Society for Surgery of the Alimentary Tract
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Muhammad Haseeb*1, Umar Hayat2, Pichamol Jirapinyo1, Christopher C. Thompson1
1Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA; 2Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA

Introduction: Bariatric surgery is the most effective treatment for morbid obesity. Laparoscopic Sleeve Gastrectomy (LSG) is the most performed bariatric surgery. However, new weight-loss medications such as glucagon-like peptide-1 receptor agonists (e.g., Semaglutide), have attracted increased attention due to non-invasiveness and effectiveness in the short term. Our study aimed to assess the cost-effectiveness of Semaglutide compared to LSG.

Methods: A state-transition Markov cohort model was constructed to compare LSG with Semaglutide from the U.S. healthcare system's perspective. The base case was a 45-year-old patient with Class II obesity having a BMI of 37. In the LSG strategy, patients were subjected to the risks of perioperative mortality and complications with resultant costs and initial decrement in quality of life (QOL). Both strategies experienced quality-of-life improvements associated with weight loss. Probabilities, costs and QOL estimates of the model were derived from published literature. Costs were reported in U.S. dollars ($) adjusted to the year 2022 using the consumer price index with health outcomes recorded in quality-adjusted life years (QALYs). A five-year time horizon with a cycle length of one month with the application of a 3% discount rate was utilized. The main outcome measure was the incremental cost-effectiveness ratio (ICER) with a willingness-to-pay threshold of $100,000/QALY. One-way and probabilistic sensitivity analyses were performed. Price-threshold analysis was also performed for the dominated strategy.

Results: At 5 years, LSG strongly dominated Semaglutide (ICER: -$238,686/QALY) due to the lower cost and higher effectiveness of the procedure. The results remained robust on one-way sensitivity analysis. Due to intolerance and other causes, ~20% of modeled patients dropped out of the Semaglutide strategy. LSG achieved and sustained greater weight loss over 5 years for the modeled patients compared to Semaglutide. (BMI of 29.9 vs. 33.1). Using a willingness-to-pay threshold of $100, 000 per QALY, LSG was cost-effective compared to Semaglutide with a probability of 0.01%, 46.41%, 96.08%, 99.93%, and 100% over 1, 2, 3, 4, and 5 years, respectively on probabilistic sensitivity analysis. The annualized price of Semaglutide to achieve non-dominance of LSG with an ICER threshold of $100,000/QALY was $5135, currently priced at $13,618.

Conclusion: LSG is cost-effective compared to Semaglutide for the treatment of Class II obesity, strongly dominating the medical therapy at 5 years. This is driven by higher cost, increased dropouts, and lower clinical effectiveness with Semaglutide. Future studies comparing these strategies on different classes of obesity would provide a better understanding regarding the optimal use of these treatment options.

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