The Role of Anti-Reflux Surgery in Tube-Feeding for Children with Severe Neurologic Impairment: A Cost-Effectiveness Analysis (S747)

Abstract

1.Understand why there is debate about the best intervention type for a child with severe neurologic impairment requiring mechanical feeds.2.Understand the basics of Markov modeling and why it was chosen to address this clinical question.3.Discover how decision analysis can be helpful at shaping next steps in clinical research for a given question. Children with severe neurological impairment are an important population followed by pediatric palliative care specialists. These children often require initiation of gastrostomy tube (G-tube) feeding because of inability to take adequate oral nutrition, and palliative care specialists frequently are asked to assist families with decision-making around G-tube placement. Gastrostomy tube feeding can worsen reflux, a major cause of mortality in this population. Anti-reflux surgery (ARS) at the time of G-tube placement can decrease the risk of post-procedural reflux, but has associated perioperative morbidity, mortality, and higher costs. This study evaluated the cost-effectiveness of the G-tube with ARS compared to the G-tube alone for children with severe neurological impairment. A Markov cohort model was constructed in TreeAge Pro to compare the cost-effectiveness of the two strategies over a lifetime time horizon. Probabilities and utilities of possible outcomes were estimated by weighted average of available data following a comprehensive literature search. Cost data was obtained from the Ontario Case-Costing Initiative. Outcome measures were quality-adjusted life years (QALYs), lifetime costs, and net monetary benefits. The G-tube alone was superior in both cost and effectiveness, with a benefit of $4,400 (17.1% savings) and 0.07 lifetime QALYs (1.0% improvement), compared to the G-tube with ARS. These results were sensitive to the probability of developing reflux after G-tube placement and the perioperative mortality associated with both strategies. From a systems-utilization perspective with currently available data, the potential long-term benefits of ARS do not outweigh its higher perioperative complication and mortality rates in children with neurological impairment. However, better understanding of the probability of reflux following G-tube placement is necessary to fully evaluate the risks and benefits of these two strategies.