Medical decision analysis for the management of unifocal, flat, low-grade dysplasia in ulcerative colitis

Abstract

Background: Management of unifocal, flat, low-grade dysplasia (LGD) in ulcerative colitis (UC) remains controversial.

Objective: To compare the relative costs and effectiveness of immediate colectomy and enhanced colonoscopic surveillance for the management of LGD.

Design and setting: Medical decision analysis by using state-transition Markov models. Transition probabilities and health utilities were derived from the literature, and costs were derived from national hospital data sets and Medicare and/or Medicaid reimbursement schedules.

Patients: Two simulated cohorts of 10,000 patients with longstanding UC who were newly diagnosed with unifocal, flat LGD on initial surveillance colonoscopy.

Interventions: Immediate colectomy or enhanced surveillance (repeated colonoscopy at 3, 6, and 12 months, and then annually).

Main outcome measurements: Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.

Results: Immediate colectomy dominated over enhanced surveillance and yielded higher QALYs (20.1 vs 19.9 years) and lower costs ($75,900 vs $83,900). These findings were robust to variations in model parameters, with immediate colectomy remaining dominant in 90% of simulations in sensitivity analysis. Varying postcolectomy health utility outside the range in the probabilistic sensitivity analysis rendered enhanced surveillance cost effective. When the health utility was below 0.77, the incremental cost-effectiveness ratio was $50,000 per QALY.

Limitations: Data based on observational studies and analyses rely on model assumptions.

Conclusions: Our analysis showed that immediate colectomy was preferable to enhanced surveillance. Health preference toward the postcolectomy state is, however, an influential factor. This decision analysis model provides a conceptual framework for physicians and patients to understand the relative benefits and costs of both interventions.