Cost-effectiveness of endoscopic surveillance of non-dysplastic Barrett's esophagus.

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Gordon, Louisa G
Mayne, George C
Hirst, Nicholas G
Bright, Tim Flaxman
Whiteman, David C
Watson, David Ian
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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.
Author version made available in accordance with Publisher copyright policy.
Barrett's esophagus, High-grade dysplasia, Intestinal metaplasia, Low-grade dysplasia, Polymerase chain reaction, Quality-adjusted life years
Gordon LG, Hirst NG, Mayne GC, Bright T, Whiteman DC, Watson DI. (2014) Cost-effectiveness of endoscopic surveillance of non-dysplastic Barrett’s oesophagus. Gastrointestinal Endoscopy. 79 242-256