S1087 Cost-Effectiveness of Endoscopic Stricturotomy versus Resection Surgery for Crohn’s Disease Strictures

Abstract

Introduction: Strictures in Crohn's disease (CD) increase the likelihood of requiring surgery, which is costly and invasive. In the last two decades, endoscopic therapies including endoscopic balloon dilation (EBD) and endoscopic stricturotomy (ESt) have emerged as effective and less invasive therapies for CD strictures.1 ESt in particular is advantageous for longer, fibrotic strictures, or strictures adjacent to anatomic structures requiring precision, and has shown a high rate of surgery-free survival.2-4 We therefore assessed the cost-effectiveness of ESt as compared to surgical resection for CD strictures. Methods: A microsimulation state-transition model compared ESt to surgical resection for patients with primary or anastomotic CD strictures. Our primary outcome was quality-adjusted life years (QALYs) over ten years, and strategies were compared at a willingness to pay (WTP) of $100,000/QALY from a societal perspective. Costs (2022 $US) and ICERs were calculated. Deterministic 1-way and probabilistic analyses assessed model uncertainty. Results: The surgery strategy cost more than 2.5 times the endoscopic stricturotomy strategy, but resulted in nine higher QALYs per 100 persons (Table). Overall, surgery had an ICER of $308,787/QALY, making ESt more cost-effective. The median number of endoscopic stricturotomies was 4 in the ESt strategy and 0 in the surgery strategy; the median number of surgeries was 0 and 2 respectively. One-way sensitivity analyses showed that quality of life after ESt as compared to that after surgery, probabilities of requiring repeated interventions, and surgical mortality and cost were the most influential parameters in our model (Figure). Probabilistic sensitivity analyses favored ESt in 65.5% of iterations. Conclusion: Endoscopic stricturotomy is cost-effective for managing primary or anastomotic Crohn's disease strictures. Post-intervention quality of life and probabilities of requiring repeated interventions exert most influence on cost-effectiveness; the decision between ESt and surgery should be made considering patients' risk and quality of life preferences. 1. Lee KE et al. Dig Dis Sci. 2022 Mar 15.2. Lan N et al. Gastrointest Endosc. 2019 Aug;90:259-268.3. Zhang LJ et al. Gastroenterol Rep (Oxf). 2019 Oct;8:143-150. 4. Lan N et al. Inflamm Bowel Dis. 2018 Mar;24:897-907.Figure 1.: Tornado diagram showing main drivers (variables and sensitivity ranges) of the incremental cost-effectiveness ratio (ICER). †Multiplicative factor by which probability Tables are multiplied. Abbreviations: CD (Crohn's disease), ESt (Endoscopic stricturotomy), ICER (Incremental cost-effectiveness ratio), Max (Maximum), WTP (Willingness to pay) Table 1. - Base Case Cost-Effectiveness Analysis Results Cost ($) Incremental Cost ($) Effectiveness (QALY) Incremental Effectiveness (QALY) ICER ($/QALY) Endoscopic Stricturotomy 16,748 6.28 Resection Surgery 45,135 28,388 6.37 9 QALYs per 100 persons 308,787 Abbreviations: QALY (Quality-adjusted life year), ICER (Incremental cost-effectiveness ratio).