Surgery may beat GLP-1s on long-term costs

Clinical takeaway: For patients with obesity and diabetes who are eligible for both options, bariatric metabolic surgery may deserve early discussion as a treatment strategy with potential long-term clinical and economic advantages.

As GLP-1 use expands, clinicians and payers need long-term data comparing medical therapy with surgery—not just for weight and A1c outcomes, but for hospitalizations, medication use, and total health care spending.

In a retrospective cohort study from Israel’s largest health care organization, investigators compared 2721 adults who initiated GLP-1 receptor agonist therapy with 2721 propensity-matched adults who underwent bariatric metabolic surgery (BMS). Patients had a mean age of 51 years, mean BMI of 40.5, mean HbA1c of 7.8%, and were followed for up to 12.5 years, with a mean follow-up of 6.5 years.

Monthly follow-up costs, excluding the cost of the index treatment itself, were higher with GLP-1RAs than with surgery: $415 versus $305 per patient, or about 36% higher. After adjustment, GLP-1RA treatment was associated with $109 more per patient per month in health care utilization costs. The gap was driven mainly by higher non-GLP-1 medication costs and hospitalization costs. Nearly three-quarters of the long-term difference accrued within the first 4 years.

Clinical trajectories also differed. After surgery, mean BMI fell from 40.5 to 29.7 by year 2, then gradually rose to 32.1 by year 10. With GLP-1RAs, BMI declined more slowly, from 40.4 to 37.9 in the first 2 years, then continued to fall gradually. HbA1c dropped more sharply after surgery, from 7.8% to 5.9% in year 1, compared with 7.8% to 7.2% with GLP-1RAs.

The authors concluded that “BMS should be prioritized over first-generation GLP-1RAs among patients eligible for both interventions.” Important caveats: the study was observational, included mostly first-generation GLP-1RAs, and did not include the direct costs of either surgery or GLP-1RA treatment.

Source:Wolff Sagy Y, et al. (2026 July 1) JAMA Netw Open. Long-Term Health Care Utilization Costs of GLP-1RA Use vs Bariatric Metabolic Surgery