Cost-effectiveness of endoscopic surveillance for gastric intestinal metaplasia.
BACKGROUND
Patients with intestinal metaplasia (IM) are at increased risk for gastric cancer. Endoscopic surveillance has been shown to anticipate cancer diagnosis in an earlier stage. Cost-effectiveness of endoscopic surveillance in IM patients is unknown. To assess the efficacy and cost-effectiveness of an yearly endoscopic surveillance in patients with IM.


METHODS
A decision analysis model was constructed in order to compare a strategy of performing an EGD every year for a 10-year period (surveillance strategy) following a new diagnosis of IM to a policy of nonsurveillance in a simulated cohort of 10,000 American patients. A 1.8% 10-year cumulative incidence of gastric cancer in IM patients was estimated from the literature. Endoscopic surveillance was simulated to downstage the detected cancers by 58-84%. Costs of EGD and cancer care were estimated from Medicare reimbursement data. The main outcome measurement was the incremental cost-effectiveness ratio.


RESULTS
The number of EGDs required to detect one cancer and to prevent one gastric cancer-related death in the surveillance arm were 556 and 3738, respectively. The incremental cost-effectiveness ratio of endoscopic surveillance as compared to a nonsurveillance policy was $72,519 per life-year gained (5-95% percentiles Monte Carlo analysis: $54,843-$98,853). At sensitivity analysis, cancer incidence and the rate of downstaging were the most important variables.


CONCLUSIONS
According to our simulation, the relatively high risk of cancer in patients with IM and the substantial efficacy of endoscopic surveillance in reducing cancer-related mortality would support the cost-effectiveness of an endoscopic surveillance program in patients with IM. Further research is needed before implementing it in the clinical practice.
Hassan
Cesare
C
"Nuovo Regina Margherita" Hospital, Rome, Italy. cesareh@hotmail.com <cesareh@hotmail.com>
Zullo
Angelo
A
Di Giulio
Emilio
E
Annibale
Bruno
B
Lahner
Edith
E
De Francesco
Vincenzo
V
Ierardi
Enzo
E
D000368:Aged; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D016099:Endoscopy, Gastrointestinal / Q000191:economics*; D006801:Humans; D008403:Mass Screening / Q000191:economics; D008679:Metaplasia / Q000175:diagnosis*; D008875:Middle Aged; D015233:Models, Statistical; D013272:Stomach Diseases / Q000175:diagnosis*