Screening and Surveillance for Barrett Esophagus in High-Risk Groups: A Cost–Utility Analysis

4 February 2003 | Volume 138 Issue 3 | Pages 176-186

Background: Once-in-a-lifetime screening for Barrett esophagus has been proposed for patients with gastroesophageal reflux disease (GERD), but there is little evidence of its cost-effectiveness.

Objective: 1] To determine the cost-effectiveness of screening high-risk groups for Barrett esophagus and providing surveillance to patients with Barrett esophagus and dysplasia or to all patients with Barrett esophagus and 2) to compare the results with the cost-effectiveness of no screening or surveillance.

Design: A decision analytic model was developed to examine no screening or surveillance and screening and surveillance for Barrett esophagus with dysplasia only or Barrett esophagus without dysplasia every 2 to 5 years. Low- or high-grade dysplasia received surveillance every 6 or 3 months, respectively.

Data Sources: Published literature and the Health Care Financing Administration.

Target Population: 50-year-old white men with symptoms of GERD.

Time Horizon: 50 years of age until 80 years of age or death.

Perspective: Third-party payer.

Outcome Measure: Incremental cost-effectiveness ratio.

Results of Base-Case Analysis: Screening with surveillance limited to patients with Barrett esophagus with dysplasia required $10 440 per quality-adjusted life-year (QALY) saved compared to no screening or surveillance. The incremental cost-effectiveness ratio of surveillance every 5 years in patients with Barrett esophagus without dysplasia compared to surveillance of patients with Barrett esophagus with dysplasia was $596 000 per QALY saved.

Results of Sensitivity Analysis: The annual incidence of adenocarcinoma must exceed 1 case per 54 patient-years of follow-up (1.9%) for surveillance of Barrett esophagus without dysplasia every 5 years to yield an incremental cost-effectiveness ratio less than $50 000 per QALY saved.

Conclusions: Screening 50-year-old men with symptoms of GERD to detect adenocarcinoma associated with Barrett esophagus is probably cost-effective. However, subsequent surveillance of patients with Barrett esophagus but no dysplasia, even at 5-year intervals, is an expensive practice.

Editors' Notes Context Barrett esophagus, a complication of gastroesophageal reflux disease (GERD), is associated with an increased risk for esophageal cancer. Some have proposed endoscopic screening for Barrett esophagus, followed by surveillance for cancer in patients with the disorder. Contribution The authors modeled the cost-effectiveness of screening 50-year-old white men with GERD. Screening followed by surveillance in patients with Barrett esophagus and dysplasia cost $10 440 per quality-adjusted life-year (QALY). Surveillance of patients with Barrett esophagus but no dysplasia every 5 years would cost an additional $596 000 per QALY. Implications One-time screening for Barrett esophagus in 50-year-old men with GERD is reasonably cost-effective if surveillance is limited. –The Editors

 

Author and Article Information

From Veterans Administration Center for Practice Management and Outcomes Research, University of Michigan, and the Consortium for Health Outcomes, Innovation, and Cost Effectiveness Studies, Ann Arbor, Michigan; Southern Arizona Veterans Affairs Healthcare System and University of Arizona, Tucson, Arizona; Karolinska Institute and Karolinska Hospital, Stockholm, Sweden; Oregon Health Sciences University, Portland, Oregon; and University of Wisconsin Medical School, Milwaukee, Wisconsin.

Grant Support: By Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service grant IIR 99-238-2 and an American College of Gastroenterology Faculty Development Award (Dr. Inadomi).

Potential Conflicts of Interest:Consultancies: A.M. Fendrick, N. Vakil; Honoraria: R. Sampliner, A.M. Fendrick, N. Vakil; Grants received: R. Sampliner, A.M. Fendrick, N. Vakil; Grants pending: R. Sampliner; Other: A.M. Fendrick.

Requests for Single Reprints: Nimish Vakil, MD, Division of Gastroenterology, University of Wisconsin Medical School, Aurora Sinai Medical Center, 945 North 12th Street, Room 4040, Milwaukee, WI 53233; e-mail, nvakil{at}wisc.edu.

Current Author Addresses: Dr. Inadomi: Veterans Affairs Ann Arbor Health Systems (111-D), 2215 Fuller Road, Ann Arbor, MI 48105.

Dr. Sampliner: Southern Arizona Veterans Affairs Healthcare System, 3601 South Sixth Avenue (111G-1), Tucson, AZ 85723.

Dr. Lagergren: Department of Medical Epidemiology, Karolinska Institute, Box 281, S-171 77 Stockholm, Sweden.

Dr. Lieberman: Portland Veterans Affairs Hospital (111A), 3710 Southwest U.S. Veterans Hospital Road, PO Box 1034, Portland, OR 97207.

Dr. Fendrick: University of Michigan Medical Center, 300 NIB, Room Ni7C27, 865 Brookside Drive, Ann Arbor, MI 48105.

Dr. Vakil: Division of Gastroenterology, Aurora Sinai Medical Center, 945 North 12th Street, Room 4040, Milwaukee, WI 53233.

Author Contributions: Conception and design: J.M. Inadomi, R. Sampliner, J. Lagergren, A.M. Fendrick, N. Vakil.

Analysis and interpretation of the data: J.M. Inadomi, J. Lagergren, D. Lieberman, A.M. Fendrick, N. Vakil.

Drafting of the article: J.M. Inadomi, J. Lagergren, D. Lieberman, A.M. Fendrick, N. Vakil.

Critical revision of the article for important intellectual content: J.M. Inadomi, R. Sampliner, J. Lagergren, D. Lieberman, A.M. Fendrick, N. Vakil.

Final approval of the article: J.M. Inadomi, R. Sampliner, J. Lagergren, D. Lieberman, A.M. Fendrick, N. Vakil.

Provision of study materials or patients: J.M. Inadomi, R. Sampliner, N. Vakil.

Statistical expertise: J.M. Inadomi, N. Vakil.

Obtaining of funding: J.M. Inadomi.

Administrative, technical, or logistic support: J.M. Inadomi, N. Vakil.

Collection and assembly of data: J.M. Inadomi, N. Vakil.