Elsevier

Gastrointestinal Endoscopy

Volume 79, Issue 2, February 2014, Pages 242-256.e6
Gastrointestinal Endoscopy

Original article
Clinical endoscopy
Cost-effectiveness of endoscopic surveillance of non-dysplastic Barrett's esophagus

https://doi.org/10.1016/j.gie.2013.07.046Get rights and content

Background

Endoscopic surveillance for non-dysplastic Barrett's esophagus (BE) is contentious and its cost effectiveness unclear.

Objective

To perform an economic analysis of endoscopic surveillance strategies.

Design

Cost-utility analysis by using a simulation Markov model to synthesize evidence from large epidemiologic studies and clinical data for surveillance, based on international guidelines, applied in a coordinator-managed surveillance program.

Setting

Tertiary care hospital, South Australia.

Patients

A total of 2040 patient-years of follow-up.

Intervention

(1) No surveillance, (2) 2-yearly endoscopic surveillance of patients with non-dysplastic BE and 6-monthly surveillance of patients with low-grade dysplasia, (3) a hypothetical strategy of biomarker-modified surveillance.

Main Outcome Measurements

U.S. cost per quality-adjusted life year (QALY) ratios.

Results

Compared with no surveillance, surveillance produced an estimated incremental cost per QALY ratio of $60,858. This was reduced to $38,307 when surveillance practice was modified by a hypothetical biomarker-based strategy. Sensitivity analyses indicated that the likelihood that surveillance alone was cost-effective compared with no surveillance was 16.0% and 60.6% if a hypothetical biomarker-based strategy was added to surveillance, at an acceptability threshold of $100,000 per QALY gained.

Limitations

Treatment options for BE that overlap those for symptomatic GERD were omitted.

Conclusion

By using best available estimates of the malignant potential of BE, endoscopic surveillance of patients with non-dysplastic BE is unlikely to be cost-effective for the majority of patients and depends heavily on progression rates between dysplasia grades. However, strategies that modify surveillance according to cancer risk might be cost-effective, provided that high-risk individuals can be identified and prioritized for surveillance.

Section snippets

Description of strategies

Three strategies were modeled: (1) no surveillance, (2) endoscopic surveillance alone, and (3) endoscopic surveillance modified by a hypothetical biomarker test. Endoscopic surveillance intervals were based on U.K. British Society of Gastroenterology guidelines—2-yearly for non-dysplastic BE with intestinal metaplasia (IM) and 6-monthly for BE with low-grade dysplasia (LGD).22 It was assumed that appropriate scheduling of endoscopies was achieved, mucosal biopsy specimens were collected by

Results

Over 30 years, the (discounted) mean cost per person for the surveillance alone strategy was $14,659, compared with $11,087 for surveillance modified by a biomarker test and $5226 for no surveillance. The corresponding mean QALYs were 12.192 for surveillance alone, 12.190 for the strategy of surveillance with biomarker testing, and 12.037 for no surveillance. On average, the additional benefit for both surveillance strategies was equivalent to 57 additional days in good quality of life.

Discussion

Our results indicated that the surveillance alone strategy, as presented here, is unlikely to be cost effective when compared with no surveillance. This result is uncertain, however, because of the volatility in the model that results from small variations in the progression rates between dysplasia grades and the subsequent development of adenocarcinoma. However, the cost effectiveness was markedly improved under the hypothetical scenario of biomarker testing, with acceptable limits of

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    DISCLOSURE: L. Gordon received support from an NHMRC Early Career Fellowship grant (no. 496714). D. Whiteman received funding from an Australian Research Council Future Fellowship. No other financial relationships relevant to this publication were disclosed.

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