title: The cost-effectiveness of radiofrequency ablation for Barrett's esophagus with low-grade dysplasia: results from a randomized controlled trial (SURF trial).
abstract: OBJECTIVE
  The Surveillance versus Radiofrequency Ablation (SURF) trial randomized 136 patients with Barrett's esophagus (BE) containing low-grade dysplasia (LGD), to receive radiofrequency ablation (ablation, n = 68) or endoscopic surveillance (control, n = 68). Ablation reduced the risk of neoplastic progression to high-grade dysplasia and esophageal adenocarcinoma (EAC) by 25% over 3 years (1.5% for ablation vs 26.5% for control). We performed a cost-effectiveness analysis from a provider perspective alongside this trial.
  
  
  METHODS
  Patients were followed for 3 years to quantify their use of health care services, including therapeutic and surveillance endoscopies, treatment of adverse events, and medication. Costs for treatment of progression were analyzed separately. Incremental cost-effectiveness ratios (ICER) were calculated by dividing the difference in costs (excluding and including the downstream costs for treatment of progression) by the difference in prevented events of progression. Bootstrap analysis (1000 samples) was used to construct 95% confidence intervals (CIs).
  
  
  RESULTS
  Patients who underwent ablation generated mean costs of U.S.$13,503 during the trial versus $2236 for controls (difference $11,267; 95% CI, $9996-$12,378), with an ICER per prevented event of progression of $45,066. Including the costs for treatment of progression, ablation patients generated mean costs of $13,523 versus $4,930 for controls (difference $8593; 95% CI, $6881-$10,153) with an ICER of $34,373. Based on the various ICER estimates derived from the bootstrap analysis, one can be reasonably certain (>75%) that ablation is efficient at a willingness to pay of $51,664 per prevented event of progression or $40,915 including downstream costs of progression.
  
  
  CONCLUSIONS
  Ablation for patients with confirmed BE-LGD is more effective and more expensive than endoscopic surveillance in reducing the risk of progression to high-grade dysplasia/EAC. The increase in costs of ablation can be justified to avoid a serious event such as neoplastic progression. At a willingness to pay of $40,915 per prevented event of progression, one can be reasonably certain that ablation is efficient. (www.trialregister.nl number: NTR 1198.).
authors.affiliation: Department of Gastroenterology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands.
authors.forename: K Nadine
authors.initials: KN
authors.lastname: Phoa
authors.affiliation: Department of Gastroenterology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands.
authors.forename: Wilda D
authors.initials: WD
authors.lastname: Rosmolen
authors.affiliation: Department of Gastroenterology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands; Department of Gastroenterology, St Antonius Hospital, Nieuwegein, the Netherlands.
authors.forename: Bas L A M
authors.initials: BLAM
authors.lastname: Weusten
authors.affiliation: Department of Gastroenterology, University Hospital Leuven, Leuven, Belgium.
authors.forename: Raf
authors.initials: R
authors.lastname: Bisschops
authors.affiliation: Department of Gastroenterology, Catharina Hospital, Eindhoven, the Netherlands.
authors.forename: Erik J
authors.initials: EJ
authors.lastname: Schoon
authors.affiliation: Department of Gastroenterology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands.
authors.forename: Shefali
authors.initials: S
authors.lastname: Das
authors.affiliation: Department of Gastroenterology, Queens Medical Centre, Nottingham, United Kingdom.
authors.forename: Krish
authors.initials: K
authors.lastname: Ragunath
authors.affiliation: Department of Surgical Gastroenterology, Glasgow Royal Infirmary, Glasgow, United Kingdom.
authors.forename: G
authors.initials: G
authors.lastname: Fullarton
authors.affiliation: Medical Research Council, Cancer Unit, Addenbrookes Hospital, Cambridge, United Kingdom.
authors.forename: Massimiliano
authors.initials: M
authors.lastname: DiPietro
authors.affiliation: Department of Clinical Medicine & Gastroenterology, St James's Hospital, Dublin, Ireland.
authors.forename: Narayanasamy
authors.initials: N
authors.lastname: Ravi
authors.affiliation: Department of Cardiology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.
authors.forename: Jan G P
authors.initials: JGP
authors.lastname: Tijssen
authors.affiliation: Clinical Research Unit, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.
authors.forename: Marcel G W
authors.initials: MGW
authors.lastname: Dijkgraaf
authors.affiliation: Department of Gastroenterology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands.
authors.forename: Jacques J G H M
authors.initials: JJGHM
authors.lastname: Bergman
mesh_terms: D000230:Adenocarcinoma / Q000517:prevention & control*; D001471:Barrett Esophagus / Q000191:economics* / Q000473:pathology / Q000628:therapy*; D017115:Catheter Ablation / Q000191:economics*; D003362:Cost-Benefit Analysis; D018450:Disease Progression; D004938:Esophageal Neoplasms / Q000517:prevention & control*; D004945:Esophagoscopy / Q000191:economics; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D000078702:Radiofrequency Therapy; D057832:Watchful Waiting / Q000191:economics*