title: Strategies for the prevention of postoperative recurrence in Crohn's disease: results of a decision analysis.
abstract: OBJECTIVE
  Nearly 70% of patients with Crohn's disease (CD) undergo surgical resection, with one-quarter subsequently developing clinical recurrence within 12 months. Several options exist for the prevention of postoperative recurrence in CD, but the comparative cost effectiveness of these competing strategies has not been previously analyzed.
  
  
  METHODS
  We developed a decision analytic model comprising five strategies--No Treatment, azathioprine (AZA), antibiotics (ABX), upfront infliximab (IFX), and tailored IFX that consisted of no upfront therapy with initiation of IFX in patients with severe endoscopic recurrence at 6 months. The base-case 1-year clinical recurrence rate was 24% with reduction in recurrence by 41%, 77%, and 99% for AZA, ABX, and IFX, respectively. A 1-year time horizon was used and sensitivity analyses were performed.
  
  
  RESULTS
  At the base-case analysis, the ABX (0.82 quality-adjusted life years (QALYs)) and AZA (0.81 QALYs) arms were more effective and less expensive than the No Treatment strategy (0.80 QALYs). The most effective strategy was upfront IFX (0.83 QALYs); however, this was also the most expensive and resulted in a high incremental cost-effectiveness ratio (ICER) ($777,732/QALY) compared with no treatment. The tailored IFX arm was less effective than upfront use but had a more acceptable ICER. On increasing the recurrence rate to 78% (high-risk patients), upfront IFX resulted in 0.07 QALYs (ICER $130,580/QALY) gained compared with No Treatment, whereas ABX, AZA, and tailored IFX arms dominated No Treatment.
  
  
  CONCLUSIONS
  Antibiotics are the most cost-effective option for preventing postoperative recurrence, but they have been associated with high rates of intolerance precluding widespread use. Upfront IFX is the most efficacious strategy but is not cost effective even in high-risk patients. Reserving IFX use for high-risk patients with early endoscopic recurrence is more cost effective than upfront use in all patients.
authors.affiliation: Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts 02114, USA. aananthakrishnan@partners.org
authors.forename: Ashwin N
authors.initials: AN
authors.lastname: Ananthakrishnan
authors.forename: Chin
authors.initials: C
authors.lastname: Hur
authors.forename: Pascal
authors.initials: P
authors.lastname: Juillerat
authors.forename: Joshua R
authors.initials: JR
authors.lastname: Korzenik
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000191:economics / Q000627:therapeutic use; D000893:Anti-Inflammatory Agents / Q000191:economics / Q000627:therapeutic use; D000911:Antibodies, Monoclonal / Q000191:economics / Q000627:therapeutic use; D001379:Azathioprine / Q000191:economics / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D003424:Crohn Disease / Q000188:drug therapy* / Q000191:economics* / Q000601:surgery; D003661:Decision Support Techniques; D003663:Decision Trees; D006801:Humans; D007166:Immunosuppressive Agents / Q000191:economics / Q000627:therapeutic use; D000069285:Infliximab; D019057:Quality-Adjusted Life Years; D055502:Secondary Prevention
chemical_list: D000900:Anti-Bacterial Agents; D000893:Anti-Inflammatory Agents; D000911:Antibodies, Monoclonal; D007166:Immunosuppressive Agents; D000069285:Infliximab; D001379:Azathioprine