Cost-effectiveness of endoscopic surveillance of non-dysplastic Barrett's esophagus.
BACKGROUND
Endoscopic surveillance for non-dysplastic Barrett's esophagus (BE) is contentious and its cost effectiveness unclear.


OBJECTIVE
To perform an economic analysis of endoscopic surveillance strategies.


METHODS
Cost-utility analysis by using a simulation Markov model to synthesize evidence from large epidemiologic studies and clinical data for surveillance, based on international guidelines, applied in a coordinator-managed surveillance program.


METHODS
Tertiary care hospital, South Australia.


METHODS
A total of 2040 patient-years of follow-up.


METHODS
(1) No surveillance, (2) 2-yearly endoscopic surveillance of patients with non-dysplastic BE and 6-monthly surveillance of patients with low-grade dysplasia, (3) a hypothetical strategy of biomarker-modified surveillance.


METHODS
U.S. cost per quality-adjusted life year (QALY) ratios.


RESULTS
Compared with no surveillance, surveillance produced an estimated incremental cost per QALY ratio of $60,858. This was reduced to $38,307 when surveillance practice was modified by a hypothetical biomarker-based strategy. Sensitivity analyses indicated that the likelihood that surveillance alone was cost-effective compared with no surveillance was 16.0% and 60.6% if a hypothetical biomarker-based strategy was added to surveillance, at an acceptability threshold of $100,000 per QALY gained.


CONCLUSIONS
Treatment options for BE that overlap those for symptomatic GERD were omitted.


CONCLUSIONS
By using best available estimates of the malignant potential of BE, endoscopic surveillance of patients with non-dysplastic BE is unlikely to be cost-effective for the majority of patients and depends heavily on progression rates between dysplasia grades. However, strategies that modify surveillance according to cancer risk might be cost-effective, provided that high-risk individuals can be identified and prioritized for surveillance.
Centre for Applied Health Economics, Griffith Health Institute, Griffith University, Logan Campus, University Dr, Meadowbrook, Queensland, Australia; QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia.
Louisa G
LG
Gordon
Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia.
George C
GC
Mayne
Centre for Applied Health Economics, Griffith Health Institute, Griffith University, Logan Campus, University Dr, Meadowbrook, Queensland, Australia.
Nicholas G
NG
Hirst
Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia.
Timothy
T
Bright
QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia.
David C
DC
Whiteman
Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia.
David I
DI
Watson
D001471:Barrett Esophagus / Q000191:economics / Q000473:pathology*; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D018450:Disease Progression; D004945:Esophagoscopy / Q000191:economics* / Q000592:standards; D005260:Female; D017048:Health Care Costs / Q000592:standards*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011230:Precancerous Conditions; D018426:SEER Program / Q000191:economics*; D014481:United States
BE; Barrett's esophagus; HGD; IM; LGD; PCR; QALY; US dollars; USD; high-grade dysplasia; intestinal metaplasia; low-grade dysplasia; polymerase chain reaction; quality-adjusted life years