Endoscopic Sleeve Gastroplasty Saves Cost Compared With Semaglutide for Class II Obesity

Both glucagon-like peptide-1 receptor agonists (e.g. semaglutide) and endoscopic sleeve gastroplasty (ESG) are being used increasingly often to treat obesity. Semaglutide is particularly appealing because of its noninvasiveness, ease of use as a weekly injection, and short-term efficacy. However, how the cost-effectiveness of these options compares is unknown.

Researchers at Brigham and Women’s Hospital conducted computer modeling to study this issue from the perspective of the U.S. healthcare system. Their results, published in JAMA Network Open, suggest ESG is cost-saving compared with semaglutide for class II obesity (body mass index of 35–39.9 kg/m2). That was due to greater effectiveness and lower costs of ESG and increased dropout rates over time with semaglutide.

The authors are Christopher C. Thompson, MD, MSc, director of Endoscopy in the Division of Gastroenterology, Hepatology and Endoscopy and co-director of the Center for Weight Management and Wellness, Muhammad Haseeb, MD, MSc, a research fellow in the Division, Pichamol Jirapinyo, MD, MPH, director of the Bariatric Endoscopy Fellowship in the Division, and colleagues.


The base case in this economic evaluation study, conducted from September 1, 2022, to May 31, 2023, was a 45-year-old patient with a BMI of 37. The time horizon for capturing outcomes of interest was five years. First-year clinical data were derived from the STEP 1 trial of semaglutide and the MERIT trial of ESG. The data for years 2 to 5 were derived from other published studies and publicly available data sources.

The hypothetical patients in the semaglutide group faced the risk of dropping out due to medication intolerance, and the model assumed they would then regain weight. Patients in the ESG group who did not have a satisfactory response underwent repeat ESG. The model included a reference group of untreated patients who were assumed to have a slight weight gain over time.

The model incorporated costs of ESG, repeat ESG, associated adverse events from ESG, and the monthly cost of semaglutide. The cost of no treatment was set at zero. The ESG group received an initial quality-of-life decrement associated with the procedure, which applied for one week. Each adverse event in the ESG group resulted in a quality-of-life decrement applied for two weeks. In both groups, a quality-of-life improvement of 0.0056 quality-adjusted life-years (QALYs) was applied per unit decrease in BMI.

Base-Case Analysis

In the base-case analysis over five years:

  • The QALYs accumulated were 3.55 for no treatment, 3.60 for semaglutide, and 3.66 for ESG
  • The semaglutide strategy cost $33,583 more than the ESG strategy
  • Due to medication intolerance or other causes, about 20% of patients dropped out of the semaglutide group
  • ESG achieved and sustained greater weight loss compared with semaglutide (BMI of 31.7 vs. 33.0)

Over a time horizon of one year, ESG was not cost-effective compared with semaglutide, with an incremental cost-effectiveness ratio of $240,265 per QALY. However, when the time horizon was extended to two years, ESG was already more cost-saving.

Sensitivity Analyses

ESG remained cost-saving in all one-way sensitivity analyses over five years, which included varying the probability of procedural mortality, quality-of-life decrements with the procedure, or associated severe adverse events and adverse events. To achieve nondominance compared with ESG, the annual price of semaglutide, currently $13,618, would have to be $3,591.

Two-way sensitivity analyses involved variations in weight loss after ESG, rate of repeat ESG, weight loss with semaglutide, and dropout rate with semaglutide. For all parameters, the cost of semaglutide would have to be decreased at least threefold for the choice of treatment to change.

The Bottom Line

The obesity pandemic in the U.S. has created a growing need for interventions that alleviate the financial strain on the healthcare system and are accessible to individuals who can’t pay out of pocket. Semaglutide is effective for weight loss, but it does not seem to be as economically viable over the long term as ESG, an emerging minimally invasive option.

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