Cost effectiveness of ulcerative colitis surveillance in the setting of 5-aminosalicylates.
OBJECTIVE
Colorectal cancer (CRC) is a feared complication of chronic ulcerative colitis (UC). Annual endoscopic surveillance is recommended for the detection of early neoplasia. 5-Aminosalicylates (5-ASAs) may prevent some UC-associated CRC. Therefore, in patients prescribed 5-ASAs for maintenance of remission, annual surveillance might be overly burdensome and inefficient. We aimed to determine the ideal frequency of surveillance in patients with UC maintained on 5-ASAs.


METHODS
We performed systematic reviews of the literature, and created a Markov computer model simulating a cohort of 35-year-old men with chronic UC, followed until the age of 90 years. Twenty-two strategies were modeled: natural history (no 5-ASA or surveillance), surveillance without 5-ASA at intervals of 1-10 years, 5-ASA plus surveillance every 1-10 years, and 5-ASA alone. The primary outcome was the ideal interval of surveillance in the setting of 5-ASA maintenance, assuming a third-party payer was willing to pay $100,000 for each quality-adjusted life-year (QALY) gained.


RESULTS
In the natural history strategy, the CRC incidence was 30%. Without 5-ASA, annual surveillance was the ideal strategy, preventing 89% of CRC and costing $69,100 per QALY gained compared with surveillance every 2 years. 5-ASA alone prevented 49% of CRC. In the setting of 5-ASA, surveillance every 3 years was ideal, preventing 87% of CRC. 5-ASA with surveillance every 2 years cost an additional $147,500 per QALY gained, and 5-ASA with annual surveillance cost nearly $1 million additional per QALY gained compared with every 2 years. In Monte Carlo simulations, surveillance every 2 years or less often was ideal in 95% of simulations.


CONCLUSIONS
If 5-ASA is efficacious chemoprevention for UC-associated CRC, endoscopic surveillance might be safely performed every 2 years or less often. Such practice could decrease burdens to patients and on endoscopic resources with a minimal decrease in quality-adjusted length of life, because 5-ASA with annual surveillance may cost nearly $1 million per additional QALY gained.
Rubenstein
Joel H
JH
The Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Michigan, USA. jhr@umich.edu
Waljee
Akbar K
AK
Jeter
Joanne M
JM
Velayos
Fernando S
FS
Ladabaum
Uri
U
Higgins
Peter D R
PD
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use*; D003093:Colitis, Ulcerative / Q000150:complications / Q000188:drug therapy*; D003113:Colonoscopy / Q000191:economics*; D015179:Colorectal Neoplasms / Q000175:diagnosis* / Q000209:etiology / Q000517:prevention & control; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D006801:Humans; D008297:Male; D008390:Markov Chains; D008403:Mass Screening / Q000191:economics; D019804:Mesalamine / Q000627:therapeutic use*; D008875:Middle Aged
D000894:Anti-Inflammatory Agents, Non-Steroidal; D019804:Mesalamine