A cost-effectiveness analysis of diagnostic strategies for symptomatic patients with ileal pouch-anal anastomosis.
OBJECTIVE
Pouchitis is often diagnosed based on symptoms and empirically treated with antibiotics (treat-first strategy). However, symptom assessment alone is not reliable for diagnosis, and an initial evaluation with pouch endoscopy (test-first strategy) has been shown to be more accurate. Cost-effectiveness of these strategies has not been compared. The aim of this study was to compare cost-effectiveness of different clinical approaches for patients with symptoms suggestive of pouchitis.


METHODS
Pouchitis was defined as pouchitis disease activity index scores > or =7. The frequency of pouchitis in symptomatic patients with ileal pouch was estimated to be 51%; the efficacy for initial therapy with metronidazole (MTZ) and ciprofloxacin (CIP) was 75% and 85%, respectively. Cost estimates were obtained from Medicare reimbursement data.


RESULTS
Six competing strategies (MTZ trial, CIP trial, MTZ-then-CIP trial, CIP-then-MTZ trial, pouch endoscopy with biopsy, and pouch endoscopy without biopsy) were modeled in a decision tree. Costs per correct diagnosis with appropriate treatment were $194 for MTZ trial, $279 for CIP trial, $208 for MTZ-then-CIP trial, $261 for CIP-then-MTZ trial, $352 for pouch endoscopy with biopsy, and $243 for pouch endoscopy without biopsy. Of the two strategies with the lowest cost, the pouch endoscopy without biopsy strategy costs $50 more per patient than the MTZ trial strategy but results in an additional 15 days for early diagnosis and thus initiation of appropriate treatment (incremental cost-effectiveness ratio $3 per additional day gained). The results of base-case analysis were robust in sensitivity analyses.


CONCLUSIONS
Although the MTZ-trial strategy had the lowest cost, the pouch endoscopy without biopsy strategy was most cost-effective. Therefore, based on its relatively low cost and the avoidance of both diagnostic delay and adverse effects associated with unnecessary antibiotics, pouch endoscopy without biopsy is the recommended strategy among those tested for the diagnosis of pouchitis.
Shen
Bo
B
Center for Inflammatory Bowel Disease: Department of Gastroenterology, I H Page Center for Health Outcomes Research, Department of Colorectal Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
Shermock
Kenneth M
KM
Fazio
Victor W
VW
Achkar
Jean-Paul
JP
Brzezinski
Aaron
A
Bevins
Charles L
CL
Bambrick
Marlene L
ML
Remzi
Feza H
FH
Lashner
Bret A
BA
D000368:Aged; D001003:Anal Canal / Q000601:surgery; D000714:Anastomosis, Surgical; D002939:Ciprofloxacin / Q000191:economics* / Q000627:therapeutic use; D002986:Clinical Trials as Topic; D015331:Cohort Studies; D039021:Colonic Pouches / Q000009:adverse effects*; D003365:Costs and Cost Analysis; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007082:Ileum / Q000601:surgery; D008297:Male; D006278:Medicare / Q000191:economics; D008795:Metronidazole / Q000191:economics* / Q000627:therapeutic use; D008875:Middle Aged; D019449:Pouchitis / Q000175:diagnosis* / Q000188:drug therapy / Q000191:economics*; D012720:Severity of Illness Index; D016896:Treatment Outcome
D008795:Metronidazole; D002939:Ciprofloxacin