Cost effectiveness of routine duodenal biopsies in iron deficiency anemia

Abstract

AIMTo investigate the cost effectiveness of routine small bowel biopsies (SBBs) in patients with iron deficiency anemia (IDA) independent of their celiac disease (CD) serology test results.METHODSWe used a state transition Markov model. Two strategies were compared: routine SBBs during esophagogastroduodenoscopy (EGD) in all patients with IDA regardless their celiac serology status (strategy A) vs SBBs only in IDA patients with positive serology (strategy B). The main outcomes were quality adjusted life years (QALY), average cost and the incremental cost effectiveness ratio (ICER). One way sensitivity analysis was performed on all variables and two way sensitivity analysis on selected variables were done. In order to validate the results, a Monte Carlo simulation of 100 sample trials with 10, and an acceptability curve were performed.RESULTSStrategy A of routine SBBs yielded 19.888 QALYs with a cost of $218.10 compared to 19.887 QALYs and $234.17 in strategy B. In terms of cost-effectiveness, strategy A was the dominant strategy, as long as the cost of SBBs stayed less than $67. In addition, the ICER of strategy A was preferable, providing the cost of biopsy stays under $77. Monte Carlo simulation demonstrated that strategy A yielded the same QALY but with lower costs than strategy B.CONCLUSIONOur model suggests that EGD with routine SBBs is a cost-effective approach with improved QALYs in patients with IDA when the prevalence of CD is 5% or greater. SBBs should be a routine screening tool for CD among patients with IDA, regardless of their celiac antibody status.

Physicians’ attitude and perception regarding celiac disease: A questionnaire-based study

“…Therefore, 6% to 22% of biopsy proven CD cases could be seronegative (2). Performing intestinal biopsy, independently of the CD serology, is also cost efficient in patients with iron-deficiency anemia of unknown origin (35). One study showed that approximately 60% of the physicians are recommending diagnostic intestinal biopsy in patients with CD (9).…”

Spectrum of Histopathological Patterns of Duodenal Biopsies in Patients With Unexplained Anaemia and Chronic Diarrhea and Their Correlation With Endoscopic Findings and Serological Markers

“…Grisolano and colleagues reported that its frequency was 8.7% (n=103) 16,17 . Broide, et al have recommended that patients with unexplained iron deficiency anaemia should be worked up for celiac disease by histopathology of biopsies 18 . In our study, 95 (65.5%) patients had unremarkable findings on EGD, but 10 (6.8%) patients were diagnosed as celiac disease on histopathology.…”

Value of routine duodenal mucosal biopsies in the evaluation of anemia in a large Australian referral centre

“…These studies have established the need for biopsies in only those with “high‐risk” features but have not categorized anemia into IDA versus non‐IDA, a group in which the incidence of celiac disease is low. Studies have also assessed the role of routine biopsy for IDA, finding a prevalence of celiac disease of around 5–10% in those with documented IDA . In addition, a 2016 cost analysis by Broide et al found that SBBx, regardless of serological status, is cost‐effective in populations in which the prevalence of celiac disease is >5% and, therefore, suggested that all patients with IDA should have SBBx during endoscopy .…”

“…Studies have also assessed the role of routine biopsy for IDA, finding a prevalence of celiac disease of around 5–10% in those with documented IDA . In addition, a 2016 cost analysis by Broide et al found that SBBx, regardless of serological status, is cost‐effective in populations in which the prevalence of celiac disease is >5% and, therefore, suggested that all patients with IDA should have SBBx during endoscopy . These studies, however, have not combined serological and endoscopic indications for biopsy and have not included demographic features to identify at‐risk populations.…”

“…This study found an incidence of celiac disease of <1% in men and all patients without IDA. Given that most guidelines only recommend SBBx with a pretest probability of >5%, these patients should not have SBBx during endoscopy unless serological or endoscopic abnormalities are found. In our population this approach would have resulted in a sensitivity of 100% (CI 85–100%) and an NPV of 100% (99.4–100%).…”