Cost-effectiveness of per oral endoscopic myotomy relative to laparoscopic Heller myotomy for the treatment of achalasia

Surg Endosc. 2018 Jan;32(1):39-45. doi: 10.1007/s00464-017-5629-3. Epub 2017 Dec 7.


Background: Per oral endoscopic myotomy (POEM) has recently emerged as a viable option relative to the classic approach of laparoscopic Heller myotomy (LHM) for the treatment of esophageal achalasia. In this cost-utility analysis of POEM and LHM, we hypothesized that POEM would be cost-effective relative to LHM.

Methods: A stochastic cost-utility analysis of treatment for achalasia was performed to determine the cost-effectiveness of POEM relative to LHM. Costs were estimated from the provider perspective and obtained from our institution's cost-accounting database. The measure of effectiveness was quality-adjusted life years (QALYs) which were estimated from direct elicitation of utility using a visual analog scale. The primary outcome was the incremental cost-effectiveness ratio (ICER). Uncertainty was assessed by bootstrapping the sample and computing the cost-effectiveness acceptability curve (CEAC).

Results: Patients treated within an 11-year period (2004-2016) were recruited for participation (20 POEM, 21 LHM). During the index admission, the mean costs for POEM ($8630 ± $2653) and the mean costs for LHM ($7604 ± $2091) were not significantly different (P = 0.179). Additionally, mean QALYs for POEM (0.413 ± 0.248) were higher than that associated with LHM (0.357 ± 0.338), but this difference was also not statistically significant (P = 0.55). The ICER suggested that it would cost an additional $18,536 for each QALY gained using POEM. There was substantial uncertainty in the ICER; there was a 48.25% probability that POEM was cost-effective at the mean ICER. At a willingness-to-pay threshold of $100,000, there was a 68.31% probability that POEM was cost-effective relative to LHM.

Conclusions: In the treatment of achalasia, POEM appears to be cost-effective relative to LHM depending on one's willingness-to-pay for an additional QALY.

Keywords: Achalasia; Cost-effectiveness analysis; Heller myotomy; Per oral endoscopic myotomy.

MeSH terms

  • Adult
  • Aged
  • Cost-Benefit Analysis
  • Esophageal Achalasia / surgery*
  • Female
  • Health Care Costs / statistics & numerical data*
  • Heller Myotomy / economics*
  • Heller Myotomy / methods
  • Hospitalization / statistics & numerical data
  • Humans
  • Laparoscopy / economics*
  • Laparoscopy / methods
  • Length of Stay / statistics & numerical data
  • Male
  • Middle Aged
  • Natural Orifice Endoscopic Surgery / economics*
  • Natural Orifice Endoscopic Surgery / methods
  • Quality-Adjusted Life Years
  • Retrospective Studies
  • Treatment Outcome
  • Visual Analog Scale
  • Young Adult