Abstract
Background: Patients with refractory gastroesophageal reflux disease (GERD) may have undiagnosed celiac disease. These patients often undergo esophagogastroduodenoscopy to determine the etiology and severity of GERD. Because a duodenal biopsy is the gold standard for diagnosing celiac disease and a gluten-free diet is an effective treatment, performing routine duodenal biopsy during endoscopy may result in early diagnosis and symptom improvement, allowing for discontinuation of proton pump inhibitor therapy. We aimed to evaluate the cost-effectiveness of performing routine duodenal biopsy during endoscopy for diagnosing celiac disease in patients with refractory GERD. Methods: We constructed a decision tree using data from published literature to calculate cost-effectiveness of endoscopy with and without duodenal biopsy in a cohort of 10,000 40-year-old patients. Results: We found that the biopsy strategy would detect 70 out of 100 celiac disease patients in a cohort of 10,000 GERD patients undergoing endoscopy if the prevalence of celiac disease was 1% in this cohort. Up-front biopsy would increase the remaining quality-adjusted life years (QALYs) by 0.0032. Testing for celiac disease using this approach would increase the lifetime cost by $389 per patient. Compared with no biopsy, the biopsy strategy cost $55,693 per celiac case detected, and $121,875 per QALY gained. The incremental cost-effectiveness ratio (ICER) met the threshold of 1.8%, the specificity of biopsy was >98%, the cost of gluten-free diet was $5,874 per year. Increasing the sensitivity of duodenal biopsy to 100% did not affect the cost-effectiveness threshold. Conclusion: Esophagogastroduodenoscopy with duodenal biopsy for refractory GERD patients can be a cost-effective approach for screening when the prevalence of celiac disease in this patient population is 1.8% or greater.
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