title: The cost of laparoscopic myotomy versus pneumatic dilatation for esophageal achalasia.
abstract: BACKGROUND
  The two main treatment options for esophageal achalasia are laparoscopic distal esophageal myotomy (LM) and pneumatic dilatation (PD). Our objective was to compare the costs of these management strategies.
  
  
  METHODS
  We constructed a decision analytic model consisting of two treatment strategies for patients diagnosed with achalasia. Probabilities of events were systematically derived from a literature review, supplemented by expert opinion when necessary. Costs were estimated from the perspective of a third-party payer and society, including both direct and indirect costs. Future costs were discounted at a rate of 5.5% over a time horizon of 5 and 10 years. Uncertainty in the probability estimates was incorporated using probabilistic sensitivity analyses. We tested uncertainty in the model by modifying key assumptions and repeating the analysis.
  
  
  RESULTS
  From the societal perspective, the expected cost per patient was $10,789 (LM) compared with $5,315 (PD) five years following diagnosis, and $11,804 (LM) compared with $7,717 (PD) after 10 years. The 95% confidence interval of the incremental cost per patient treated with LM was ($5,280, $5,668) after five years, and ($3,863, $4,311) after 10 years. The incremental cost of LM was similar from the third-party payer perspective and in the secondary model analyzed.
  
  
  CONCLUSIONS
  Initial LM is a more costly management strategy under all clinically plausible scenarios tested in this model. Further research is needed to determine patients' preferences for the two treatment modalities, and society's willingness to bear the incremental cost of LM for those who choose it.
authors.affiliation: Department of Surgery, The University of Western Ontario, London, Canada. pjkarani@uwo.ca
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Karanicolas
authors.forename: Shona E
authors.initials: SE
authors.lastname: Smith
authors.forename: Richard I
authors.initials: RI
authors.lastname: Inculet
authors.forename: Richard A
authors.initials: RA
authors.lastname: Malthaner
authors.forename: Richard P
authors.initials: RP
authors.lastname: Reynolds
authors.forename: Ron
authors.initials: R
authors.lastname: Goeree
authors.forename: Amiram
authors.initials: A
authors.lastname: Gafni
mesh_terms: D000704:Analysis of Variance; D002170:Canada; D002404:Catheterization / Q000191:economics*; D003362:Cost-Benefit Analysis; D004931:Esophageal Achalasia / Q000191:economics* / Q000628:therapy*; D004945:Esophagoscopy / Q000191:economics; D005260:Female; D017048:Health Care Costs; D006801:Humans; D010535:Laparoscopy / Q000191:economics*; D008297:Male; D018803:Models, Economic; D011336:Probability; D012680:Sensitivity and Specificity