title: Economic analysis of esophageal stenting for management of malignant dysphagia.
abstract: Over half of patients diagnosed with esophageal cancer are unsuitable for curative resection. A significant proportion of these patients will subsequently require palliative stenting to alleviate dysphagia. There is growing consensus in the literature that the deployment of a Self-Expanding Metal Stent is the optimum stenting strategy; however, it remains unclear whether covered or uncovered metal stents are more cost-effective. In order to determine which type of prosthesis is more cost-effective, we compared the different stenting strategies in terms of 1-year stent-related mortality, health-related quality of life, and cost. A decision analytical model was constructed to compare the 1-year stent-related mortality, health-related quality of life, and cost between covered and uncovered stents. Probabilistic sensitivity analysis was performed to quantify the uncertainty associated with our results. Value of Information analysis was performed to assess the value of further research. In order to fully characterize the uncertainty associated with this decision, plastic stents were included in our analysis. Stent-related mortality was slightly lower following covered stent deployment compared with uncovered stent deployment (1.00% vs. 1.26%). Covered stents were more effective by 0.0013 Quality-Adjusted Life Years (Standard Deviation [SD] 0.0013 Quality-Adjusted Life Years). They were also less expensive by $729.58 (SD $390.63). Probabilistic sensitivity analysis suggested that these results were not sensitive to model parameter uncertainty. Plastic stents deployment was $2832.64 (SD $1182.72) more expensive than uncovered metal stent deployment. Value of Information analysis suggests that the maximum value of further research in the UK is $61,124.30. The results of this study represent strong evidence for the cost-effectiveness of covered compared with uncovered self-expanding metal stents for the palliation of patients with malignant dysphagia. The findings support previously published literature asserting the dominance of self-expanding metal stents over plastic stents. Value of Information analysis suggests that further research may not be cost-effective. These findings have significant implication for both current clinical practice and future clinical research.
authors.affiliation: Department of Bio-surgery and Surgical Technology, Imperial College London, London, UK.
authors.forename: C
authors.initials: C
authors.lastname: Rao
authors.forename: A
authors.initials: A
authors.lastname: Haycock
authors.forename: E
authors.initials: E
authors.lastname: Zacharakis
authors.forename: G
authors.initials: G
authors.lastname: Krasopoulos
authors.forename: D
authors.initials: D
authors.lastname: Yakoub
authors.forename: A
authors.initials: A
authors.lastname: Protopapas
authors.forename: A
authors.initials: A
authors.lastname: Darzi
authors.forename: G B
authors.initials: GB
authors.lastname: Hanna
authors.forename: T
authors.initials: T
authors.lastname: Athanasiou
mesh_terms: D016001:Confidence Intervals; D017281:Cost of Illness; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D003680:Deglutition Disorders / Q000191:economics* / Q000209:etiology / Q000628:therapy*; D004938:Esophageal Neoplasms / Q000150:complications* / Q000191:economics; D005260:Female; D017048:Health Care Costs; D006801:Humans; D010166:Palliative Care / Q000191:economics*; D011336:Probability; D011788:Quality of Life; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D015607:Stents / Q000191:economics*; D006113:United Kingdom