Reference: JAMA Netw Open. 2024 Apr 1;7(4):e246221
Practice Point: Over five years, semaglutide results in less weight loss than endoscopic sleeve gastroscopy, yet costs $33,500 more.
EBM Pearl: Cost-effectiveness studies in healthcare are necessarily local, but may provide global insights.
Have you ever tried to calculate how much your time is worth? Well, if you have ever attempted to prescribe GLP-1s such as semaglutide for weight loss, a better question might be: how many patient-pounds are lost per clinician-minute of extra administrative time spent trying to get one approved? Framed in this way, the cost-effectiveness of many GLP-1s might be in question! The authors of a recent study in JAMA took a slightly more patient-centered approach and evaluated the number of patient-pounds lost relative to cost comparing semaglutide to the minimally invasive incisionless procedure, endoscopic sleeve gastroplasty (ESG).
This was an interesting study by way of design. A five-year economic evaluation of cost-effectiveness for individuals with class II obesity (BMI 35-39.9 kg/m2) was derived from multiple studies and datasets, including two high-quality trials as well as some lower-quality observational data. Five-year costs were simulated using a Markov cohort model analysis based on the perspective of the U.S. healthcare system. (Markov models are “stochastic,” which means they evaluate a given point in time independent of prior or future events, similar to how the result of a given coin toss is not dependent on the results of the 100 coin tosses preceding it.) Clinical outcomes such as BMI and quality-adjusted life years (QALYs) were also predicted.
The model assumed an annual cost of $13,618 for semaglutide and a one-time procedural cost of $16,360 for ESG. Over 5 years, ESG was found to be more cost-effective than semaglutide with a cost savings of $33,500, more sustained weight loss (BMI 31.7 vs 33.0 kg/m2 from baseline 37), and slightly higher QALY. In a year-by-year analysis, ESG became more cost-effective than semaglutide by year two and dominated thereafter. The model estimated that in order for semaglutide to be as cost-effective as ESG, the annual cost would need to decrease to $3,591; in order to be on-par with lifestyle modification, which may include costs such as gym membership, organic vegetables, etc., the annual cost of semaglutide would need to be lowered to $7,494.
If we may take the liberty of extrapolating beyond five years, the cost-effectiveness of semaglutide gets even worse over time. (You pay for surgery once; you pay for semaglutide indefinitely.) If GLP-1s become generic, the financial playing field will likely level somewhat. However, this model predicted that 20% of people taking semaglutide would discontinue the drug due to intolerance over five years and hypothesized an even higher drop-out rate with extended use, diminishing the effectiveness from a weight loss perspective. Of course, surgery has a higher potential for more permanent adverse effects. While this study actually predicted more QALYs for ESG than semaglutide, patients who are too nauseated with semaglutide can stop the medication (and weight loss). The same isn’t true with nausea and vomiting due to a surgical change in anatomy.
So, what’s our point? We suppose it’s that while efficacy studies seem to be coming out left and right about the health benefits of semaglutide, the truth is that for a lot of people it’s just a carrot dangled in front of them that they’ll never get to eat because it costs too much. You might have noticed that you won’t often find study summaries about cost-analysis in DynaMedex. That’s because the product serves an international audience with users who practice in different models of healthcare delivery. Important conclusions for a user in one geographical location might be misleading to a user in another. However, our team decided to color outside of the lines and address cost with this edition of the EBM Focus because we practice in the real world and the reality is that if an intervention has high efficacy but is inaccessible due to cost, it has no effectiveness at all.
Speaking of dangling a carrot, once again we are daring to dream differently when it comes to the EBM Focus. We will be taking the next two months to work on some exciting changes that we will unveil in August. So please stay tuned, and as always, thank you for your readership. We’ll see you on the other side!
DynaMed EBM Focus Editorial Team
This EBM Focus was written by Katharine DeGeorge, MD, MS, Senior Deputy Editor at DynaMed and Associate Professor of Family Medicine at the University of Virginia. Edited by Alan Ehrlich, MD, FAAFP, Executive Editor at DynaMed and Associate Professor in Family Medicine at the University of Massachusetts Medical School; Dan Randall, MD, MPH, FACP, Deputy Editor at DynaMed; Nicole Jensen, MD, Family Physician at WholeHealth Medical; Vincent Lemaitre, PhD, Medical Editor at DynaMed; Hannah Ekeh, MA, Senior Associate Editor at DynaMed; and Jennifer Wallace, BA, Senior Associate Editor at DynaMed.