Cost-effectiveness of screening a population with chronic gastroesophageal reflux

doi:10.1067/mge.2003.101

Gastrointestinal Endoscopy

Volume 57, Issue 3, March 2003, Pages 311-318

https://doi.org/10.1067/mge.2003.101 Get 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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Cited by (57)

Prevalence of Barrett's esophagus and performance of societal screening guidelines in an unreferred primary care population of U.S. veterans
2021, Gastrointestinal Endoscopy
Less than 10% of patients diagnosed with esophageal adenocarcinoma have a pre-existing Barrett’s esophagus (BE) diagnosis, possibly because of suboptimal performance of guidelines. We examined the prevalence of BE in a previously unscreened primary care population and the potential yield of practice BE screening guidelines.
This was a retrospective analysis of a prospective cross-sectional study of consecutively recruited unreferred patients from primary care clinics who underwent study upper endoscopy. We examined the performance of BE screening guidelines of the European Society of Gastrointestinal Endoscopy (ESGE), British Society of Gastroenterology (BSG), American Society for Gastrointestinal Endoscopy (ASGE), American College of Gastroenterology (ACG), American Gastroenterological Association (AGA), and our own modification of guidelines.
We identified 44 BE cases and 469 control subjects (prevalence, 8.6%). Among 371 patients without GERD symptoms, 25 (6.7%) had BE. The AGA guidelines requiring ≥2 BE risk factors had sensitivity of 100% and specificity of only .2%, whereas ACG, ASGE, ESGE, and BSG guidelines (all requiring GERD first) had low sensitivities (38.6%-43.2%), specificities ranging from 67.4% to 76.5%, and area under the receiver operating curve (AUROC) of .50 to .60. Our 2-pronged approach depending on presence or absence of GERD symptoms but with other risk factors achieved sensitivity of 81.8%, specificity of 51.2%, and AUROC of .66.
Over half of BE cases were without frequent GERD symptoms, but virtually all had at least 1 known BE risk factor. Practice guidelines requiring GERD symptoms have low sensitivity, whereas those not requiring GERD have low specificity. We have proposed a screening guideline with better use of known risk factors.
Endoscopic Screening for Barrett's Esophagus and Esophageal Adenocarcinoma: Rationale, Candidates, and Challenges
2021, Gastrointestinal Endoscopy Clinics of North America
ASGE guideline on screening and surveillance of Barrett's esophagus
2019, Gastrointestinal Endoscopy
Endosheath ultrathin transnasal endoscopy is a cost-effective method for screening for Barrett's esophagus in patients with GERD symptoms
2019, Gastrointestinal Endoscopy
Barrett’s esophagus (BE) screening is currently not considered to be cost effective in the general population but may be effective in high-risk subgroups, such as 50-year-old white men with chronic reflux disease (GERD). A new modality for screening is unsedated transnasal endoscopy using endosheath technology (uTNE), which has been shown to be safe and effective in clinical practice. In this study, we determined the cost-utility of uTNE in a high-risk subgroup compared with no screening or screening with standard endoscopy.
A Markov model was used to simulate screening of 50-year-old white men with symptoms of GERD with either uTNE or standard endoscopy compared with no screening, over a lifetime horizon. Input variables were based on the literature and recent data on uTNE screening for BE. The study was designed from a healthcare payer perspective by using direct costs. Primary outcome measures were costs, quality-adjusted life years (QALYs), and the incremental cost-utility ratio (ICUR) of uTNE and standard endoscopy compared with no screening. Sensitivity analysis was performed for several factors, such as prevalence of BE.
Costs of uTNE, standard endoscopy, and no screening were estimated at, $2495, $2957, and $1436, respectively. Compared with no screening, uTNE screening resulted in an overall QALY increase of 0.039 (95% percentile 0.018; 0.063) and an ICUR of $29,446 per QALY gained (95% confidence interval [CI], 18.516-53.091), whereas standard endoscopy compared with no screening resulted in a QALY increase of 0.034 (95% CI, 0.015-0.056) and an ICUR of $47,563 (95% CI, 31,036-82,970).
Both uTNE and standard endoscopy seem to be cost-effective screening methods in a screening cohort of 50-year-old white men with GERD at a willingness-to-pay cutoff of $50,000.
Acceptability, Accuracy, and Safety of Disposable Transnasal Capsule Endoscopy for Barrett's Esophagus Screening
2019, Clinical Gastroenterology and Hepatology
Screening for Barrett’s esophagus (BE) with conventional esophagogastroduodenoscopy (C-EGD) is expensive. We assessed the performance of a clinic-based, single use transnasal capsule endoscope (EG Scan II) for the detection of BE, compared to C-EGD as the reference standard.
We performed a prospective multicenter cohort study of patients with and without BE recruited from 3 referral centers (1 in the United States and 2 in the United Kingdom). Of 200 consenting participants, 178 (89%) completed both procedures (11% failed EG Scan due to the inability to intubate the nasopharynx). The mean age of participants was 57.9 years and 67% were male. The prevalence of BE was 53%. All subjects underwent the 2 procedures on the same day, performed by blinded endoscopists. Patients completed preference and validated tolerability (10-point visual analogue scale [VAS]) questionnaires within 14 days of the procedures.
A higher proportion of patients preferred the EG Scan (54.2%) vs the C-EGD (16.7%) (P < .001) and the EG Scan had a higher VAS score (7.2) vs the C-EGD (6.4) (P = .0004). No serious adverse events occurred. The EG Scan identified any length BE with a sensitivity value of 0.90 (95% CI, 0.83–0.96) and a specificity value of 0.91 (95% CI, 0.82–0.96). The EG Scan identified long segment BE with a sensitivity value of 0.95 and short segment BE with a sensitivity values of 0.87.
In a prospective study, we found the EG Scan to be safe and to detect BE with higher than 90% sensitivity and specificity. A higher proportion of patients preferred the EG Scan to C-EGD. This device might be used as a clinic-based tool to screen populations at risk for BE. ISRCTN registry identifier: 70595405; ClinicalTrials.gov no: NCT02066233.
Costs associated with Barrett's esophagus screening in the community: an economic analysis of a prospective randomized controlled trial of sedated versus hospital unsedated versus mobile community unsedated endoscopy
2018, Gastrointestinal Endoscopy
Data on the economic impact associated with screening for Barrett’s esophagus (BE) are limited. As part of a comparative effectiveness randomized trial of unsedated transnasal endoscopy (uTNE) and sedated EGD (sEGD), we assessed costs associated with BE screening.
Patients were randomly allocated to 3 techniques: sEGD or uTNE in a hospital setting (huTNE) versus uTNE in a mobile research van (muTNE). Patients were called 1 and 30 days after screening to assess loss of work (because of the screening procedure) and medical care sought after procedure. Direct medical costs were extracted from billing claims databases. Indirect costs (loss of work for subject and caregiver) were estimated using patient reported data. Statistical analyses including multivariable analysis accounting for comorbidities were conducted to compare costs.
Two hundred nine patients were screened (61 sEGD, 72 huTNE, and 76 muTNE). Thirty-day direct medical costs and indirect costs were significantly higher in the sEGD than the huTNE and muTNE groups. Total costs (direct medical + indirect costs) were also significantly higher in the sEGD than in the uTNE group. The muTNE group had significantly lower costs than the huTNE group. Adjustment for age, sex, and comorbidities on multivariable analysis did not change this conclusion.
Short-term direct, indirect, and total costs of screening are significantly lower with uTNE compared with sEGD. Mobile uTNE costs were lower than huTNE costs, raising the possibility of mobile screening as a novel method of screening for BE and esophageal adenocarcinoma.

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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).

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

^★: 0016-5107/2003/$30.00 + 0

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

Abstract

Section snippets

Patients and methods

Baseline scenario

Discussion

J Thorac Cardiovasc Surg

Gastroenterology

Am J Gastroenterol

Am J Gastroenterol

Gastroenterology

Gastrointest Endosc

Am J Gastroenterol

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastroenterology

Am J Gastroenterol

Gastrointest Endosc

Gastrointest Endosc

Gastroenterology

Gastroenterology

Gastrointest Endosc Clin N Am

Gastroenterology

Am J Med

Gastroenterology

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