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Background

Prior to anti-obesity medications (AOMs), weight loss surgery (WLS) had demonstrated cost-effectiveness. The purpose of this study was to conduct a cost-effectiveness analysis comparing weight loss surgery versus AOMs with a long-term societal perspective.

Methods

Utilizing TreeAge Pro, a decision tree was designed for a base case of a patient with body mass index > 40 utilizing long-term use of AOMs versus weight loss surgery (Figure 1). Strategies in the decision tree included escalating therapy from AOMs to WLS, surgical revision conversion if treatment response not met, use of adjuvant AOMs after weight loss surgery, and complications of weight loss surgery. Sensitivity testing was performed to identify a potential breakeven point. The model was informed by systematic review and expert opinion as needed. Future costs and quality of life years (QALYS) were by convention discounted at 3% per year and standardized to 2019 U.S. dollars.

Results

Weight loss surgery as initial therapy was the dominant strategy yielding 21.96 versus 20.58 QALYs for long-term AOMs alone at a cost of $301,374 versus $687,885, respectively. Drivers of inferiority for AOMs included the high continuing costs relative to the lower cost of weight loss surgery. On sensitivity analysis, no combination of more willingness to convert from medications to surgery, drug pricing, or medication adherence changed the dominance of an upfront surgery recommendation.

Conclusions

Relative to AOMs, the low cost and durability of surgery argues it is the societally favorable option with better expected quality of life as well as lower total costs.