A Cost-Utility Analysis of Ablative Therapy for Barrett's Esophagus

Abstract

Background & Aims Recommendations for patients with Barrett’s esophagus (BE) include endoscopic surveillance with esophagectomy for early-stage cancer, although new technologies to ablate dysplasia and metaplasia are available. This study compares the cost-utility of ablation with that of endoscopic surveillance strategies. Methods A decision analysis model was created to examine a population of patients with BE (mean age 50), with separate analyses for patients with no dysplasia, low-grade dysplasia (LGD), or high-grade dysplasia (HGD). Strategies compared were: no endoscopic surveillance; endoscopic surveillance with ablation for incident dysplasia; immediate ablation followed by endoscopic surveillance in all patients or limited to patients in whom metaplasia persisted, and esophagectomy. Ablation modalities modeled included radiofrequency, argon plasma coagulation, multipolar electrocoagulation and photodynamic therapy. Results Endoscopic ablation for patients with HGD could increase life expectancy by 3 quality-adjusted years at an incremental cost of < $6,000, compared with no intervention. Patients with LGD or no dysplasia can also be optimally managed with ablation, but continued surveillance after eradication of metaplasia is expensive. If ablation permanently eradicates at least 28% of LGD or 40% of non-dysplastic metaplasias, ablation would be preferred to surveillance. Conclusions Endoscopic ablation could be the preferred strategy for managing patients with BE with HGD. Ablation might also be preferred in subjects with LGD or no dysplasia, but the cost-effectiveness depends on the long-term effectiveness of ablation and whether surveillance endoscopy can be discontinued following successful ablation. As further post-ablation data become available, the optimal management strategy will be clarified.

Cost–effectiveness analysis of endoscopic eradication therapy for treatment of high-grade dysplasia in Barrett’s esophagus

“…Three studies were identified that reported transition probabilities [25][26][27]. Many of the inputs reported were the same or similar.…”

“…However, these data were mostly taken from Shaheen et al [25] which is considered separately. Therefore, the options included in the model were two sets of probabilities from Inadomi et al [26] and one from Shaheen et al [25]. Inadomi et al was selected for the base case input because this was the most up-to-date.…”

“…-Complete eradication of dysplasia 92.6% - [28] -Residual dysplasia 7.4% - [28] -Natural history transition probabilities Full table available in reference - [26] Cost inputs RFA GB£1509 per session Average number of treatments = 3 [29,30] EMR GB£702 per session Average number of treatments = 1 [29,30] Stricture GB£3931 Average number of sessions to treat stricture is 1.3 (average) endoscopies and dilatations [19,[29][30] Perforation GB£7807 Cc score of 2-3. 6-day stay [30] Esophagectomy GB£9678 Excess bed days included.…”

“…Cured (or no Barrett's esophagus) 0.80 [32] NDBE 0.71 Calculated from the disutilities used in [29] LGD 0.65 Calculated from the disutilities used in [29] HGD 0.57 Calculated from the disutilities used in [29] OAC 0.48 Calculated from the disutilities used in [29] Cured -postesophagectomy 0.774 Calculated from [26] Stricture -0.03 (applied for 0.25 months) Calculated from [29] Surgery for perforation -0.28 (applied for 0.5 months) Calculated from [29] EMR and RFA surgery -0.06 (applied for 0.5 months) -…”

Modeling the Cost-effectiveness of Strategies for Treating Esophageal Adenocarcinoma and High-grade Dysplasia

“…This has been a particularly contentious topic with health economic studies producing mixed results as to the cost-effectiveness of endoscopic surveillance of Barrett's esophagus [5]. In 2009 two US studies recorded mean costs per patient under surveillance of $2,769 [31] and $11,532 [32] for surveillance programs involving 5-yearly screening intervals, and $7,940 was reported for one UK study with 3-yearly intervals (converted to $ 2009) [13]. Our cost cut-off of $4971 per patient within an early detection program appears to be in the overall range of these costs.…”