title: Determining the cost-effectiveness of endoscopic surveillance for gastric cancer in patients with precancerous lesions.
abstract: OBJECTIVE
  To identify the optimal strategy for gastric cancer (GC) prevention by evaluating the cost-effectiveness of esophagogastroduodenoscopy (EGD)-based preventive strategies.
  
  
  METHODS
  We conducted a model-based cost-effectiveness analysis. Adopting a healthcare payer's perspective, Markov models simulated the clinical experience of the target population (Singaporean Chinese 50-69 years old) undergoing endoscopic screening, endoscopic surveillance and usual care of do-nothing. The screening strategy examined the cohort every alternate year whereas the surveillance strategy provided annual EGD only to people with precancerous lesions. For each strategy, discounted lifetime costs ($) and quality adjusted life years (QALY) were estimated and compared to generate incremental cost-effectiveness ratio (ICER). Deterministic and probabilistic sensitivity analysis was conducted to identify influential parameters and quantify the impact of model uncertainties.
  
  
  RESULTS
  Annual EGD surveillance with an ICER of $34 200/QALY was deemed cost-effective for GC prevention within the Singapore healthcare system. To inform implementation, the models identified six influential factors and their respective thresholds, namely discount rate (<4.20%), age of starting surveillance (>51.6 years), proportion of program cost in delivering endoscopy (<65%), cost of follow-up EGD (<$484), utility of stage 1 GC patients (>0.72) and odds ratio of GC for high-risk subjects (>3.93). The likelihood that surveillance is the most cost-effective strategy is 69.5% accounting for model uncertainties.
  
  
  CONCLUSIONS
  Endoscopic surveillance of gastric premalignancies can be a cost-effective strategy for GC prevention. Its implementation requires careful assessment on factors influencing the actual cost-effectiveness.
authors.affiliation: First Affiliated Hospital of Fuzhou General Hospital, Pu Tian City Fu Jian province, PR China.
authors.forename: Jin Tong
authors.initials: JT
authors.lastname: Wu
authors.affiliation: First Affiliated Hospital of Fuzhou General Hospital, Pu Tian City Fu Jian province, PR China.
authors.forename: Jun
authors.initials: J
authors.lastname: Zhou
authors.affiliation: Department of Pathology, Faculty of Medicine and Health Sciences, University of Stellenbosch, Tygerberg, Cape Town, South Africa.
authors.forename: Nasheen
authors.initials: N
authors.lastname: Naidoo
authors.affiliation: First Affiliated Hospital of Fuzhou General Hospital, Pu Tian City Fu Jian province, PR China.
authors.forename: Wen Yu
authors.initials: WY
authors.lastname: Yang
authors.affiliation: First Affiliated Hospital of Fuzhou General Hospital, Pu Tian City Fu Jian province, PR China.
authors.forename: Xiao Cheng
authors.initials: XC
authors.lastname: Lin
authors.affiliation: Saw Swee Hock School of Public Health, National University of Singapore, Singapore.
authors.forename: Pei
authors.initials: P
authors.lastname: Wang
authors.affiliation: First Affiliated Hospital of Fuzhou General Hospital, Pu Tian City Fu Jian province, PR China.
authors.forename: Jin Qin
authors.initials: JQ
authors.lastname: Ding
authors.affiliation: First Affiliated Hospital of Fuzhou General Hospital, Pu Tian City Fu Jian province, PR China.
authors.forename: Chen Bin
authors.initials: CB
authors.lastname: Wu
authors.affiliation: Pharmacy and Therapeutics Office, Group Corporate Development, National Healthcare Group, Singapore.
authors.forename: Hui Jun
authors.initials: HJ
authors.lastname: Zhou
mesh_terms: D000368:Aged; D003362:Cost-Benefit Analysis; D055088:Early Detection of Cancer; D004724:Endoscopy / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019057:Quality-Adjusted Life Years; D013274:Stomach Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology
keywords: Markov chains; cost-benefit analysis; early detection of cancer; gastrointestinal endoscopy; stomach neoplasm