title: Cost-effectiveness analysis of chromoendoscopy for colorectal cancer surveillance in patients with ulcerative colitis.
abstract: BACKGROUND
  Recent studies report that the risk of colorectal cancer (CRC) among patients with ulcerative colitis (UC) may be lower than previously estimated. Although white-light endoscopy (WLE) with random biopsies is recommended for dysplasia detection in patients with UC, several studies reported increased detection of dysplasia by chromoendoscopy.
  
  
  OBJECTIVE
  To analyze the cost effectiveness of chromoendoscopy relative to WLE or no endoscopy for CRC surveillance in patients with UC.
  
  
  METHODS
  Decision-analytic state-transition (Markov) model with Monte Carlo simulation.
  
  
  METHODS
  To simulate the clinical course of chronic UC, we estimated dysplasia and CRC incidence and progression, endoscopic test characteristics, stage-specific mortality rates, and costs from published literature and Medicare reimbursement data.
  
  
  METHODS
  Patients from a population-based age distribution with ulcerative colitis for ≥8 years.
  
  
  METHODS
  We compared 3 different strategies at various surveillance intervals: chromoendoscopy with targeted biopsies, WLE with random biopsies, and no surveillance. The robustness of the model was assessed by using probabilistic sensitivity analysis. One-way sensitivity analyses were performed to evaluate individual variables, and 3-dimensional analysis was used to examine the effects of varying screening intervals.
  
  
  METHODS
  Incremental cost-effectiveness ratio (ICER).
  
  
  RESULTS
  Chromoendoscopy was found to be more effective and less costly than WLE at all surveillance intervals. However, compared with no surveillance, chromoendoscopy was cost effective only at surveillance intervals of at least 7 years, with an ICER of $77,176. Chromoendoscopy was the most cost effective strategy at sensitivity levels >0.23 for dysplasia detection and cost <$2200, regardless of the level of sensitivity of WLE for dysplasia detection. The estimated population lifetime risk of developing CRC ranged from 2.5% (annual chromoendoscopy) to 5.9% (chromoendoscopy every 10 years).
  
  
  CONCLUSIONS
  Estimates used for the model are based on best available data in the literature.
  
  
  CONCLUSIONS
  Chromoendoscopy is both more effective and less costly than WLE and becomes cost effective relative to no surveillance when performed at intervals of ≥7 years.
authors.affiliation: Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Gauree Gupta
authors.initials: GG
authors.lastname: Konijeti
authors.affiliation: Harvard Interfaculty Initiative in Health Policy, Cambridge; Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Mark G
authors.initials: MG
authors.lastname: Shrime
authors.affiliation: Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Ashwin N
authors.initials: AN
authors.lastname: Ananthakrishnan
authors.affiliation: Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA; Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Andrew T
authors.initials: AT
authors.lastname: Chan
mesh_terms: D000236:Adenoma / Q000175:diagnosis*; D000368:Aged; D019985:Benchmarking; D003113:Colonoscopy / Q000592:standards*; D015179:Colorectal Neoplasms / Q000175:diagnosis*; D055088:Early Detection of Cancer / Q000592:standards*; D005260:Female; D006785:Hospitals, University; D006801:Humans; D007196:Indiana; D008297:Male; D008875:Middle Aged; D011159:Population Surveillance; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies