < 0.001
Microvascular complications in patients with euglycemia compared to prediabetes
From Carlsson et al, Lancet D&E 2017
Higher risk and benefit in prediabetes
Microvascular complications in SOS patients with euglycemia
Low normal High normal
Microvascular complications in SOS patients with euglycemia
The relative risk reduction after bariatric surgery was similar across the normoglycemic range
Low normal High normal
Microvascular complications in SOS patients with euglycemia
The relative risk reduction after bariatric surgery was similar across the normoglycemic range
0.00
0.10
0.20
0.30
0.40
0.50
0 5 10 15 20
Follow-up time, years
PrediabetesLow normal High normal
Health-care costs over 15 years after bariatric surgery and usual care in subgroups with:
- euglycemia- prediabetes- diabetes
Results from real data, not based on modeling!
What is the effect of baseline glucose status on long-term health-care costs?
0
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90 000
100 000
Surgery Control Surgery Control Surgery Control
Euglycemic Prediabetes Diabetes
15-Year Accumulated Costs ($)
Inpatient Care
Outpatient Care
Drugs
P=0.81 P=0.007 P<0.0001
Data from Keating, Neovius, Sjöholm, Peltonen, Narbro, Eriksson, Sjöström & Carlsson
Lancet Diabetes Endocrinol. 2015 Sep 16
Drug costs were lower after surgery compared to usual carein patients with prediabetes or diabetes
Euglycemia
Prediabetes
Diabetes
Control group
Surgery group
Cost savings explained by reduced costs of diabetes drugs
Euglycemia
Prediabetes
Diabetes
Control group
Surgery group
Cost savings explained by reduced costs of diabetes drugs
Importance of long follow-up – it takes many years to detect a difference
0
10 000
20 000
30 000
40 000
50 000
60 000
70 000
80 000
90 000
100 000
Surgery Control Surgery Control Surgery Control
Euglycemic Prediabetes Diabetes
15-Year Accumulated Costs ($)
Inpatient Care
Outpatient Care
Drugs
P=0.86 P=0.38 P=0.90
Outpatient costs were similar in surgery and control patients for the three glucose groups
Data from Keating, Neovius, Sjöholm, Peltonen, Narbro, Eriksson, Sjöström & Carlsson
Lancet Diabetes Endocrinol. 2015 Sep 16
Euglycemia
Prediabetes
Diabetes
15-year inpatient costs were higher in surgery patients
0
10 000
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30 000
40 000
50 000
60 000
70 000
80 000
90 000
100 000
Surgery Control Surgery Control Surgery Control
Euglycemic Prediabetes Diabetes
Inpatient Care
Outpatient Care
Drugs
P<0.0001 P<0.0001 P=0.09
15-year total healthcare costs are similar for surgical and non-surgical treatment in patients with baseline diabetes
Data from Keating, Neovius, Sjöholm, Peltonen, Narbro, Eriksson, Sjöström & Carlsson
Lancet Diabetes Endocrinol. 2015 Sep 16
P=0.01
P=0.48
15-Year Total Healthcare Costs By Diabetes DurationAdj. Mean Difference between Surgery and Control groups
US Dollar
Longer diabetes duration:Higher costs in surgery group
Data from Keating et al,Lancet Diabetes Endocrinol. 2015 Sep 16
P=0.01
P=0.48
15-Year Total Healthcare Costs By Diabetes DurationAdj. Mean Difference between Surgery and Control groups
US Dollar
Newly diagnosed diabetes:No difference between surgery and control groups
Longer diabetes duration:Higher costs in surgery group
Data from Keating et al,Lancet Diabetes Endocrinol. 2015 Sep 16
P=0.01
P=0.48
15-Year Total Healthcare Costs By Diabetes DurationAdj. Mean Difference between Surgery and Control groups
US Dollar
Newly diagnosed diabetes:No difference between surgery and control groupsLonger remissionBetter prevention of complications
Longer diabetes duration:Higher costs in surgery group
Data from Keating et al,Lancet Diabetes Endocrinol. 2015 Sep 16