Cost-Benefit Analysis of Double Balloon Enteroscopy Compared to Other Diagnostic Modalities for Obscure Gastrointestinal Hemorrhage

Abstract

Background: Double balloon enteroscopy (DBE) is a new technology that allows for non-surgical exploration in patients with obscure bleeding. We created a decision analysis to determine the cost-effectiveness of initial DBE compared to capsule endoscopy (CE), push enteroscopy, intraoperative enteroscopy, or angiography for the diagnosis and management of small bowel arteriovenous malformations (AVMs). Methods: We created a decision tree (TreeAge Pro 2005, TreeAge, MA) to compare costs and outcomes for patients with transfusion-dependent obscure occult bleeding. The base case was no treatment. Competing alternative strategies included push enteroscopy, intraoperative enteroscopy, CE followed by DBE if a lesion was detected, angiography, and DBE. DBE was initiated using the oral approach, followed by the rectal approach if no lesion was found. Patients with unsuccessful treatment were assumed to have ongoing transfusion requirements of 4 units/month. We calculated that there would be a spontaneous cessation rate for AVM-related hemorrhage of 22% per year. We assumed that the probability of detecting an AVM on CE would be 67% (Triester Am J Gastro 2005) with a probability of finding an AVM on DBE of 60%. Procedural costs were obtained from the 2005 American Medical Association CPT website. Cost of CE was estimated at $1120, DBE oral approach $282, and DBE rectal approach $790. Costs of inpatient hospital services were obtained by using the 2004 Medicare Prospective Payment System DRG. The time horizon of the model was 1 year. Results: Baseline analysis results are shown in the Table. Initial oral DBE approach was the most effective strategy with an average cost-effectiveness ratio of $6000 per patient successfully treated compared to no therapy. Threshold values on sensitivity analysis that would lead to capsule-directed DBE as the preferred approach included a probability of AVM on oral DBE <59%, probability of AVM after capsule >66%, and probability of AVM on CE >69%. Intraoperative enteroscopy was preferred if the probability of success on oral DBE <54%. No other changes in probabilities or costs altered the model results. Conclusions: For patients with obscure occult bleeding from small bowel AVMs, initial DBE is a cost-effective approach.