Cost-effectiveness of endoscopic surveillance of non-dysplastic Barrett's esophagus
Cost-effectiveness of endoscopic surveillance of non-dysplastic Barrett's esophagus
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DOI：
10.1016/j.gie.2013.07.046
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发表时间：
2014-02-01
影响因子：
7.7
通讯作者：
Watson, David I.
中科院分区：
文献类型：
--
作者：
Gordon, Louisa G.;Mayne, George C.;Watson, David I.
背景：非发育不良Barrett‘s食道(BE)的内窥镜监测存在争议，其成本效益尚不清楚。目的：对内窥镜监测策略进行经济学分析。设计：根据国际指南，使用模拟马尔科夫模型综合来自大型流行病学研究的证据和用于监测的临床数据进行成本-效用分析。地点：南澳大利亚三级保健医院。患者：总计2040名患者-年的随访。干预：(1)无监测，(2)两年一次的非发育不良BE患者的内窥镜监测和六个月一次的低级别异型增生患者的监测；(3)生物标记物修饰监测的假设策略。主要结果衡量标准：美国每质量调整生命年(QALY)比率的成本。结果：与无监测相比，监测产生的每QALY比率的估计增量成本为60,858美元。当监测实践被假想的基于生物标记物的战略修改时，这一数字减少到38,307美元。敏感性分析表明，如果将基于生物标记物的假设策略添加到监测中，与没有监测相比，单独监测具有成本效益的可能性分别为16.0%和60.6%，每获得100,000美元的可接受阈值。限制：BE的治疗选择与有症状的GERD重叠。结论：通过对BE恶性潜能的最佳可用估计，对大多数患者来说，对非发育不良BE的内窥镜监测不太可能具有成本效益，并且在很大程度上取决于异型增生级别之间的进展率。然而，根据癌症风险修改监测的策略可能是具有成本效益的，前提是高危个人能够被识别并优先进行监测。
Background: Endoscopic surveillance for non-dysplastic Barrett's esophagus (BE) is contentious and its cost effectiveness unclear.Objective: To perform an economic analysis of endoscopic surveillance strategies.Design: Cost-utility analysis by using a simulation Markov model to synthesize evidence from large epidemiologic studies and clinical data for surveillance, based on international guidelines, applied in a coordinator-managed surveillance program.Setting: Tertiary care hospital, South Australia.Patients: A total of 2040 patient-years of follow-up.Intervention: (1) No surveillance, (2) 2-yearly endoscopic surveillance of patients with non-dysplastic BE and 6-monthly surveillance of patients with low-grade dysplasia, (3) a hypothetical strategy of biomarker-modified surveillance.Main Outcome Measurements: U.S. cost per quality-adjusted life year (QALY) ratios.Results: Compared with no surveillance, surveillance produced an estimated incremental cost per QALY ratio of $60,858. This was reduced to $38,307 when surveillance practice was modified by a hypothetical biomarker-based strategy. Sensitivity analyses indicated that the likelihood that surveillance alone was cost-effective compared with no surveillance was 16.0% and 60.6% if a hypothetical biomarker-based strategy was added to surveillance, at an acceptability threshold of $100,000 per QALY gained.Limitations: Treatment options for BE that overlap those for symptomatic GERD were omitted.Conclusion: By using best available estimates of the malignant potential of BE, endoscopic surveillance of patients with non-dysplastic BE is unlikely to be cost-effective for the majority of patients and depends heavily on progression rates between dysplasia grades. However, strategies that modify surveillance according to cancer risk might be cost-effective, provided that high-risk individuals can be identified and prioritized for surveillance.