Cost Utility Analysis of Topical Steroids Compared With Dietary Elimination for Treatment of Eosinophilic Esophagitis

Abstract

Background & aims: Topical corticosteroids or dietary elimination are recommended as first-line therapies for eosinophilic esophagitis, but data to directly compare these therapies are scant. We performed a cost utility comparison of topical corticosteroids and the 6-food elimination diet (SFED) in treatment of eosinophilic esophagitis, from the payer perspective.

Methods: We used a modified Markov model based on current clinical guidelines, in which transition between states depended on histologic response simulated at the individual cohort-member level. Simulation parameters were defined by systematic review and meta-analysis to determine the base-case estimates and bounds of uncertainty for sensitivity analysis. Meta-regression models included adjustment for differences in study and cohort characteristics.

Results: In the base-case scenario, topical fluticasone was about as effective as SFED but more expensive at a 5-year time horizon ($9261.58 vs $5719.72 per person). SFED was more effective and less expensive than topical fluticasone and topical budesonide in the base-case scenario. Probabilistic sensitivity analysis revealed little uncertainty in relative treatment effectiveness. There was somewhat greater uncertainty in the relative cost of treatments; most simulations found SFED to be less expensive.

Conclusions: In a cost utility analysis comparing topical corticosteroids and SFED for first-line treatment of eosinophilic esophagitis, the therapies were similar in effectiveness. SFED was on average less expensive, and more cost effective in most simulations, than topical budesonide and topical fluticasone, from a payer perspective and not accounting for patient-level costs or quality of life.

Keywords: Cost Effectiveness; Cost Utility; Diet; Eosinophilic Esophagitis; Steroids; Treatment.

Figure 1

A: Simplified Markov Structure. B: Dietary Elimination Process.

Figure 1

A: Simplified Markov Structure. B: Dietary Elimination Process.

Figure 2

Incremental Costs and Quality Adjusted Life Years per Cohort in 10,000 Probabilistic Sensitivity Analysis Iterations Comparing Initial Topical Fluticasone to Initial Six Food Elimination Diet.

Figure 3

Incremental Costs and Quality Adjusted Life Years per Cohort in 10,000 Probabilistic Sensitivity Analysis Iterations Comparing Initial Topical Budesonide to Initial Six Food Elimination Diet.

Figure 4

Cost Effectiveness Acceptability Curve of Two Topical Steroids Compared to Six Food Elimination Diet