Abstract
Barrett’s esophagus (BE) is an abnormality arising from gastroesophageal reflux disease that can progressively evolve into a sequence of dysplasia and adenocarcinoma. Progression of Barrett’s esophagus into dysplasia is monitored with endoscopic surveillance. The current surveillance standard requests random biopsies plus targeted biopsies of suspicious lesions under white-light endoscopy, known as the Seattle protocol. Recently, published evidence has shown that narrow-band imaging (NBI) can guide targeted biopsies to identify dysplasia and reduce the need for random biopsies. We aimed to assess the health economic implications of adopting NBI-guided targeted biopsy vs. the Seattle protocol from a National Health Service England perspective. A decision tree model was developed to undertake a cost-consequence analysis. The model estimated total costs (i.e. staff and overheads; histopathology; adverse events; capital equipment) and clinical implications of monitoring a cohort of patients with known/suspected BE, on an annual basis. In the simulation, BE patients (N = 161,657 at Year 1; estimated annual increase: +20%) entered the model every year and underwent esophageal endoscopy. After 7 years, the adoption of NBI with targeted biopsies resulted in cost reduction of £458.0 mln vs. HD-WLE with random biopsies (overall costs: £1,966.2 mln and £2,424.2 mln, respectively). The incremental investment on capital equipment to upgrade hospitals with NBI (+£68.3 mln) was offset by savings due to the reduction of histological examinations (-£505.2 mln). Reduction of biopsies also determined savings for avoided adverse events (-£21.1 mln). In the base-case analysis, the two techniques had the same accuracy (number of correctly identified cases: 1.934 mln), but NBI was safer than HD-WLE. Budget impact analysis and cost-effectiveness analyses confirmed the findings of the cost-consequence analysis. In conclusion, NBI-guided targeted biopsies was a cost-saving strategy for NHS England, compared to current practice for detection of dysplasia in patients with BE, whilst maintaining at least comparable health outcomes for patients.
Highlights
Barrett’s esophagus (BE) is a condition in which the typical squamous epithelium of the esophageal mucosa is replaced with columnar intestinal epithelium [1,2]
In the budget impact analysis, the estimated annual savings were shown to increase each year as the population attending for surveillance endoscopy continued to grow (Table 4)
Each conducted analysis showed that the adoption of narrow-band imaging (NBI) would be cost-saving in those scenarios where diagnostic accuracy was measured on a per-patient level (NBI and HD-white-light endoscopy (WLE) have same detection rate [17]), and dominant in those scenarios where diagnostic accuracy was measured on a per-lesion level (NBI has higher detection rate than HD-WLE [20])
Summary
Barrett’s esophagus (BE) is a condition in which the typical squamous epithelium of the esophageal mucosa is replaced with columnar intestinal epithelium [1,2]. The prevalence of BE ranges from 0.5% to 2% of the general adult population, with gastroesophageal reflux disease (GERD), obesity, cigarette smoking, alcohol, and Helicobacter pylori infection being the most common risk factors of development [3]. BE can progressively evolve into a sequence of low-grade dysplasia (LG-BE), high-grade dysplasia (HG-BE), and eventually esophageal adenocarcinoma (EAC) [4], a malignancy that has witnessed increasing incidence over the past 40 years [5,6]. Large cohort studies on BE patients have reported rates of progression ranging from 0.1 to 0.3% [7–9]. The risk of EAC among patients with BE is estimated to be 30 to 125 fold greater than that of the general population [10]. Incidence of EAC is expected to continue to increase [11]. The predicted ranges of incidence and mortality rates (cases per 100,000 person years) in 2030 are 8.4 to 10.1 and 5.4 to 7.4, respectively, for males, and 1.3 to 1.8 and 0.9 to 1.2 for females, approximately doubling the number of deaths in the past 20 years, and at an accelerating rate [11]
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