Original Articles
Cost-effectiveness of screening a population with chronic gastroesophageal reflux☆,☆☆,★

https://doi.org/10.1067/mge.2003.101Get rights and content

Abstract

Background: Persons with chronic esophageal reflux are at increased risk for the development of Barrett's esophagus and adenocarcinoma. Recently developed ultrathin endoscopes are less expensive and better tolerated than standard endoscopes, they can be used without sedation, and are sensitive and specific for Barrett's esophagus. The cost-effectiveness of one-time screening strategies were evaluated for 50-year-old patients with chronic reflux: no screening, standard endoscopy, and screening by an ultrathin endoscope. Methods: Markov models were created to simulate the clinical course for patients with chronic reflux. Costs and quality-adjusted life-years were estimated from cancer registry data, published medical data, and expert opinion. Results: Under baseline assumptions, no screening resulted in average costs of $11,785 per person and 19.3226 quality-adjusted life-years. Ultrathin endoscopy screening resulted in costs of $12,119 per person and 19.3326 quality-adjusted life-years, yielding a marginal cost-effectiveness ratio of $55,764 per quality-adjusted life-year. Using standard endoscopy yielded costs of $12,332 with only slightly greater effectiveness, yielding a marginal cost-effectiveness ratio of $709,260 when compared with ultrathin endoscopy and $86,833 compared with no screening. Results were most sensitive to variation in the incidence of cancer in the population with Barrett's esophagus. Conclusions: Screening for Barrett's esophagus with ultrathin endoscopy is more cost-effective than standard endoscopy, and both strategies appear to improve quality-adjusted life-years among patients with chronic reflux at costs that are similar to those of other accepted preventive measures. (Gastrointest Endosc 2003;57:311-8.)

Section snippets

Patients and methods

The cost-effectiveness (CE) analysis was designed to determine the average lifetime-costs and average lifetime quality-adjusted life-years (QALYs) associated with each of 3 strategies: no screening, screening with UTE, and screening with SE. In these analyses, all patients are assumed to have GERD, defined for the purposes of the study as heartburn and/or acid reflux at least once per week. For all strategies, patients identified as having BE with no or low-grade dysplasia are assumed to be in

Baseline scenario

The outcomes of modeling the 3 screening strategies are shown in Table 3.Under a strategy of no screening, the baseline assumptions used in the model indicate that 882 cases of esophageal adenocarcinoma would be expected over the lifetimes of 100,000 patients 50 years of age with GERD, with 266 cases having distant disease. Under the UTE strategy, only 431 cases of esophageal adenocarcinoma would be expected, with 26 cases of distant disease, and under the strategy of screening with SE, 396

Discussion

This study finds that screening patients with chronic GERD for BE is cost-effective and comparable with other commonly accepted medical procedures such as hemodialysis,24 screening for colorectal cancer,25 and mammography.7, 8, 26 Screening with UTE, which generally does not require sedation, is more cost effective than SE with sedation, despite the loss of some optical quality and the inability to obtain biopsy specimens.

Endoscopic screening of patients with GERD for BE and surveillance of

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    Funded, in part, by a grant from the U.S. Office of Naval Research (No. N00014-99-1-0784) to the Medical University of South Carolina. Dr. Wallace was funded by the American Digestive Health Foundation (TAP Pharmaceutical Outcomes Research Award).

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    Reprint requests: Paul J. Nietert, PhD, Center for Health Care Research, 135 Cannon St., Suite 403, P.O. Box 250837, Charleston, SC 29425.

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