title: Colectomy with Permanent End Ileostomy Is More Cost-Effective than Ileal Pouch-Anal Anastomosis for Crohn's Colitis.
abstract: BACKGROUND
  Much of the economic burden of Crohn's disease (CD) is related to surgery. Twenty percent of patients with CD have isolated colonic disease. While permanent end ileostomy (EI) is generally the procedure of choice for patients with refractory CD colitis, single-center experiences suggest that restorative proctocolectomy (IPAA) is durable in select patients.
  
  
  OBJECTIVE
  We assessed the cost-effectiveness of total colectomy with permanent EI versus IPAA in medically refractory colonic CD.
  
  
  METHODS
  We used a lifetime Markov model with 6-month cycles to simulate quality-adjusted life years (QALYs) and cost. In each of the EI and IPAA strategies, patients could transition between multiple health states. One-way and multivariable sensitivity analysis and tornado analysis were performed to identify thresholds for factors influencing cost-effectiveness.
  
  
  RESULTS
  IPAA was more effective than EI surgery with an incremental cost-effectiveness ratio of $70,715 per QALY gained. We identified the following variables of importance in our model: (1) the cost of the EI surgery, (2) the cost of infliximab, and (3) the cost of gastroenterology ambulatory visit and labs. Threshold analysis revealed that if the costs associated with EI surgery exceeded $20,167 or if the utility of IPAA with CD remission without medical therapy exceeded 0.37, IPAA became the more cost-effective strategy.
  
  
  CONCLUSIONS
  In patients with medically refractory CD isolated to the colon, colectomy with permanent EI is more cost-effective than IPAA unless the costs associated with the EI surgery exceed $20,167 or if the utility associated with IPAA and CD remission exceeds 0.37.
authors.affiliation: F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, 8730 Alden Drive, Thalians Building, 2nd Floor East, Los Angeles, CA, 90048, USA. staleban@yahoo.com.|Division of Gastroenterology, Department of Medicine, University of Arizona Medical Center, 1501 N. Campbell Ave, Tucson, AZ, 85724, USA. staleban@yahoo.com.
authors.forename: Sasha
authors.initials: S
authors.lastname: Taleban
authors.affiliation: Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. m.g.vanoijen@amc.uva.nl.|Department of Medical Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. m.g.vanoijen@amc.uva.nl.
authors.forename: Martijn G H
authors.initials: MG
authors.lastname: Van Oijen
authors.affiliation: F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, 8730 Alden Drive, Thalians Building, 2nd Floor East, Los Angeles, CA, 90048, USA. Eric.Vasiliauskas@cshs.org.
authors.forename: Eric A
authors.initials: EA
authors.lastname: Vasiliauskas
authors.affiliation: F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, 8730 Alden Drive, Thalians Building, 2nd Floor East, Los Angeles, CA, 90048, USA. phillip.fleshner@cshs.org.|, 8737 W Beverly Blvd Ste. 101, West Hollywood, CA, 90048, USA. phillip.fleshner@cshs.org.
authors.forename: Phillip R
authors.initials: PR
authors.lastname: Fleshner
authors.affiliation: Department of Gastroenterology and Hepatology, Cleveland Clinic Main Campus, 9500 Euclid Avenue, Mail Code A30, Cleveland, OH, 44195, USA. shenb@ccf.org.
authors.forename: Bo
authors.initials: B
authors.lastname: Shen
authors.affiliation: F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, 8730 Alden Drive, Thalians Building, 2nd Floor East, Los Angeles, CA, 90048, USA. andrew.ippoliti@cshs.org.
authors.forename: Andrew F
authors.initials: AF
authors.lastname: Ippoliti
authors.affiliation: F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, 8730 Alden Drive, Thalians Building, 2nd Floor East, Los Angeles, CA, 90048, USA. stephan.targan@cshs.org.
authors.forename: Stephan R
authors.initials: SR
authors.lastname: Targan
authors.affiliation: F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, 8730 Alden Drive, Thalians Building, 2nd Floor East, Los Angeles, CA, 90048, USA. gil.melmed@cshs.org.
authors.forename: Gil Y
authors.initials: GY
authors.lastname: Melmed
mesh_terms: D000328:Adult; D001003:Anal Canal / Q000601:surgery*; D000714:Anastomosis, Surgical / Q000191:economics / Q000379:methods*; D000893:Anti-Inflammatory Agents / Q000191:economics / Q000627:therapeutic use; D003082:Colectomy / Q000191:economics / Q000379:methods*; D039021:Colonic Pouches; D003362:Cost-Benefit Analysis; D003424:Crohn Disease / Q000601:surgery*; D005765:Gastrointestinal Agents / Q000191:economics / Q000627:therapeutic use; D006801:Humans; D007081:Ileostomy / Q000191:economics / Q000379:methods*; D008297:Male
chemical_list: D000893:Anti-Inflammatory Agents; D005765:Gastrointestinal Agents
keywords: Colectomy; Colitis; Cost-effectiveness; Crohn’s disease; Ileostomy; Restorative proctocolectomy