Roux-en-Y Gastric Bypass Compared to Glucagon-like Peptide-1 Receptor Agonists is Associated with Lower Out-of-Pocket Costs in Insured Patients with Type 2 Diabetes and Obesity

Roux-en-Y Gastric Bypass Compared to Glucagon-like Peptide-1 Receptor Agonists is Associated with Lower Out-of-Pocket Costs in Insured Patients with Type 2 Diabetes and Obesity | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Roux-en-Y Gastric Bypass Compared to Glucagon-like Peptide-1 Receptor Agonists is Associated with Lower Out-of-Pocket Costs in Insured Patients with Type 2 Diabetes and Obesity Sibi Thiyagarajan, Elizabeth Wall-Wieler, Yuki Liu, Feibi Zheng, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7623447/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Jan, 2026 Read the published version in Obesity Surgery → Version 1 posted 14 You are reading this latest preprint version Abstract Objective To evaluate 2-year cost to insured patients treated with Roux-en-Y gastric bypass (RYGB) or glucagon-like peptide-1 receptor agonists (GLP-1 RAs) for type 2 diabetes (T2D) and obesity. Methods Using the 2017 to 2023 Merative™ claims database, we identified adult patients with severe obesity and T2D who were treated with a RYGB or GLP-1 RAs. Patients with RYGB had no treatment with GLP-1 RAs, and those who received GLP-1 RA therapy with tirzepatide or semaglutide for ≥ 2 years had no metabolic and bariatric surgery (MBS) procedures. The study cohorts were matched on demographics including obesity, associated medical problems, and baseline direct or out-of-pocket (OOP) costs to patients in the year prior to treatment initiation. Direct costs included those from outpatient services, inpatient admissions, and outpatient prescription filled that were paid directly by patients. We compared this cost up to two years after treatment initiation using paired t-tests. Results 1012 matched RYGB and GLP-1 RA patients were analyzed, including 35% male. At 1-year after treatment initiation, healthcare costs paid directly by patients were similar for the RYGB ( $ 2,301) and GLP-1 RA ( $ 2,179) (delta = $ 122, p = 0.15) cohorts. From one to two years after index treatment date, OOP costs were significantly lower in the RYGB treatment group ( $ 1,277 vs. $ 2,104, p < 0.01). Two years after treatment initiation, RYGB patients spent $ 704 less in OOP costs than similar patients treated with GLP-1 RA medications (p < 0.01). Conclusions Direct OOP healthcare costs were lower for RYGB compared to GLP-1 RA use patients 2-years after treatment initiation. Figures Figure 1 INTRODUCTION Severe obesity and type 2 diabetes (T2D) remains public health challenges placing significant burdens on the global economy.[ 1 ] Obesity has a strong association with T2D.[ 2 – 3 ] Among individuals with both conditions, weight management and glycemic control are essential to reducing long-term morbidity. In these patients, Glucagon-like Peptide-1 Receptor Agonists (GLP-1 RAs) [ 4 – 6 ] and Roux-en-Y gastric bypass (RYGB) [ 7 – 9 ] are two treatment options that can significantly impact weight loss and control of T2D. The choice to proceed with a GLP-1 RAs or bariatric surgery as initial therapy involves a complex shared decision with considerations related to tolerability of side effects and complications, durability of treatment, compliance with treatment, and financial implications for health systems, insurers, and patients. Higher cost sharing, deductibles, and consumer-directed health plans can create a financial burden even for patients with private insurance, making it difficult for them to afford care [ 10 ] and increasing their out-of-pocket (OOP) expenses.[ 11 – 13 ] We have previously shown that OOP patient cost difference between sleeve gastrectomy (SG) and Ozempic was similar at one year whereas SG patients spent considerably less by the end of two years.[ 14 ] While SG and RYGB are effective treatments for patients with severe obesity[ 15 – 16 ] prior studies have shown that RYGB leads to greater weight loss and higher rates of diabetes resolution[ 17 – 18 ] but is more costly to patients from an OOP perspective when compared to SG.[ 19 ] To date, no studies have evaluated the OOP cost to patients for RYGB compared to GLP-1 RAs. Furthermore, new GLP-1 RAs have entered the US market since our analysis comparing OOP cost for SG compared to Ozempic. The introduction of these new GLP-1 RAs may have resulted in downward pricing pressure leading to OOP cost savings for patients. Roux-en-Y is considered the gold standard for weight loss operations[ 20 – 21 ] and remains the second most performed MBS.[ 20 ],[ 22 ] As GLP-1 RA options continue to evolve, the goal of our study is to analyze out-of-pocket healthcare costs to commercially insured RYGB and GLP-1 RA patients with class 2 or 3 obesity and T2D, two years after treatment initiation. We aim to provide real world cost data from patients who have chosen these two different treatment pathways, enabling more data driven conversations between obesity care providers and their patients. MATERIALS AND METHODS Data Source The 2017–2023 Merative™ MarketScan Research Databases (Merative™) were used for this cohort study. This retrospective claims data source is an aggregated registry of insured employees and their dependents, and includes data on healthcare services used, including inpatient, outpatient, and prescription drug services.[ 23 ] Type 2 Diabetes Inclusion Type 2 diabetes was assigned to patients who had at least one diagnostic claim for T2D and at least one pharmacy claim for diabetes during the year preceding treatment initiation. The International Classification of Diseases (ICD-10) used to identify T2D included code E11.xx.[ 24 ] Pharmacy claims related to diabetes were identified using National Drug Codes (NDCs) for diabetes medication, including Metformin, alpha-glucosidase inhibitors, amylin analogs, antidiabetic combinations, dipeptidyl peptidase-4 (DPP-4) inhibitors, meglitinides, sodium glucose co-transporter-2 (SGLT-2) inhibitors, sulfonylureas, thiazolidinediones, and Insulin.[ 25 – 26 ] Obesity Inclusion Inpatient and outpatient claims were used to identify body mass index (BMI). Using such claims data, Class 2 (BMI 35-39.9 kg/m 2 ) and Class 3 (BMI ≥ 40 kg/m 2 ) obesity were determined using several ICD-10 codes (Z68.35-Z68.39, Z68.4x). Pre-treatment obesity was assigned to patients who had at least one obesity claim with a BMI ≥ 35 kg/m 2 during the year preceding treatment initiation. During this period, if patients had more than one obesity-related claim, the one closest to treatment initiation was used. Treatments Cohorts RYGB and GLP-1 RAs as treatment options for severe obesity and T2D were compared. Using inpatient admissions and outpatient services claims, RYGB was identified using CPT-4 codes (43633, 43644, 43645, 43846, 43847) and ICD-10 Procedural codes (0D16079, 0D1607A, 0D160J9, 0D160JA, 0D160K9, 0D160KA, 0D160Z9, 0D160ZA, 0D1607A, 0D160JA, 0D160KA, 0D160ZA, 0D1687A, 0D168JA, 0D168K9, 0D168KA, 0D168ZA, 0D168Z9, 0D16879, 0D1687A, 0D168ZA, 0D168J9, 0D16479, 0D1647A, 0D164J9, 0D164JA, 0D164K9, 0D164KA, 0D164Z9, 0D164ZA).[ 27 ] GLP-1 RAs were identified in Redbook™ using NDCs. In the prescription claims drug registry, these codes identified individuals who filled a prescription for semaglutide or tirzepatide ( see Table S1 for specific NDC codes used ). The GLP-1 RA cohort had to meet three requirements for inclusion: 1) continuous prescriptions in the two years after the first prescription was filled, 2) a prescription gap that was 45 days or less, and 3) at least 80% of the days covered with prescriptions in the two years after initiating GLP-1RA medications.[ 28 ] Patients not meeting the above criteria were excluded from the GLP-1 RA cohort. Cohort Even though our study period is 2017 to 2023, our study cohort was limited to adult patients in the 2017 to 2021 Merative data registry, ages 21 to 65 years, with class 2 or 3 obesity and T2D. This was feasible as the first semaglutide prescriptions were documented in the registry in 2018, and those included in the study needed to have at least 2-years of follow-up from index treatment date. Those assigned to the RYGB cohort did not have any documented GLP-1 RA prescriptions filled. Those assigned to the GLP-1 RA cohort had no documentation of a bariatric procedure performed. Both study cohorts had T2D, an insurance covered prescription plan, and continuous insurance coverage 1-year before treatment initiation that continued for at least 2-years following index treatment date. For the GLP-1 RA cohort, this included filling at least 2-years of GLP-1 RA supply after initiating this treatment. Following exclusions, we compared outcomes in those treated with RYGB (n = 1,350) and GLP-1 RAs (n = 2,908) (Fig. 1 ). Out-of-Pocket Healthcare Costs OOP healthcare costs were assessed up to 2-years after treatment initiation. For the RYGB cohort, RYGB-related cost was included in overall OOP cost at 1-year after treatment initiation. All dollar amounts paid directly to a healthcare provider or pharmacy by patients were used to determine OOP cost,[ 19 ] which was adjusted to 2023 constant dollars leveraging the Medical Care component of the Bureau of Labor Statistics Consumer Price Index ( http://www.bls.gov/cpi/ ). To reduce potential biases associated with extreme outliers, we truncated costs for inpatient admissions and outpatient services at the 1st and 99th percentile. Statistical Analysis We performed a 1:1 matched analysis of the RYGB and GLP-1 RA cohorts using greedy nearest neighbor propensity scores,[ 29 ] and compared OOP costs. Matching covariates included patient demographics such as age and BMI, obesity-related associated medical conditions, ( see Table S2 for ICD-10 codes used to identify these conditions ), whether they had an inpatient admission, and OOP healthcare costs in the year before index treatment date. We assessed balance diagnostics to ensure that the matched groups were balanced on all baseline characteristics. Covariates were considered balanced if the standardized difference was ≤ 0.25.[ 30 ] Between treatment cohorts, differences in OOP costs up to 2-years from treatment initiation were compared using paired t-tests. Given the different GLP-1 RAs included in this study, we also examined whether differences in OOP costs for patients treated with GLP-1 RAs differed from their matches based on whether they had been treated with semaglutide or tirzepatide. For most of the study window, only semaglutide was approved for use; therefore, most patients treated with GLP-1 RAs are expected to only have filled semaglutide prescriptions. Among these patients we also examined whether the type of semaglutide – Wegovy, Ozempic, or Rybelsus – impacted OOP cost comparisons with their matched RYGB cohort. This article follows the STROBE statement for conducting cohort studies. Ethics The study utilized de-identified patient data available in the Merative™ database. As such, Institutional Review Board approval and consent were exempt for the observational study in accordance with the Health Insurance Portability and Accountability Act Privacy Rule. RESULTS 4,258 cases met inclusion criteria, including 1,350 (31.7%) in the RYGB treatment and 2,908 (68.3%) in the GLP-1 RA treatment cohorts (Table 1 ). In unmatched cohort analyses, the RYGB group were more likely to be younger, female, have a higher BMI, and obesity-associated medical conditions when compared to the GLP-1 RA group. After propensity score matching, baseline characteristics for the 506 RYGB and 506 GLP-1 RA treated individuals were balanced. Table 1 Baseline Characteristics among those who had type 2 diabetes and Class 2 or Class 3 Obesity at Baseline, by Treatment Type Baseline Characteristics Unmatched Cohort Matched Cohort RYGB (N = 1,350) GLP-1 RA (N = 2,908) Absolute Standardized Mean Difference RYGB (N = 506) GLP-1 RA (N = 506) Absolute Standardized Mean Difference Baseline BMI, Mean (SD) 43.4 (6.3) 40.8 (5.5) 0.437 41.5 (4.6) 41.5 (4.6) 0.003 Age; Mean (SD) 47.9 (8.7) 51.0 (7.6) 0.378 50.5 (6.9) 50.6 (6.8) 0.013 Out-of-Pocket Healthcare Costs, Mean a (SD) 2242 (1618) 2050 (1540) 0.122 1755 (998) 1753 (999) 0.001 Male Sex, n (%) 384 (28.4) 1594 (54.8) 0.352 167 (33.0) 190 (37.6) 0.100 Inpatient Admission a 101 (7.5) 286 (9.8) 0.084 26 (5.1) 25 (4.9) 0.007 Obesity-Related Comorbidities, n (%) Hypertension 1059 (78.4) 2313 (79.5) 0.027 393 (77.7) 398 (78.7) 0.024 Dyslipidemia 974 (72.2) 2224 (76.5) 0.010 383 (75.7) 380 (75.1) 0.014 OSA 796 (59.0) 974 (33.5) 0.528 241 (47.6) 234 (46.3) 0.029 Knee OA 159 (11.8) 289 (9.9) 0.059 50 (9.9) 57 (11.3) 0.044 GERD 753 (55.8) 467 (16.1) 0.909 161 (31.8) 132 (26.1) 0.131 MAFLD/MASH 282 (20.9) 300 (10.3) 0.294 78 (15.4) 50 (9.9) 0.154 Number of Obesity-Related Comorbidities, n (%) 1 27 (2.0) 129 (4.4) 0.138 12 (2.4) 23 (4.6) 0.123 2 127 (9.4) 515 (17.7) 0.244 72 (14.2) 66 (13.0) 0.035 3+ 1196 (88.6) 2264 (77.9) 0.290 422 (83.4) 417 (82.4) 0.027 RYGB = Roux-en-Y Gastric Bypass, GLP-1 RA = Glucagon-like Peptide-1 Receptor Agonist, BMI = body mass index, SD = standard deviation, OSA = obstructive sleep apnea, OA = osteoarthritis, GERD = gastroesophageal reflux disease, MAFLD = metabolic dysfunction associated fatty liver disease, MASH = metabolic dysfunction-associated steatohepatitis a In the year before the Index Date In 1-year after the treatment initiation date, OOP healthcare costs were similar between the RYGB ( $ 2,301) and GLP-1 RAs ( $ 2,179) treatment groups (difference = $ 122, p = 0.15) (Table 2 ). However, OOP healthcare costs in the second year following treatment initiation were significantly less in the RYGB cohort ( $ 1,277) compared to the GLP-1 RAs ( $ 2,104) (difference = $ 327; p < 0.01). 2years following index treatment date, on average, having a RYGB was associated with $ 704 less in OOP healthcare costs, compared to treatment with GLP-1 RAs (p < 0.01). Table 2 Differences in Out-of-Pocket Costs for Roux-en-Y Gastric Bypass and GLP-1 Ras Time Frame RYGB $ (95% CI) GLP-1 RA $ (95% CI) Difference $ (95% CI) p-value 0–12 Months After 2301 (2155, 2447) 2179 (2068, 2289) -122 (-305, 61) 0.15 12–24 Months After 1277 (1158, 1396) 2104 (1983, 2224) 827 (657, 996) < 0.01 0–24 Months After 3578 (3368, 3788) 4283 (4073, 4492) 704 (408, 1001) < 0.01 GLP = glucagon-like peptide, RA = receptor agonist, RYGB = Roux-en-Y gastric bypass, CI = confidence interval Of the 507 individuals treated with GLP-1 RAs, all started their treatment with semaglutide; 34 (6.7%) switched to tirzepatide within the first two years. Compared to their RYBG-treated matches, in both groups (those who only used semaglutide, and those who switched to tirzepatide), OOP costs were similar in the first year, and significantly higher than their second-year post treatment initiation (Table 3 ). In the two years after treatment initiation, individuals in the RYGB group saw $ 721 in savings compared to individuals who were just treated with semaglutide, whereas there was no significant difference in OOP costs when comparing individuals treated with semaglutide and tirzepatide compared with individuals who had a RYGB procedure. Table 3 Differences in Out-Of-Pocket Costs for Roux-en-Y Gastric Bypass and GLP-1 Ras, by type of GLP-1 RAs Prescriptions Filled GLP-1 RA Type/ Time Frame RYGB Mean $ GLP-1 RA Mean $ Difference $ (95% CI) p-value Semaglutide Only (N = 472 matches) 0–12 Months 2314 2206 -108 (-278, 61) 0.21 12–24 Months After 1296 2125 829 (670, 988) < 0.01 0–24 Months After 3611 4331 721 (459, 983) < 0.01 Semaglutide and Tirzepatide (N = 34 matches) 0–12 Months 2113 1799 -314 (-1023, 395) 0.37 12–24 Months After 1012 1805 793 (388, 1199) < 0.01 0–24 Months After 3143 2049 479 (-479, 1437) 0.32 GLP = glucagon-like peptide, RA = receptor agonist, RYGB = Roux-en-Y gastric bypass, CI = confidence interval Among the 472 individuals treated only with semaglutide, 399 (85.0%) filled Ozempic prescriptions only, 23 (4.9%) filled Ozempic and at least one other semaglutide prescription (Rybelsus, Wegovy), and 50 (10.6%) filled only a Rybelsus or Wegovy prescription. The OOP costs for individuals who filled only one type of semaglutide prescription were significantly higher in the two years after treatment initiation than the OOP costs seen among similar individuals who were treated with a RYGB procedure (Table 4 ). Table 4 Differences in Out-of-Pocket Costs for Roux-en-Y Gastric Bypass and type of Semaglutide Prescriptions Filled GLP-1 RA Type/ Time Frame RYGB Mean $ GLP-1 RA Mean $ Difference $ (95% CI) p-value Ozempic Only (n = 399 matches) 0–12 Months 2392 2201 -191 (-375, -8) 0.041 12–24 Months After 1304 2112 808 (639, 978) < 0.01 0–24 Months After 3697 4313 616 (338, 895) < 0.01 Rybelsus or Wegovy Only (n = 50 matches) 0–12 Months 1774 2280 506 (-65, 1079) 0.08 12–24 Months After 1162 2322 1161 (593, 1728) < 0.01 0–24 Months After 2936 4603 1667 (739, 2596) < 0.01 Ozempic and (Wegovy and/or Rybelsus) (n = 23 matches) 0–12 Months 2142 2135 -734 (-668, 653) 0.98 12–24 Months After 1442 1920 478 (-324, 1281) 0.23 0–24 Months After 3584 4056 471 (-824, 1766) 0.46 GLP = glucagon-like peptide, RA = receptor agonist, RYGB = Roux-en-Y gastric bypass, CI = confidence interval DISCUSSION In this study, we analyzed OOP healthcare costs in those with commercial insurance who have T2D and Class 2 or Class 3 obesity and were treated with either GLP-1 RAs or RYGB. OOP costs between the two groups were comparable in the first year whereas those who underwent RYGB patients experienced a significant decrease in OOP costs in the second year after treatment initiation. Patients who had RYGB, compared to continuous GLP-1 RA treatment, saved an average of $ 704 in OOP costs. Beyond OOP cost, there are other considerations for providers and patients when determining treatment plans for obesity and diabetes. These factors may include complications or side effects of RYGB and GLP-1 RAs, weight loss outcomes, durability of treatment, need for repeated treatment, and impact on diabetes remission or improvement. Adverse outcomes associated with these obesity treatment options are low. For RYGB patients, both short-term and long-term adverse outcomes must be considered. Anastomotic leak is a short-term complications associated with significant morbidity, including mortality, but is reported in less than 1% of patients.[ 31 – 32 ] Several studies reported an average long term complication rate of 18.5–21%.[ 33 – 34 ] The most common long-term complications reported post RYGB are nutritional deficiencies, weight regain, dumping syndrome and gastrointestinal complications and reoperation rates.[ 33 , 35 – 38 ] Common gastrointestinal complications included internal hernias, small bowel obstructions, marginal ulcers, and gallstone diseases.[ 37 ] Among patients requiring reoperation, internal hernias and small bowel obstructions remained prevalent, with additional occurrences of anastomotic strictures.[ 33 , 35 , 36 ] Adverse outcomes are also attributable to GLP-1 RAs, including high rates of gastrointestinal complications.[ 39 ] These adverse side effects have led to variability in compliance and adherence to GLP-1RAs treatment both in real world use [ 40 ] and in clinical trials,[ 39 ],[ 41 ] which must be discussed during encounters with patients seeking care for severe obesity and type 2 diabetes as such intolerance can impact treatment effectiveness. Despite usually being short-term and dose related, these side effects can be ongoing as well and there are a few trials that report potential long term complications.[ 42 – 45 ] In a trial assessing efficacy and safety of liraglutide, dose dependent gastrointestinal events were the most reported adverse events, especially nausea. While both treatment options are associated with some adverse outcomes, they are also effective treatment options for patients with obesity. RYGB results in significant long-term weight loss, with studies reporting 10-year excess weight loss of 54–71%.[ 35 ],[ 46 – 48 ] In long-term follow-up, Barberá-Carbonell et al ., report of 28.4 and 26.7%TBWL at 15 and 20 years after RYGB, respectively.[ 34 ] As a treatment modality, there is little long-term data on weight loss outcomes associated with latest generation GLP-1RA medications. Some studies have reported a mean %TBWL with weekly semaglutide 2.4mg of 13–16% at 68 weeks.[ 48 – 50 ] Xie et al ., confirm that the magnitude of weight loss is dose-dependent and greater with longer treatment duration, higher baseline BMI, and in individuals without diabetes.[ 48 ] A few studies have compared weight loss outcomes between the RYGB and GLP-1RA, and have reported RYGB to be superior.[ 51 – 51 ] In the systematic review by Sarm et al ., the mean difference in weight and BMI between RYGB and GLP-1RAs was − 22.8kg and − 10.6kg/m 2 , respectively.[ 51 ] In a matched comparative study, Wu et al . similarly showed superior weight loss and metabolic improvement with bariatric surgery over medication.[ 52 ] Gastric bypass and GLP-1RAs have also been shown to be impactful on the remission or improvement of T2D. Numerous studies have shown the impact of RYGB on T2DM remission.[ 53 – 56 ] McTigue et al ., in comparing RYGB and sleeve gastrectomy reported T2DM remission rate of 86.1% at 5 years.[ 53 ], while Purnell et al . reported 7-year remission rate of 46%.[ 55 ] In the short-term, GLP-1 RAs have also been shown to impact diabetes remission.[ 52 , 57 – 59 ] Wilding et al. showed that 84% of patients treated with once a week semaglutide 2.4 mg reverted to normoglycemia by the end of 68 weeks.[ 59 ] In the clinical trial by Jastreboff et al ., GLP1-RA use on obese and prediabetic patients resulted in 99% of patients treated with tirzepatide remaining diabetes free at the end of 176 weeks.[ 58 ] However, the impact of GLP-1 RA on T2D remission may be reversed once such medications are withdrawn or discontinued, as highlighted by Shi et al .[ 57 ] While there is a risk of T2D remission also after RYGB, the effects of the operation on T2D remission can be long-lasting for many patients, presenting a potential advantage of of RYGB over GLP-1 RA medications. Healthcare expenditure for the treatment of obesity and related conditions is estimated to be $ 260– $ 385 billion annually.[ 60 ] Such cost may represent direct and indirect cost associated with hospitalization, management of complications, medications, or outpatient visits/encounters.[ 61 ] Cost distribution associated with RYGB compared to GLP-1 RA treatment varies. RYGB tend to have a higher upfront cost related to the patients’ operative care [ 62 ], whereas cost associated with GLP-1 RA is distributed more longitudinally.[ 63 ] Often excluded in cost analyses studies comparing treatment options for obesity and diabetes is the OOP cost to patients over time. We have previously reported on OOP cost for patients with obesity and diabetes treated with sleeve gastrectomy (SG) compared to GLP-1 RA, showing that the 2-year OOP costs were significantly lower for the SG cohort.[ 14 ] In a cost-analysis study, Docimo et.al . utilized the 2015 Premier database to compare cost associated with GLP-1 RA and RYGB. After adjusting for inflation, 2023 RYGB costs was estimated to be $ 17,877.64 whereas GLP1-RAs monthly average maintenance was $ 1305.37.[ 64 ] They estimate that the maintenance cost for GLP1-RA treatment would surpass the estimated RYGB cost within about 14-months. A primary limitation of the Docimo et al . study is that they are comparing Premier, which calculates hospital costs for providing surgery, with GoodRx, which is what patients pay for GLP-1RAs without insurance,[ 64 ] whereas our study evaluates OOP cost to patients with insurance, receiving either treatment modality. The difference in OOP cost for RYGB and GLP-1 RAs treatment, if significant, may lead to nonadherence which can impact follow-up, treatment compliance, and treatment effectiveness. In their study assessing 30 day OOP costs and GLP-1RA use, Zhang et al . found that high OOP cost for GLP1-RA was associated with nonadherence.[ 65 ] Prior studies have shown that this non-adherence can impact outcomes such as weight loss and diabetes remission[ 28 ],[ 39 ],[ 49 ],[ 57 ]. Mody et al . assessed the efficacy of adhering to different types of GLP-1RA, and highlighted that treatment adherence resulted in excellent glycemic control; and that nonadherence is the main reason for reduced efficacy of GLP-1RA on improving HbA1C levels noted between clinical practice and clinical trials.[ 28 ] This importance of ongoing adherence to GLP-1 RA to optimize outcomes, including preventing weight regain and recurrence of resolved or improved obesity-related condition, has been reinforced by Arrone et al . in the SURMOUNT-4 trials.[ 39 ]. There remains a paucity of literature focusing on OOP costs to patients undergoing different treatment options for severe obesity and diabetes. In this matched comparative study, we have shown that two years after treatment initiation, the OOP cost to patients was significantly higher for GLP-1 RAs treated cohort in comparison to treatment with RYGB. While there are many strengths to our study, there are also limitations. While the strength of using claims databases for such studies is leveraging large-scale cohorts, such databases have several limitations including the potential for study biases related to incomplete and inaccurate data (e.g. diagnostic and procedure codes) capture. Unlike other claims healthcare databases that may lack information on medication prescription and cost, the Merative™ database does, representing a strength of the data used for this study. Nonetheless, the database does lack clinical depth and granularity; as a result, we were not able to leverage the database to assess comparative impact on outcomes (e.g. weight loss and diabetes remission) for the two treatment modalities for obesity and diabetes evaluated. We used BMI diagnostic codes in our matching algorithm as the Merative database lacks specific weight data. This is a limitation because as BMI increases, the diagnostic codes become less precise and may have resulted in less accuracy in matching for those with a BMI over 40kg/m 2 . Cost associated with RYGB may also be impacted by variables not captured in the database, such as surgical approach. Some studies have reported higher costs associated with bariatric cases performed robotically. However, while this may impact on the overall cost of care, it may not have any impact on OOP cost to the patient. It is reported that about 30% of individuals who initiate semaglutide stop using it within the first year [ 24 ]. This may be due to a variety of reasons, including side effects, drug availability or direct costs to patients. The GLP-1 RA cohort analyzed in this study either did not experiencing significant side effects or adjusted to such side effects and had no other barriers to medication access, as they were able to have continuous GLP-1 RA access and use for at least 2-years after treatment initiation. This cohort may represent a best-case scenario for GLP-1 RAs adherence and may not be generalizable to the broader GLP-1 RA medication use population. Two-year follow-up after bariatric surgery, including RYGB, is considered intermediate-term follow-up, and may not account for needed beyond 2-years to achieve long-term weight loss and glycemic control. Given the current lack of longer-term data for GLP-1 RAs, long-term comparative impact of these treatment modalities is not feasible but should be assessed in future studies. The matching process also reduced the sample size of the two treatment cohrts analyzed, which limits the generalizability of these results. Lastly, these are insured patients only. We don’t have cost data related to patients going outside of their insurers to get access to GLP-1RAs, including patients going through manufacturer direct pay programs, compounding pharmacies or online wellness/weight loss programs like Hims and Hers. This remains a moving target as the availability of new GLP-1RAs, including oral formulations or FDA approval of foreign developed GLP-1RAs may lead to downward pricing pressures affecting OOP cost to patients. CONCLUSION While GLP-1 RAs and RYGB are both effective treatments for obesity with T2D, they have very different financial implications for patients. Despite RYGB having an upfront higher OOP cost, the monthly OOP costs of GLP-1 RAs over a period of one year is similar. Over a period of two years, individuals on a GLP-1RAs therapeutic regimen spend more in OOP costs than patients who undergo RYGB. It is important for physicians to consider the cost differences in therapy regimens to counsel patients in making an informed decision whether to pursue surgery or pharmacotherapy as an initial treatment for obesity with T2D. Declarations Author Contribution S.T. assisted with drafting and revising the manuscript.E.W. assisted with drafting of original manuscript text and provided critical revisionY.L. performed statistical analysis, created result tables and figures, and assisted with manuscript revision.F.Z. performed critical review M.A.E. References Ruze R, Liu T, Zou X, Song J, Chen Y, Xu R, Yin X, Xu Q. Obesity and type 2 diabetes mellitus: connections in epidemiology, pathogenesis, and treatments. Front Endocrinol 2023;14:1161521. https://doi.org/10.3389/fendo.2023.1161521. Khan MAB, Hashim MJ, King JK, Govender RD, Mustafa H, Al Kaabi J. Epidemiology of Type 2 Diabetes – Global Burden of Disease and Forecasted Trends. 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07:44:40","extension":"html","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":188217,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7623447/v1/153d93f8016dc2b69e7cdc9d.html"},{"id":95795734,"identity":"fbae4b81-b5fa-4de0-9094-3122df59f7dc","added_by":"auto","created_at":"2025-11-13 07:44:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":576038,"visible":true,"origin":"","legend":"\u003cp\u003eConsort diagram\u003c/p\u003e","description":"","filename":"Figure1.Consortdiagram.docx.png","url":"https://assets-eu.researchsquare.com/files/rs-7623447/v1/bae5bf51dc4915c7d4172fc8.png"},{"id":99545535,"identity":"f2fd21eb-a2ef-4589-8f37-1e27cba833a9","added_by":"auto","created_at":"2026-01-05 16:08:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1675534,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7623447/v1/1f500612-1433-41ee-8b45-12a3fedcb91b.pdf"},{"id":95795741,"identity":"713f45d8-1fbc-4250-a1f4-b6602bcee017","added_by":"auto","created_at":"2025-11-13 07:44:40","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":25411,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementTableS1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7623447/v1/b529ba204efe50828589dcf1.docx"},{"id":95818628,"identity":"8a0b404c-0116-4536-ab4d-eb4dfe223d27","added_by":"auto","created_at":"2025-11-13 10:21:05","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":27381,"visible":true,"origin":"","legend":"","description":"","filename":"SupplmentTableS2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7623447/v1/8a11acbb3b4664df7195c2f3.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Roux-en-Y Gastric Bypass Compared to Glucagon-like Peptide-1 Receptor Agonists is Associated with Lower Out-of-Pocket Costs in Insured Patients with Type 2 Diabetes and Obesity","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eSevere obesity and type 2 diabetes (T2D) remains public health challenges placing significant burdens on the global economy.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Obesity has a strong association with T2D.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Among individuals with both conditions, weight management and glycemic control are essential to reducing long-term morbidity. In these patients, Glucagon-like Peptide-1 Receptor Agonists (GLP-1 RAs) [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and Roux-en-Y gastric bypass (RYGB) [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] are two treatment options that can significantly impact weight loss and control of T2D. The choice to proceed with a GLP-1 RAs or bariatric surgery as initial therapy involves a complex shared decision with considerations related to tolerability of side effects and complications, durability of treatment, compliance with treatment, and financial implications for health systems, insurers, and patients.\u003c/p\u003e\u003cp\u003eHigher cost sharing, deductibles, and consumer-directed health plans can create a financial burden even for patients with private insurance, making it difficult for them to afford care [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] and increasing their out-of-pocket (OOP) expenses.[\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] We have previously shown that OOP patient cost difference between sleeve gastrectomy (SG) and Ozempic was similar at one year whereas SG patients spent considerably less by the end of two years.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] While SG and RYGB are effective treatments for patients with severe obesity[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] prior studies have shown that RYGB leads to greater weight loss and higher rates of diabetes resolution[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] but is more costly to patients from an OOP perspective when compared to SG.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] To date, no studies have evaluated the OOP cost to patients for RYGB compared to GLP-1 RAs. Furthermore, new GLP-1 RAs have entered the US market since our analysis comparing OOP cost for SG compared to Ozempic. The introduction of these new GLP-1 RAs may have resulted in downward pricing pressure leading to OOP cost savings for patients.\u003c/p\u003e\u003cp\u003eRoux-en-Y is considered the gold standard for weight loss operations[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and remains the second most performed MBS.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e],[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] As GLP-1 RA options continue to evolve, the goal of our study is to analyze out-of-pocket healthcare costs to commercially insured RYGB and GLP-1 RA patients with class 2 or 3 obesity and T2D, two years after treatment initiation. We aim to provide real world cost data from patients who have chosen these two different treatment pathways, enabling more data driven conversations between obesity care providers and their patients.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eData Source\u003c/h2\u003e\u003cp\u003eThe 2017\u0026ndash;2023 Merative\u0026trade; MarketScan Research Databases (Merative\u0026trade;) were used for this cohort study. This retrospective claims data source is an aggregated registry of insured employees and their dependents, and includes data on healthcare services used, including inpatient, outpatient, and prescription drug services.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eType 2 Diabetes Inclusion\u003c/h3\u003e\n\u003cp\u003eType 2 diabetes was assigned to patients who had at least one diagnostic claim for T2D and at least one pharmacy claim for diabetes during the year preceding treatment initiation. The International Classification of Diseases (ICD-10) used to identify T2D included code E11.xx.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] Pharmacy claims related to diabetes were identified using National Drug Codes (NDCs) for diabetes medication, including Metformin, alpha-glucosidase inhibitors, amylin analogs, antidiabetic combinations, dipeptidyl peptidase-4 (DPP-4) inhibitors, meglitinides, sodium glucose co-transporter-2 (SGLT-2) inhibitors, sulfonylureas, thiazolidinediones, and Insulin.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e\n\u003ch3\u003eObesity Inclusion\u003c/h3\u003e\n\u003cp\u003eInpatient and outpatient claims were used to identify body mass index (BMI). Using such claims data, Class 2 (BMI 35-39.9 kg/m\u003csup\u003e2\u003c/sup\u003e) and Class 3 (BMI\u0026thinsp;\u0026ge;\u0026thinsp;40 kg/m\u003csup\u003e2\u003c/sup\u003e) obesity were determined using several ICD-10 codes (Z68.35-Z68.39, Z68.4x). Pre-treatment obesity was assigned to patients who had at least one obesity claim with a BMI\u0026thinsp;\u0026ge;\u0026thinsp;35 kg/m\u003csup\u003e2\u003c/sup\u003e during the year preceding treatment initiation. During this period, if patients had more than one obesity-related claim, the one closest to treatment initiation was used.\u003c/p\u003e\n\u003ch3\u003eTreatments Cohorts\u003c/h3\u003e\n\u003cp\u003eRYGB and GLP-1 RAs as treatment options for severe obesity and T2D were compared. Using inpatient admissions and outpatient services claims, RYGB was identified using CPT-4 codes (43633, 43644, 43645, 43846, 43847) and ICD-10 Procedural codes (0D16079, 0D1607A, 0D160J9, 0D160JA, 0D160K9, 0D160KA, 0D160Z9, 0D160ZA, 0D1607A, 0D160JA, 0D160KA, 0D160ZA, 0D1687A, 0D168JA, 0D168K9, 0D168KA, 0D168ZA, 0D168Z9, 0D16879, 0D1687A, 0D168ZA, 0D168J9, 0D16479, 0D1647A, 0D164J9, 0D164JA, 0D164K9, 0D164KA, 0D164Z9, 0D164ZA).[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eGLP-1 RAs were identified in Redbook\u0026trade; using NDCs. In the prescription claims drug registry, these codes identified individuals who filled a prescription for semaglutide or tirzepatide (\u003cem\u003esee Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e for specific NDC codes used\u003c/em\u003e). The GLP-1 RA cohort had to meet three requirements for inclusion: 1) continuous prescriptions in the two years after the first prescription was filled, 2) a prescription gap that was 45 days or less, and 3) at least 80% of the days covered with prescriptions in the two years after initiating GLP-1RA medications.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] Patients not meeting the above criteria were excluded from the GLP-1 RA cohort.\u003c/p\u003e\n\u003ch3\u003eCohort\u003c/h3\u003e\n\u003cp\u003eEven though our study period is 2017 to 2023, our study cohort was limited to adult patients in the 2017 to 2021 Merative data registry, ages 21 to 65 years, with class 2 or 3 obesity and T2D. This was feasible as the first semaglutide prescriptions were documented in the registry in 2018, and those included in the study needed to have at least 2-years of follow-up from index treatment date. Those assigned to the RYGB cohort did not have any documented GLP-1 RA prescriptions filled. Those assigned to the GLP-1 RA cohort had no documentation of a bariatric procedure performed. Both study cohorts had T2D, an insurance covered prescription plan, and continuous insurance coverage 1-year before treatment initiation that continued for at least 2-years following index treatment date. For the GLP-1 RA cohort, this included filling at least 2-years of GLP-1 RA supply after initiating this treatment. Following exclusions, we compared outcomes in those treated with RYGB (n\u0026thinsp;=\u0026thinsp;1,350) and GLP-1 RAs (n\u0026thinsp;=\u0026thinsp;2,908) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eOut-of-Pocket Healthcare Costs\u003c/h2\u003e\u003cp\u003eOOP healthcare costs were assessed up to 2-years after treatment initiation. For the RYGB cohort, RYGB-related cost was included in overall OOP cost at 1-year after treatment initiation. All dollar amounts paid directly to a healthcare provider or pharmacy by patients were used to determine OOP cost,[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] which was adjusted to 2023 constant dollars leveraging the Medical Care component of the Bureau of Labor Statistics Consumer Price Index (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.bls.gov/cpi/\u003c/span\u003e\u003cspan address=\"http://www.bls.gov/cpi/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). To reduce potential biases associated with extreme outliers, we truncated costs for inpatient admissions and outpatient services at the 1st and 99th percentile.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eWe performed a 1:1 matched analysis of the RYGB and GLP-1 RA cohorts using greedy nearest neighbor propensity scores,[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and compared OOP costs. Matching covariates included patient demographics such as age and BMI, obesity-related associated medical conditions, (\u003cem\u003esee Table \u003cspan refid=\"MOESM2\" class=\"InternalRef\"\u003eS2\u003c/span\u003e for ICD-10 codes used to identify these conditions\u003c/em\u003e), whether they had an inpatient admission, and OOP healthcare costs in the year before index treatment date. We assessed balance diagnostics to ensure that the matched groups were balanced on all baseline characteristics. Covariates were considered balanced if the standardized difference was \u0026le;\u0026thinsp;0.25.[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eBetween treatment cohorts, differences in OOP costs up to 2-years from treatment initiation were compared using paired t-tests. Given the different GLP-1 RAs included in this study, we also examined whether differences in OOP costs for patients treated with GLP-1 RAs differed from their matches based on whether they had been treated with semaglutide or tirzepatide. For most of the study window, only semaglutide was approved for use; therefore, most patients treated with GLP-1 RAs are expected to only have filled semaglutide prescriptions. Among these patients we also examined whether the type of semaglutide \u0026ndash; Wegovy, Ozempic, or Rybelsus \u0026ndash; impacted OOP cost comparisons with their matched RYGB cohort. This article follows the STROBE statement for conducting cohort studies.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003eThe study utilized de-identified patient data available in the Merative\u0026trade; database. As such, Institutional Review Board approval and consent were exempt for the observational study in accordance with the Health Insurance Portability and Accountability Act Privacy Rule.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e4,258 cases met inclusion criteria, including 1,350 (31.7%) in the RYGB treatment and 2,908 (68.3%) in the GLP-1 RA treatment cohorts (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In unmatched cohort analyses, the RYGB group were more likely to be younger, female, have a higher BMI, and obesity-associated medical conditions when compared to the GLP-1 RA group. After propensity score matching, baseline characteristics for the 506 RYGB and 506 GLP-1 RA treated individuals were balanced.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline Characteristics among those who had type 2 diabetes and Class 2 or Class 3 Obesity at Baseline, by Treatment Type\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eBaseline Characteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eUnmatched Cohort\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e\u003cp\u003eMatched Cohort\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRYGB\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;1,350)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGLP-1 RA\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;2,908)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAbsolute Standardized Mean Difference\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRYGB\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;506)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eGLP-1 RA \u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;506)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eAbsolute Standardized Mean Difference\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBaseline BMI, Mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e43.4 (6.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40.8 (5.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.437\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e41.5 (4.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e41.5 (4.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge; Mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47.9 (8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51.0 (7.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.378\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e50.5 (6.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e50.6 (6.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOut-of-Pocket Healthcare Costs, Mean\u003csup\u003ea\u003c/sup\u003e (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2242 (1618)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2050 (1540)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.122\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1755 (998)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1753 (999)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale Sex, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e384 (28.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1594 (54.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.352\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e167 (33.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e190 (37.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInpatient Admission\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e101 (7.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e286 (9.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.084\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e26 (5.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e25 (4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.007\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eObesity-Related Comorbidities, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypertension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1059 (78.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2313 (79.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.027\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e393 (77.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e398 (78.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDyslipidemia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e974 (72.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2224 (76.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e383 (75.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e380 (75.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e796 (59.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e974 (33.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.528\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e241 (47.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e234 (46.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.029\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnee OA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e159 (11.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e289 (9.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.059\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e50 (9.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e57 (11.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.044\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGERD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e753 (55.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e467 (16.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.909\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e161 (31.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e132 (26.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.131\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMAFLD/MASH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e282 (20.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e300 (10.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.294\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e78 (15.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e50 (9.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.154\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of Obesity-Related Comorbidities, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27 (2.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e129 (4.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.138\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12 (2.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e23 (4.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.123\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e127 (9.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e515 (17.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.244\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e72 (14.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e66 (13.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.035\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3+\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1196 (88.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2264 (77.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.290\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e422 (83.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e417 (82.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.027\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eRYGB\u0026thinsp;=\u0026thinsp;Roux-en-Y Gastric Bypass, GLP-1 RA\u0026thinsp;=\u0026thinsp;Glucagon-like Peptide-1 Receptor Agonist, BMI\u0026thinsp;=\u0026thinsp;body mass index, SD\u0026thinsp;=\u0026thinsp;standard deviation, OSA\u0026thinsp;=\u0026thinsp;obstructive sleep apnea, OA\u0026thinsp;=\u0026thinsp;osteoarthritis, GERD\u0026thinsp;=\u0026thinsp;gastroesophageal reflux disease, MAFLD\u0026thinsp;=\u0026thinsp;metabolic dysfunction associated fatty liver disease, MASH\u0026thinsp;=\u0026thinsp;metabolic dysfunction-associated steatohepatitis\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e \u003cem\u003eIn the year before the Index Date\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn 1-year after the treatment initiation date, OOP healthcare costs were similar between the RYGB (\u003cspan\u003e$\u003c/span\u003e2,301) and GLP-1 RAs (\u003cspan\u003e$\u003c/span\u003e2,179) treatment groups (difference = \u003cspan\u003e$\u003c/span\u003e122, p\u0026thinsp;=\u0026thinsp;0.15) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). However, OOP healthcare costs in the second year following treatment initiation were significantly less in the RYGB cohort (\u003cspan\u003e$\u003c/span\u003e1,277) compared to the GLP-1 RAs (\u003cspan\u003e$\u003c/span\u003e2,104) (difference = \u003cspan\u003e$\u003c/span\u003e327; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). 2years following index treatment date, on average, having a RYGB was associated with \u003cspan\u003e$\u003c/span\u003e704 less in OOP healthcare costs, compared to treatment with GLP-1 RAs (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDifferences in Out-of-Pocket Costs for Roux-en-Y Gastric Bypass and GLP-1 Ras\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTime Frame\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eRYGB\u003c/p\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGLP-1 RA\u003c/p\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003eDifference\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u0026ndash;12 Months After\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2301\u003c/p\u003e\u003cp\u003e(2155, 2447)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2179\u003c/p\u003e\u003cp\u003e(2068, 2289)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-122\u003c/p\u003e \u003cp\u003e(-305, 61)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u0026ndash;24 Months After\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1277\u003c/p\u003e\u003cp\u003e(1158, 1396)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2104\u003c/p\u003e\u003cp\u003e(1983, 2224)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e827\u003c/p\u003e\u003cp\u003e(657, 996)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u0026ndash;24 Months After\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3578\u003c/p\u003e\u003cp\u003e(3368, 3788)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4283\u003c/p\u003e\u003cp\u003e(4073, 4492)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e704\u003c/p\u003e\u003cp\u003e(408, 1001)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eGLP\u0026thinsp;=\u0026thinsp;glucagon-like peptide, RA\u0026thinsp;=\u0026thinsp;receptor agonist, RYGB\u0026thinsp;=\u0026thinsp;Roux-en-Y gastric bypass, CI\u0026thinsp;=\u0026thinsp;confidence interval\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOf the 507 individuals treated with GLP-1 RAs, all started their treatment with semaglutide; 34 (6.7%) switched to tirzepatide within the first two years. Compared to their RYBG-treated matches, in both groups (those who only used semaglutide, and those who switched to tirzepatide), OOP costs were similar in the first year, and significantly higher than their second-year post treatment initiation (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In the two years after treatment initiation, individuals in the RYGB group saw \u003cspan\u003e$\u003c/span\u003e721 in savings compared to individuals who were just treated with semaglutide, whereas there was no significant difference in OOP costs when comparing individuals treated with semaglutide and tirzepatide compared with individuals who had a RYGB procedure.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDifferences in Out-Of-Pocket Costs for Roux-en-Y Gastric Bypass and GLP-1 Ras, by type of GLP-1 RAs Prescriptions Filled\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGLP-1 RA Type/ Time Frame\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eRYGB Mean \u003cspan\u003e$\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGLP-1 RA Mean \u003cspan\u003e$\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eDifference\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eSemaglutide Only (N\u0026thinsp;=\u0026thinsp;472 matches)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u0026ndash;12 Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2314\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2206\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-108 (-278, 61)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u0026ndash;24 Months After\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1296\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e829 (670, 988)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u0026ndash;24 Months After\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3611\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4331\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e721 (459, 983)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSemaglutide and Tirzepatide (N\u0026thinsp;=\u0026thinsp;34 matches)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u0026ndash;12 Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2113\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1799\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-314 (-1023, 395)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u0026ndash;24 Months After\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1805\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e793 (388, 1199)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u0026ndash;24 Months After\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3143\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2049\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e479 (-479, 1437)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eGLP\u0026thinsp;=\u0026thinsp;glucagon-like peptide, RA\u0026thinsp;=\u0026thinsp;receptor agonist, RYGB\u0026thinsp;=\u0026thinsp;Roux-en-Y gastric bypass, CI\u0026thinsp;=\u0026thinsp;confidence interval\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAmong the 472 individuals treated only with semaglutide, 399 (85.0%) filled Ozempic prescriptions only, 23 (4.9%) filled Ozempic and at least one other semaglutide prescription (Rybelsus, Wegovy), and 50 (10.6%) filled only a Rybelsus or Wegovy prescription. The OOP costs for individuals who filled only one type of semaglutide prescription were significantly higher in the two years after treatment initiation than the OOP costs seen among similar individuals who were treated with a RYGB procedure (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDifferences in Out-of-Pocket Costs for Roux-en-Y Gastric Bypass and type of Semaglutide Prescriptions Filled\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGLP-1 RA Type/ Time Frame\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eRYGB Mean \u003cspan\u003e$\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGLP-1 RA Mean \u003cspan\u003e$\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eDifference\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cspan\u003e$\u003c/span\u003e (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eOzempic Only (n\u0026thinsp;=\u0026thinsp;399 matches)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u0026ndash;12 Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2392\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2201\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-191 (-375, -8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.041\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u0026ndash;24 Months After\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1304\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e808 (639, 978)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u0026ndash;24 Months After\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3697\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4313\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e616 (338, 895)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRybelsus or Wegovy Only (n\u0026thinsp;=\u0026thinsp;50 matches)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u0026ndash;12 Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1774\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2280\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e506 (-65, 1079)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u0026ndash;24 Months After\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1162\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2322\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1161 (593, 1728)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u0026ndash;24 Months After\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2936\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4603\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1667 (739, 2596)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOzempic and (Wegovy and/or Rybelsus) (n\u0026thinsp;=\u0026thinsp;23 matches)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u0026ndash;12 Months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2142\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2135\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-734 (-668, 653)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.98\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u0026ndash;24 Months After\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1442\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1920\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e478 (-324, 1281)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u0026ndash;24 Months After\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3584\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4056\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e471 (-824, 1766)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.46\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eGLP\u0026thinsp;=\u0026thinsp;glucagon-like peptide, RA\u0026thinsp;=\u0026thinsp;receptor agonist, RYGB\u0026thinsp;=\u0026thinsp;Roux-en-Y gastric bypass, CI\u0026thinsp;=\u0026thinsp;confidence interval\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this study, we analyzed OOP healthcare costs in those with commercial insurance who have T2D and Class 2 or Class 3 obesity and were treated with either GLP-1 RAs or RYGB. OOP costs between the two groups were comparable in the first year whereas those who underwent RYGB patients experienced a significant decrease in OOP costs in the second year after treatment initiation. Patients who had RYGB, compared to continuous GLP-1 RA treatment, saved an average of \u003cspan\u003e$\u003c/span\u003e704 in OOP costs. Beyond OOP cost, there are other considerations for providers and patients when determining treatment plans for obesity and diabetes. These factors may include complications or side effects of RYGB and GLP-1 RAs, weight loss outcomes, durability of treatment, need for repeated treatment, and impact on diabetes remission or improvement. Adverse outcomes associated with these obesity treatment options are low. For RYGB patients, both short-term and long-term adverse outcomes must be considered. Anastomotic leak is a short-term complications associated with significant morbidity, including mortality, but is reported in less than 1% of patients.[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] Several studies reported an average long term complication rate of 18.5\u0026ndash;21%.[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] The most common long-term complications reported post RYGB are nutritional deficiencies, weight regain, dumping syndrome and gastrointestinal complications and reoperation rates.[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan additionalcitationids=\"CR36 CR37\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] Common gastrointestinal complications included internal hernias, small bowel obstructions, marginal ulcers, and gallstone diseases.[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] Among patients requiring reoperation, internal hernias and small bowel obstructions remained prevalent, with additional occurrences of anastomotic strictures.[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eAdverse outcomes are also attributable to GLP-1 RAs, including high rates of gastrointestinal complications.[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] These adverse side effects have led to variability in compliance and adherence to GLP-1RAs treatment both in real world use [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] and in clinical trials,[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e],[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] which must be discussed during encounters with patients seeking care for severe obesity and type 2 diabetes as such intolerance can impact treatment effectiveness. Despite usually being short-term and dose related, these side effects can be ongoing as well and there are a few trials that report potential long term complications.[\u003cspan additionalcitationids=\"CR43 CR44\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] In a trial assessing efficacy and safety of liraglutide, dose dependent gastrointestinal events were the most reported adverse events, especially nausea.\u003c/p\u003e\u003cp\u003eWhile both treatment options are associated with some adverse outcomes, they are also effective treatment options for patients with obesity. RYGB results in significant long-term weight loss, with studies reporting 10-year excess weight loss of 54\u0026ndash;71%.[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e],[\u003cspan additionalcitationids=\"CR47\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] In long-term follow-up, Barber\u0026aacute;-Carbonell \u003cem\u003eet al\u003c/em\u003e., report of 28.4 and 26.7%TBWL at 15 and 20 years after RYGB, respectively.[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] As a treatment modality, there is little long-term data on weight loss outcomes associated with latest generation GLP-1RA medications. Some studies have reported a mean %TBWL with weekly semaglutide 2.4mg of 13\u0026ndash;16% at 68 weeks.[\u003cspan additionalcitationids=\"CR49\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] Xie \u003cem\u003eet al\u003c/em\u003e., confirm that the magnitude of weight loss is dose-dependent and greater with longer treatment duration, higher baseline BMI, and in individuals without diabetes.[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] A few studies have compared weight loss outcomes between the RYGB and GLP-1RA, and have reported RYGB to be superior.[\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e] In the systematic review by Sarm \u003cem\u003eet al\u003c/em\u003e., the mean difference in weight and BMI between RYGB and GLP-1RAs was \u0026minus;\u0026thinsp;22.8kg and \u0026minus;\u0026thinsp;10.6kg/m\u003csup\u003e2\u003c/sup\u003e, respectively.[\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e] In a matched comparative study, Wu \u003cem\u003eet al\u003c/em\u003e. similarly showed superior weight loss and metabolic improvement with bariatric surgery over medication.[\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eGastric bypass and GLP-1RAs have also been shown to be impactful on the remission or improvement of T2D. Numerous studies have shown the impact of RYGB on T2DM remission.[\u003cspan additionalcitationids=\"CR54 CR55\" citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e] McTigue \u003cem\u003eet al\u003c/em\u003e., in comparing RYGB and sleeve gastrectomy reported T2DM remission rate of 86.1% at 5 years.[\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], while Purnell \u003cem\u003eet al\u003c/em\u003e. reported 7-year remission rate of 46%.[\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e] In the short-term, GLP-1 RAs have also been shown to impact diabetes remission.[\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan additionalcitationids=\"CR58\" citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e] Wilding \u003cem\u003eet al.\u003c/em\u003e showed that 84% of patients treated with once a week semaglutide 2.4 mg reverted to normoglycemia by the end of 68 weeks.[\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e] In the clinical trial by Jastreboff \u003cem\u003eet al\u003c/em\u003e., GLP1-RA use on obese and prediabetic patients resulted in 99% of patients treated with tirzepatide remaining diabetes free at the end of 176 weeks.[\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e] However, the impact of GLP-1 RA on T2D remission may be reversed once such medications are withdrawn or discontinued, as highlighted by Shi \u003cem\u003eet al\u003c/em\u003e.[\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] While there is a risk of T2D remission also after RYGB, the effects of the operation on T2D remission can be long-lasting for many patients, presenting a potential advantage of of RYGB over GLP-1 RA medications.\u003c/p\u003e\u003cp\u003eHealthcare expenditure for the treatment of obesity and related conditions is estimated to be \u003cspan\u003e$\u003c/span\u003e260\u0026ndash;\u003cspan\u003e$\u003c/span\u003e385\u0026nbsp;billion annually.[\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e] Such cost may represent direct and indirect cost associated with hospitalization, management of complications, medications, or outpatient visits/encounters.[\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e] Cost distribution associated with RYGB compared to GLP-1 RA treatment varies. RYGB tend to have a higher upfront cost related to the patients\u0026rsquo; operative care [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e], whereas cost associated with GLP-1 RA is distributed more longitudinally.[\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e] Often excluded in cost analyses studies comparing treatment options for obesity and diabetes is the OOP cost to patients over time. We have previously reported on OOP cost for patients with obesity and diabetes treated with sleeve gastrectomy (SG) compared to GLP-1 RA, showing that the 2-year OOP costs were significantly lower for the SG cohort.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] In a cost-analysis study, Docimo \u003cem\u003eet.al\u003c/em\u003e. utilized the 2015 Premier database to compare cost associated with GLP-1 RA and RYGB. After adjusting for inflation, 2023 RYGB costs was estimated to be \u003cspan\u003e$\u003c/span\u003e17,877.64 whereas GLP1-RAs monthly average maintenance was \u003cspan\u003e$\u003c/span\u003e1305.37.[\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e] They estimate that the maintenance cost for GLP1-RA treatment would surpass the estimated RYGB cost within about 14-months. A primary limitation of the Docimo \u003cem\u003eet al\u003c/em\u003e. study is that they are comparing Premier, which calculates hospital costs for providing surgery, with GoodRx, which is what patients pay for GLP-1RAs without insurance,[\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e] whereas our study evaluates OOP cost to patients with insurance, receiving either treatment modality.\u003c/p\u003e\u003cp\u003eThe difference in OOP cost for RYGB and GLP-1 RAs treatment, if significant, may lead to nonadherence which can impact follow-up, treatment compliance, and treatment effectiveness. In their study assessing 30 day OOP costs and GLP-1RA use, Zhang \u003cem\u003eet al\u003c/em\u003e. found that high OOP cost for GLP1-RA was associated with nonadherence.[\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e] Prior studies have shown that this non-adherence can impact outcomes such as weight loss and diabetes remission[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e],[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e],[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e],[\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Mody \u003cem\u003eet al\u003c/em\u003e. assessed the efficacy of adhering to different types of GLP-1RA, and highlighted that treatment adherence resulted in excellent glycemic control; and that nonadherence is the main reason for reduced efficacy of GLP-1RA on improving HbA1C levels noted between clinical practice and clinical trials.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] This importance of ongoing adherence to GLP-1 RA to optimize outcomes, including preventing weight regain and recurrence of resolved or improved obesity-related condition, has been reinforced by Arrone \u003cem\u003eet al\u003c/em\u003e. in the SURMOUNT-4 trials.[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThere remains a paucity of literature focusing on OOP costs to patients undergoing different treatment options for severe obesity and diabetes. In this matched comparative study, we have shown that two years after treatment initiation, the OOP cost to patients was significantly higher for GLP-1 RAs treated cohort in comparison to treatment with RYGB. While there are many strengths to our study, there are also limitations. While the strength of using claims databases for such studies is leveraging large-scale cohorts, such databases have several limitations including the potential for study biases related to incomplete and inaccurate data (e.g. diagnostic and procedure codes) capture. Unlike other claims healthcare databases that may lack information on medication prescription and cost, the Merative\u0026trade; database does, representing a strength of the data used for this study. Nonetheless, the database does lack clinical depth and granularity; as a result, we were not able to leverage the database to assess comparative impact on outcomes (e.g. weight loss and diabetes remission) for the two treatment modalities for obesity and diabetes evaluated. We used BMI diagnostic codes in our matching algorithm as the Merative database lacks specific weight data. This is a limitation because as BMI increases, the diagnostic codes become less precise and may have resulted in less accuracy in matching for those with a BMI over 40kg/m\u003csup\u003e2\u003c/sup\u003e. Cost associated with RYGB may also be impacted by variables not captured in the database, such as surgical approach. Some studies have reported higher costs associated with bariatric cases performed robotically. However, while this may impact on the overall cost of care, it may not have any impact on OOP cost to the patient. It is reported that about 30% of individuals who initiate semaglutide stop using it within the first year [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This may be due to a variety of reasons, including side effects, drug availability or direct costs to patients. The GLP-1 RA cohort analyzed in this study either did not experiencing significant side effects or adjusted to such side effects and had no other barriers to medication access, as they were able to have continuous GLP-1 RA access and use for at least 2-years after treatment initiation. This cohort may represent a best-case scenario for GLP-1 RAs adherence and may not be generalizable to the broader GLP-1 RA medication use population. Two-year follow-up after bariatric surgery, including RYGB, is considered intermediate-term follow-up, and may not account for needed beyond 2-years to achieve long-term weight loss and glycemic control. Given the current lack of longer-term data for GLP-1 RAs, long-term comparative impact of these treatment modalities is not feasible but should be assessed in future studies. The matching process also reduced the sample size of the two treatment cohrts analyzed, which limits the generalizability of these results. Lastly, these are insured patients only. We don\u0026rsquo;t have cost data related to patients going outside of their insurers to get access to GLP-1RAs, including patients going through manufacturer direct pay programs, compounding pharmacies or online wellness/weight loss programs like Hims and Hers. This remains a moving target as the availability of new GLP-1RAs, including oral formulations or FDA approval of foreign developed GLP-1RAs may lead to downward pricing pressures affecting OOP cost to patients.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eWhile GLP-1 RAs and RYGB are both effective treatments for obesity with T2D, they have very different financial implications for patients. Despite RYGB having an upfront higher OOP cost, the monthly OOP costs of GLP-1 RAs over a period of one year is similar. Over a period of two years, individuals on a GLP-1RAs therapeutic regimen spend more in OOP costs than patients who undergo RYGB. It is important for physicians to consider the cost differences in therapy regimens to counsel patients in making an informed decision whether to pursue surgery or pharmacotherapy as an initial treatment for obesity with T2D.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eS.T. assisted with drafting and revising the manuscript.E.W. assisted with drafting of original manuscript text and provided critical revisionY.L. performed statistical analysis, created result tables and figures, and assisted with manuscript revision.F.Z. performed critical review M.A.E.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRuze R, Liu T, Zou X, Song J, Chen Y, Xu R, Yin X, Xu Q. Obesity and type 2 diabetes mellitus: connections in epidemiology, pathogenesis, and treatments. 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Nutritional priorities to support GLP-1 therapy for obesity: a joint Advisory from the American College of Lifestyle Medicine, the American Society for Nutrition, the Obesity Medicine Association, and The Obesity Society. Am J Clin Nutr 2025;122:344\u0026ndash;67. https://doi.org/10.1016/j.ajcnut.2025.04.023.\u003c/li\u003e\n\u003cli\u003eDocimo S, Shah J, Warren G, Ganam S, Sujka J, DuCoin C. A cost comparison of GLP-1 receptor agonists and bariatric surgery: what is the break even point? Surg Endosc 2024;38:6560\u0026ndash;5. https://doi.org/10.1007/s00464-024-11191-1.\u003c/li\u003e\n\u003cli\u003eZhang D, Gencerliler N, Mukhopadhyay A, Blecker S, Grams ME, Wright DR, Wang VH-C, Rajan A, Butt E, Shin J-I, Xu Y, Chhabra KR, Divers J. Association of Patient Cost-Sharing With Adherence to GLP-1a and Adverse Health Outcomes. Diabetes Care 2025:dc242746. https://doi.org/10.2337/dc24-2746.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"obesity-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"obsu","sideBox":"Learn more about [Obesity Surgery](https://link.springer.com/journal/11695)","snPcode":"11695","submissionUrl":"https://submission.springernature.com/new-submission/11695/3","title":"Obesity Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7623447/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7623447/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo evaluate 2-year cost to insured patients treated with Roux-en-Y gastric bypass (RYGB) or glucagon-like peptide-1 receptor agonists (GLP-1 RAs) for type 2 diabetes (T2D) and obesity.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eUsing the 2017 to 2023 Merative\u0026trade; claims database, we identified adult patients with severe obesity and T2D who were treated with a RYGB or GLP-1 RAs. Patients with RYGB had no treatment with GLP-1 RAs, and those who received GLP-1 RA therapy with tirzepatide or semaglutide for \u0026ge;\u0026thinsp;2 years had no metabolic and bariatric surgery (MBS) procedures. The study cohorts were matched on demographics including obesity, associated medical problems, and baseline direct or out-of-pocket (OOP) costs to patients in the year prior to treatment initiation. Direct costs included those from outpatient services, inpatient admissions, and outpatient prescription filled that were paid directly by patients. We compared this cost up to two years after treatment initiation using paired t-tests.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003e1012 matched RYGB and GLP-1 RA patients were analyzed, including 35% male. At 1-year after treatment initiation, healthcare costs paid directly by patients were similar for the RYGB (\u003cspan\u003e$\u003c/span\u003e2,301) and GLP-1 RA (\u003cspan\u003e$\u003c/span\u003e2,179) (delta = \u003cspan\u003e$\u003c/span\u003e122, p\u0026thinsp;=\u0026thinsp;0.15) cohorts. From one to two years after index treatment date, OOP costs were significantly lower in the RYGB treatment group (\u003cspan\u003e$\u003c/span\u003e1,277 vs. \u003cspan\u003e$\u003c/span\u003e2,104, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Two years after treatment initiation, RYGB patients spent \u003cspan\u003e$\u003c/span\u003e704 less in OOP costs than similar patients treated with GLP-1 RA medications (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eDirect OOP healthcare costs were lower for RYGB compared to GLP-1 RA use patients 2-years after treatment initiation.\u003c/p\u003e","manuscriptTitle":"Roux-en-Y Gastric Bypass Compared to Glucagon-like Peptide-1 Receptor Agonists is Associated with Lower Out-of-Pocket Costs in Insured Patients with Type 2 Diabetes and Obesity","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-13 07:44:35","doi":"10.21203/rs.3.rs-7623447/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-17T16:08:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-13T06:34:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-06T16:33:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-06T12:09:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-05T14:20:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"139227022490461673823271312880765179128","date":"2025-11-05T10:41:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"202787870065113347938748868219040317537","date":"2025-11-03T06:09:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"153721998692821030147786176554688733051","date":"2025-11-03T01:54:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"169310732402629063530513634193981857758","date":"2025-11-02T16:13:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-01T15:39:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309322553635776087843374673410653369544","date":"2025-11-01T15:30:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-31T09:26:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-29T23:54:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"Obesity Surgery","date":"2025-10-22T01:33:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"obesity-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"obsu","sideBox":"Learn more about [Obesity Surgery](https://link.springer.com/journal/11695)","snPcode":"11695","submissionUrl":"https://submission.springernature.com/new-submission/11695/3","title":"Obesity Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"ec6a7562-494e-49e3-829f-dae94c344d8e","owner":[],"postedDate":"November 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-05T16:06:18+00:00","versionOfRecord":{"articleIdentity":"rs-7623447","link":"https://doi.org/10.1007/s11695-025-08467-3","journal":{"identity":"obesity-surgery","isVorOnly":false,"title":"Obesity Surgery"},"publishedOn":"2026-01-03 15:58:21","publishedOnDateReadable":"January 3rd, 2026"},"versionCreatedAt":"2025-11-13 07:44:35","video":"","vorDoi":"10.1007/s11695-025-08467-3","vorDoiUrl":"https://doi.org/10.1007/s11695-025-08467-3","workflowStages":[]},"version":"v1","identity":"rs-7623447","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7623447","identity":"rs-7623447","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}