title: Toward More Efficient Surveillance of Barrett's Esophagus: Identification and Exclusion of Patients at Low Risk of Cancer.
abstract: Endoscopic surveillance of Barrett's esophagus (BE) is probably not cost-effective. A sub-population with BE at increased risk of high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) who could be targeted for cost-effective surveillance was sought.
  
  
  
  The outcome for BE surveillance from 2003 to 2012 in a structured program was reviewed. Incidence rates and incidence rate ratios for developing HGD or EAC were calculated. Risk stratification identified individuals who could be considered for exclusion from surveillance. A health-state transition Markov cohort model evaluated the cost-effectiveness of focusing on higher-risk individuals.
  
  
  
  During 2067 person-years of follow-up of 640 patients, 17 individuals progressed to HGD or EAC (annual IR 0.8%). Individuals with columnar-lined esophagus (CLE) ≥2 cm had an annual IR of 1.2% and >8-fold increased relative risk of HGD or EAC, compared to CLE <2 cm [IR-0.14% (IRR 8.6, 95% CIs 4.5-12.8)]. Limiting the surveillance cohort after the first endoscopy to individuals with CLE ≥2 cm, or dysplasia, followed by a further restriction after the second endoscopy-exclusion of patients without intestinal metaplasia-removed 296 (46%) patients, and 767 (37%) person-years from surveillance. Limiting surveillance to the remaining individuals reduced the incremental cost-effectiveness ratio from US$60,858 to US$33,807 per quality-adjusted life year (QALY). Further restrictions were tested but failed to improve cost-effectiveness.
  
  
  
  Based on stratification of risk, the number of patients requiring surveillance can be reduced by at least a third. At a willingness-to-pay threshold of US$50,000 per QALY, surveillance of higher-risk individuals becomes cost-effective.
authors.affiliation: Department of Surgery, Flinders University, Flinders Medical Centre, Room 3D211, Bedford Park, Adelaide, SA, 5042, Australia.|Division of Upper Gastrointestinal Surgery, Centre of Digestive Diseases, Karolinska, University Hospital, Stockholm, Sweden.
authors.forename: Mats
authors.initials: M
authors.lastname: Lindblad
authors.affiliation: Department of Surgery, Flinders University, Flinders Medical Centre, Room 3D211, Bedford Park, Adelaide, SA, 5042, Australia.
authors.forename: Tim
authors.initials: T
authors.lastname: Bright
authors.affiliation: Department of Surgery, Flinders University, Flinders Medical Centre, Room 3D211, Bedford Park, Adelaide, SA, 5042, Australia.
authors.forename: Ann
authors.initials: A
authors.lastname: Schloithe
authors.affiliation: Department of Surgery, Flinders University, Flinders Medical Centre, Room 3D211, Bedford Park, Adelaide, SA, 5042, Australia.
authors.forename: George C
authors.initials: GC
authors.lastname: Mayne
authors.affiliation: Flinders Centre for Innovation in Cancer, Flinders University, Adelaide, Australia.
authors.forename: Gang
authors.initials: G
authors.lastname: Chen
authors.affiliation: Department of Surgery, Flinders University, Flinders Medical Centre, Room 3D211, Bedford Park, Adelaide, SA, 5042, Australia.
authors.forename: Jeff
authors.initials: J
authors.lastname: Bull
authors.affiliation: Department of Gastroenterology and Hepatology, Flinders University, Adelaide, Australia.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Bampton
authors.affiliation: Department of Gastroenterology and Hepatology, Flinders University, Adelaide, Australia.
authors.forename: Robert J L
authors.initials: RJ
authors.lastname: Fraser
authors.affiliation: Department of Surgery, Royal Surrey County Hospital, Guildford, UK.
authors.forename: Piers A
authors.initials: PA
authors.lastname: Gatenby
authors.affiliation: Centre for Applied Health Economics, Griffith University, Brisbane, Australia.
authors.forename: Louisa G
authors.initials: LG
authors.lastname: Gordon
authors.affiliation: Department of Surgery, Flinders University, Flinders Medical Centre, Room 3D211, Bedford Park, Adelaide, SA, 5042, Australia. david.watson@flinders.edu.au.|Flinders Centre for Innovation in Cancer, Flinders University, Adelaide, Australia. david.watson@flinders.edu.au.
authors.forename: David I
authors.initials: DI
authors.lastname: Watson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001315:Australia; D001471:Barrett Esophagus / Q000473:pathology*; D002471:Cell Transformation, Neoplastic; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011230:Precancerous Conditions / Q000473:pathology*; D019057:Quality-Adjusted Life Years; D018570:Risk Assessment; D057832:Watchful Waiting / Q000191:economics*