title: Cost Effectiveness of Routine Duodenal Biopsy Analysis for Celiac Disease During Endoscopy for Gastroesophageal Reflux.
abstract: OBJECTIVE
  Some patients with refractory gastroesophageal reflux disease (GERD) actually have undiagnosed celiac disease. These patients often undergo an esophagogastroduodenoscopy (EGD) to determine the etiology and severity of GERD. Performing routine duodenal biopsy analysis during an EGD could identify patients with celiac disease. We evaluated the cost effectiveness of this approach.
  
  
  METHODS
  We performed a systematic search of the MEDLINE database to identify publications through March 2014 on patients who underwent a duodenal biopsy analysis during an EGD for GERD. Data collected were used to construct a decision tree to calculate the cost effectiveness of an EGD with and without celiac disease tests.
  
  
  RESULTS
  Among 10,000 patients with refractory GERD who underwent an EGD, we predicted a biopsy strategy would detect 70% of patients with celiac disease if the prevalence of celiac disease was 1% in this cohort. Biopsy analysis at the start of the EGD procedure would increase the remaining quality-adjusted life years (QALYs) by 0.0032, and increase the lifetime cost by $389/patient. Compared with no biopsy, the biopsy strategy cost $55,692.86/case of celiac disease detected, and $121,875/QALY gained. The incremental cost-effectiveness ratio for the biopsy strategy met the threshold of less than $50,000/QALY when 1 of the following parameters was met: when the utility of living with GERD was less than 0.88, when the prevalence of celiac disease in patients with refractory GERD was greater than 1.8%, when biopsy analysis detected celiac disease with more than 98.1% specificity, when the cost of a gluten-free diet was less than $645.85/y, or if the cost of proton pump inhibitor therapy was more than $5874.01/y.
  
  
  CONCLUSIONS
  Based on base-case values, it is not cost effective to perform a biopsy analysis to detect celiac disease in patients undergoing an EGD for refractory GERD. However, the approach becomes cost effective when the prevalence of celiac disease in this population is 1.8% or greater.
authors.affiliation: Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York.
authors.forename: Janie J
authors.initials: JJ
authors.lastname: Yang
authors.affiliation: Department of Biostatistics, Columbia University Mailman School of Public Health, New York, New York.
authors.forename: Anusorn
authors.initials: A
authors.lastname: Thanataveerat
authors.affiliation: Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York.
authors.forename: Peter H R
authors.initials: PH
authors.lastname: Green
authors.affiliation: Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York. Electronic address: BL114@columbia.edu.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Lebwohl
mesh_terms: D000328:Adult; D001706:Biopsy / Q000191:economics* / Q000379:methods; D002446:Celiac Disease / Q000175:diagnosis*; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D016145:Endoscopy, Digestive System / Q000191:economics* / Q000379:methods; D005260:Female; D005764:Gastroesophageal Reflux / Q000175:diagnosis*; D006801:Humans; D008297:Male
keywords: Antibody; ICER; PPI; Screening
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