Gastroenterology

Gastroenterology

Volume 143, Issue 3, September 2012, Pages 567-575
Gastroenterology

Original Research
Clinical—Alimentary Tract
The Cost Effectiveness of Radiofrequency Ablation for Barrett's Esophagus

https://doi.org/10.1053/j.gastro.2012.05.010Get rights and content

Background & Aims

Radiofrequency ablation (RFA) reduces the risk of esophageal adenocarcinoma (EAC) in patients with Barrett's esophagus (BE) with high-grade dysplasia (HGD), but its effects in patients without dysplasia are debatable. We analyzed the effectiveness and cost effectiveness of RFA for the management of BE.

Methods

We constructed a decision analytic Markov model. We conducted separate analyses of hypothetical cohorts of patients with BE with dysplasia (HGD or low-grade [LGD]) and without dysplasia. In the analysis of the group with HGD, we compared results of initial RFA with endoscopic surveillance with surgery when cancer was detected. In analyzing the group with LGD or no dysplasia, we compared 3 strategies: endoscopic surveillance with surgery when cancer was detected (S1), endoscopic surveillance with RFA when HGD was detected (S2), and initial RFA followed by endoscopic surveillance (S3).

Results

Among patients with HGD, initial RFA was more effective and less costly than endoscopic surveillance. Among patients with LGD, when S3 was compared with S2, the incremental cost-effectiveness ratio was $18,231/quality-adjusted life-year, assuming an annual rate of progression rate from LGD to EAC of 0.5%/year. For patients without dysplasia, S2 was more effective and less costly than S1. In a comparison of S3 with S2, the incremental cost-effectiveness ratios were $205,500, $124,796, and $118,338/quality-adjusted life-year using annual rates of progression of no dysplasia to EAC of 0.12%, 0.33%, or 0.5% per year, respectively.

Conclusions

By using updated data, initial RFA might not be cost effective for patients with BE without dysplasia, within the range of plausible rates of progression of BE to EAC, and be prohibitively expensive, from a policy perspective. RFA might be cost effective for confirmed and stable LGD. Initial RFA is more effective and less costly than endoscopic surveillance in HGD.

Section snippets

Model Design

A decision-analytic Markov-state transition model was constructed in TreeAge Pro (TreeAge, Williamstown, MA). Health states in the model included Barrett's esophagus (no dysplasia [ND]), LGD, HGD, completely eradicated intestinal metaplasia or dysplasia after RFA, buried crypt after RFA, after successful esophagectomy for cancer, inoperable or an incomplete resection of cancer, and death. Possible causes of death included age-related mortality, surgical mortality, EAC, and RFA complications.

Base-Case Results

The base-case analyses of the HGD and LGD cohorts are presented in Table 2. For the HGD analysis, the surveillance strategy with esophagectomy at the detection of cancer was dominated by the initial RFA strategy, resulting in 0.704 more QALYs and costing $25,609. For the LGD patients, surveillance with esophagectomy for cancer was dominated by the surveillance with RFA at HGD, with the latter strategy resulting in 0.17 more QALYs and costing $7446 less. In LGD patients, when comparing initial

Discussion

Our analysis found that radiofrequency ablation of Barrett's HGD appears appropriate because it is more effective and less costly than continued endoscopic surveillance with surgery when cancer is confirmed by biopsy.

The ablation of LGD costs more than continued surveillance with RFA when HGD is found; however, the improvement in QALYs results in an ICER that is below our willingness to pay threshold of $100,000/QALY, making it the most plausible strategy in terms of cost effectiveness. The

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    This article has an accompanying continuing medical education activity on page e20. Learning Objective: Upon completion of this educational exercise, successful learners will be able to demonstrate have an enhanced comprehension of cost-effectiveness analysis as applied to radiofrequency ablation for different grades of Barrett's esophagus.

    Conflicts of interest N.S.N.: Research support from BARRX Medical as a site for the HALO Patient Registry Study.

    Funding Supported by National Institutes of Health grants R01-CA140574 (C.H.), U01-CA152926 (C.H. and J.M.I.), K25-CA133141 (C.Y.K.), K23DK079291 (J.H.R.), and R03 DK089150 (J.H.R.).

    The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government (D.T.P.).

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