Cost-effectiveness of endoscopic surveillance of non-dysplastic Barrett's esophagus

Gastrointest Endosc. 2014 Feb;79(2):242-56.e6. doi: 10.1016/j.gie.2013.07.046. Epub 2013 Sep 27.


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.

Keywords: BE; Barrett's esophagus; HGD; IM; LGD; PCR; QALY; US dollars; USD; high-grade dysplasia; intestinal metaplasia; low-grade dysplasia; polymerase chain reaction; quality-adjusted life years.

Publication types

  • Practice Guideline
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Barrett Esophagus / economics
  • Barrett Esophagus / pathology*
  • Cost-Benefit Analysis
  • Decision Support Techniques
  • Disease Progression
  • Esophagoscopy / economics*
  • Esophagoscopy / standards
  • Female
  • Health Care Costs / standards*
  • Humans
  • Male
  • Middle Aged
  • Precancerous Conditions
  • SEER Program / economics*
  • United States