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Cost-Utility of Screening for Barrett's Esophagus with Esophageal Capsule Endoscopy Versus Conventional Upper Endoscopy

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Rubenstein, Joel H. MD, MSc; Inadomi, John M. MD; Brill, Joel V. MD; Eisen, Glenn M. MD, MPH

American Journal of Gastroenterology: September 2006 - Volume 101 - Issue - p S42
Abstracts: ESOPHAGUS
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Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, MI; Division of Gastroenterology, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, MI; Division of Gastroenterology, University of California San Francisco Medical School, San Francisco, CA; Division of Gastroenterology, San Francisco General Hospital, San Francisco, CA; Predictive Health, LLC, Phoenix, AZ and Division of Gastroenterology, Oregon Health Sciences University, Portland, OR.

Purpose: Esophageal adenocarcinoma is rising in incidence, and screening with conventional upper endoscopy to decrease cancer mortality is recommended. Esophageal capsule endoscopy (ECE) has recently been shown to be accurate in detecting Barrett's esophagus, the accepted precursor of this malignancy. We aimed to compare the cost-effectiveness of screening by ECE with screening by conventional upper endoscopy for esophageal adenocarcinoma.

Methods: A Markov model of hypothetical 50 year-old Caucasian men with symptoms of gastroesophageal reflux was constructed to calculate outcomes associated with Barrett's esophagus and esophageal cancer. The model incorporated direct medical costs, costs of lost productivity, and patient preferences for health states (utilities), and followed the patients until age 80 or death. The primary outcome was the incremental cost-effectiveness ratio, and was analyzed from the societal perspective. Other outcomes included were life expectancy, quality-adjusted life expectancy, and proportion of cancer deaths averted.

Results: Screening by conventional upper endoscopy prevented 60.4% of cancer deaths, at a cost of $11,254 per quality-adjusted life-year gained compared to no screening. ECE prevented 59.0% of cancer deaths, and provided 2 fewer quality-adjusted days and at greater cost than conventional upper endoscopy. The only scenario in which ECE would be the preferred strategy is if the patient and his driver earned more than $153,423 annually, resulting in substantial lost productivity to society compared to the incremental gain in patient outcomes with EGD.

Conclusions: Screening for esophageal adenocarcinoma with either conventional endoscopy or ECE result in similar outcomes, but conventional endoscopy is the preferred strategy. Both strategies appear cost-effective and the model does not take into account patient or health care provider preferences for screening modality or adherence.

© The American College of Gastroenterology 2006. All Rights Reserved.