title: Cost utility of ERCP-based modalities for the diagnosis of cholangiocarcinoma in primary sclerosing cholangitis.
abstract: OBJECTIVE
  Cholangiocarcinoma (CCA) is a leading cause of morbidity and mortality in patients with primary sclerosing cholangitis (PSC). Although several ERCP-based diagnostic modalities are available for diagnosing CCA, it is unclear whether one modality is more cost-effective than the others. The primary aim of this study was to compare the cost-effectiveness of ERCP-based techniques for diagnosing CCA in patients with PSC-induced biliary strictures.
  
  
  METHODS
  We performed a cost utility analysis to assess the net monetary benefit for accurately diagnosing CCA using 5 different diagnostic strategies: (1) ERCP with bile duct brushing for cytology, (2) ERCP with brushings for cytology and fluorescence in situ hybridization (FISH)-trisomy, (3) ERCP with brushings for cytology and FISH-polysomy, (4) ERCP with intraductal biopsy sampling, and (5) single-operator cholangioscopy (SOC) with targeted biopsy sampling. A Monte Carlo simulation assessed outcomes including quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio (ICER). Sensitivity analyses were also performed.
  
  
  RESULTS
  SOC with targeted biopsy sampling, as compared with ERCP with brushing for FISH-polysomy, produced an incremental QALY gain of .22 at an additional cost of $8562.44, resulting in a base case ICER of $39,277.25. Deterministic and probabilistic sensitivity analyses demonstrated that diagnosis with SOC was cost-effective at conventional willingness-to-pay thresholds of $50,000 and $100,000. SOC was the most cost-effective diagnostic strategy.
  
  
  CONCLUSIONS
  SOC with biopsy sampling is the most cost-effective diagnostic modality for CCA in PSC strictures.
authors: Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA; Investigative Medicine Program, Yale Center of Clinical Investigation, New Haven, Connecticut, USA.
authors: Basile
authors: B
authors: Njei
authors: Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.
authors: Thomas R
authors: TR
authors: McCarty
authors: Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA.
authors: Shyam
authors: S
authors: Varadarajulu
authors: Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA.
authors: Udayakumar
authors: U
authors: Navaneethan
mesh_terms: D000782:Aneuploidy; D001650:Bile Duct Neoplasms / Q000175:diagnosis* / Q000209:etiology / Q000235:genetics / Q000473:pathology; D001706:Biopsy; D018281:Cholangiocarcinoma / Q000175:diagnosis* / Q000209:etiology / Q000235:genetics / Q000473:pathology; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000191:economics*; D015209:Cholangitis, Sclerosing / Q000150:complications*; D003251:Constriction, Pathologic; D003362:Cost-Benefit Analysis; D003581:Cytodiagnosis; D006801:Humans; D017404:In Situ Hybridization, Fluorescence; D009010:Monte Carlo Method; D019057:Quality-Adjusted Life Years; D014314:Trisomy