title: Comparative Effectiveness of Esophagectomy Versus Endoscopic Treatment for Esophageal High-grade Dysplasia.
abstract: OBJECTIVE
  The purpose of this study is to determine the comparative effectiveness of esophagectomy versus endoscopic mucosal resection followed by radiofrequency ablation (EMR-RFA) for the treatment of Barrett esophagus with high-grade dysplasia (HGD).
  
  
  BACKGROUND
  HGD of the esophagus may be managed by surgical resection or EMR-RFA. National guidelines suggest that EMR-RFA is effective at eradicating HGD. The comparative effectiveness and cost-effectiveness of EMR-RFA versus esophagectomy for HGD remains unclear.
  
  
  METHODS
  A decision-analysis model was constructed to represent 3 management strategies for HGD: (1) esophagectomy, (2) EMR-RFA, and (3) endoscopic surveillance. Estimates for model variables were obtained from literature review, and costs were estimated from Medicare fee schedules. Costs and utilities were discounted at an annual rate of 3%. The baseline model was adjusted for alternative age groups and high-risk dysplastic variants. One-way and multivariable probabilistic sensitivity analyses were conducted.
  
  
  RESULTS
  For a 65-year-old patient, compared to esophagectomy, EMR-RFA yields equivalent utility (11.5 vs 11.4 discounted quality-adjusted life years) with lower total cost ($52.5K vs $74.3K) over the first 20 years. Dominance of EMR-RFA over esophagectomy persists for all age groups. Patients with diffuse or ulcerated HGD are more effectively treated with esophagectomy. Model outcomes are sensitive to estimated rates of disease progression and postintervention utility parameters.
  
  
  CONCLUSIONS
  Existing evidence supports EMR-RFA over esophagectomy for the treatment of esophageal HGD. Long-term outcomes and more definitive quality-of-life studies for both interventions are crucial to better inform decision-making.
authors.affiliation: *Department of Surgery/Division of Thoracic Surgery, University of Virginia Health System, Charlottesville, VA †Department of Surgery/Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO ‡Department of Medicine/Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA §Department of Public Health Sciences, University of Virginia Health System, Charlottesville, VA.
authors.forename: Yinin
authors.initials: Y
authors.lastname: Hu
authors.forename: Varun
authors.initials: V
authors.lastname: Puri
authors.forename: Vanessa M
authors.initials: VM
authors.lastname: Shami
authors.forename: George J
authors.initials: GJ
authors.lastname: Stukenborg
authors.forename: Benjamin D
authors.initials: BD
authors.lastname: Kozower
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001471:Barrett Esophagus / Q000191:economics / Q000473:pathology / Q000601:surgery*; D017115:Catheter Ablation; D057186:Comparative Effectiveness Research; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D016629:Esophagectomy; D004945:Esophagoscopy; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008390:Markov Chains; D006278:Medicare; D008875:Middle Aged; D011230:Precancerous Conditions / Q000191:economics / Q000473:pathology / Q000601:surgery*; D019057:Quality-Adjusted Life Years; D016896:Treatment Outcome; D014481:United States