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Comparative Study
. 2021 Aug 1;116(8):1620-1631.
doi: 10.14309/ajg.0000000000001336.

Comparative Cost Effectiveness of Reflux-Based and Reflux-Independent Strategies for Barrett's Esophagus Screening

Sarmed S Sami  1 , James P Moriarty  2 , Jordan K Rosedahl  2 , Bijan J Borah  2   3 , David A Katzka  4 , Kenneth K Wang  4 , John B Kisiel  5 , Krish Ragunath  6 , Joel H Rubenstein  7   8 , Prasad G Iyer  4
Affiliations
Comparative Study

Comparative Cost Effectiveness of Reflux-Based and Reflux-Independent Strategies for Barrett's Esophagus Screening

Sarmed S Sami et al. Am J Gastroenterol. .

Abstract

Introduction: Minimally invasive tests for Barrett's esophagus (BE) detection have raised the prospect of broader nonreflux-based testing. Cost-effectiveness studies have largely studied men aged 50 years with chronic gastroesophageal reflux disease (GERD) symptoms. We evaluated the comparative cost effectiveness of BE screening tests in GERD-based and GERD-independent testing scenarios.

Methods: Markov modeling was performed in 3 scenarios in 50 years old individuals: (i) White men with chronic GERD (GERD-based); (ii) GERD-independent (all races, men and women), BE prevalence 1.6%; and (iii) GERD-independent, BE prevalence 5%. The simulation compared multiple screening strategies with no screening: sedated endoscopy (sEGD), transnasal endoscopy, swallowable esophageal cell collection devices with biomarkers, and exhaled volatile organic compounds. A hypothetical cohort of 500,000 individuals followed for 40 years using a willingness to pay threshold of $100,000 per quality-adjusted life year (QALY) was simulated. Incremental cost-effectiveness ratios (ICERs) comparing each strategy with no screening and comparing screening strategies with each other were calculated.

Results: In both GERD-independent scenarios, most non-sEGD BE screening tests were cost effective. Swallowable esophageal cell collection devices with biomarkers were cost effective (<$35,000/QALY) and were the optimal screening tests in all scenarios. Exhaled volatile organic compounds had the highest ICERs in all scenarios. ICERs were low (<$25,000/QALY) for all tests in the GERD-based scenario, and all non-sEGD tests dominated no screening. ICERs were sensitive to BE prevalence and test costs.

Discussion: Minimally invasive nonendoscopic tests may make GERD-independent BE screening cost effective. Participation rates for these strategies need to be studied.

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Conflict of interest statement

Guarantor of the article: Prasad G. Iyer, MD, MSc.

Specific author contributions: S.S.S. contributed to the study concept and design, acquisition of data, analysis, interpretation of data, and drafted the manuscript. J.P.M. contributed to the acquisition of data, statistical analysis, drafting of the manuscript, and critical revision of the manuscript for important intellectual content. J.K.R. contributed to the acquisition of data, statistical analysis, and critical revision of the manuscript for important intellectual content. B.J.B. contributed to the acquisition of data, statistical analysis, and critical revision of the manuscript for important intellectual content. J.B.K. contributed to the study concept and critical revision of the manuscript for important intellectual content. D.A.K. contributed to the study concept and critical revision of the manuscript for important intellectual content. K.K.W. contributed to the study concept and critical revision of the manuscript for important intellectual content. K.R. contributed to the study concept and design and critical revision of the manuscript for important intellectual content. J.H.R. contributed to the study concept and design and critical revision of the manuscript for important intellectual content. P.G.I. contributed to study concept and design, acquisition of data, analysis and interpretation of data, critical revision of the manuscript for important intellectual content, obtained funding, and study supervision.

Financial support: This work was partially supported by grants from the National Cancer Institute (CA241164 to PGI and JBK, U01CA199336 to JHR), the Department of Veterans Affairs (I01-CX000899 to JHR), and the Freeman Foundation.

Potential competing interests: S.S.S.: No relevant disclosures. J.P.M.: No relevant disclosures. J.K.R.: No relevant disclosures. B.J.B.: No relevant disclosures. D.A.K.: Consultant Shire. K.K.W.: Research funding from Nine Point Medical, C2 therapeutics, Olympus, Medtronic, and Boston Scientific. J.B.K.: Research funding from Exact Sciences. P.G.I.: Research funding from Exact Sciences and C2 Therapeutics Consultant: Medtronic and Symple Surgical. J.H.R.: No relevant disclosures. K.R.: No relevant disclosures. Mayo Clinic is a minor equity investor in Exact Sciences. J.B.K. is a coinventor on technology licensed to Exact Sciences.

Figures

None
Graphical abstract
Figure 1.
Figure 1.
Model structure. BE, Barrett's esophagus.
Figure 2.
Figure 2.
Tornado diagram of parameters model is sensitive (GERD-independent 1.6% prevalence). y axis signifies the sensitive parameter and which strategy is affected compared with no screening; arrows on ICER lines indicate that the line extends beyond the limit on the x axis. Dots represent ICER for base case assumption. Values on each end of a tornado bar represent the ranges for sensitivity analysis. The dotted line is the cost-effectiveness threshold. Figures to the right of the dotted line are the values at which the sensitive parameter results in an ICER equal to the threshold value of $100,000/QALY. eVOC, exhaled volatile organic compounds; GERD, gastroesophageal reflux disease; hTNE, hospital transnasal endoscopy; ICER, incremental cost-effectiveness ratio; MDM, methylated DNA marker; mTNE, mobile transnasal endoscopy; sEGD, sedated endoscopy; SoS, sponge on a string test (EsophaCap + MDMs).
Figure 3.
Figure 3.
“Pseudo”tornado diagram of parameters: the optimal strategy model is sensitive to in the GERD-independent 5% prevalence population, where the SoS test is optimal. The color of the line represents which strategy is optimal at that level of the parameter magnitude. There are 10 parameters (y axis) which had crossover points in this analysis. The X sign on the line marks the base case value (and result), whereas the dot marks the crossover point at which the optimal strategy changes. This change is demonstrated by the lines on either side being different colors. eVOC, exhaled volatile organic compounds; GERD, gastroesophageal reflux disease; hTNE, hospital transnasal endoscopy; MDM, methylated DNA marker; mTNE, mobile van transnasal endoscopy; sEGD, sedated endoscopy; SoS, sponge on a string test (EsophaCap + MDMs).
Figure 4.
Figure 4.
“Pseudo”tornado diagram of parameters the optimal strategy model is sensitive to in the GERD-independent 1.6% prevalence population, where the Cytosponge + TFF3 test is optimal. The color of the line represents which strategy is optimal at that level of the parameter magnitude. There are 10 parameters (y axis) which had crossover points in this analysis. The X sign on the line marks the base case value (and result), whereas the dot marks the crossover point at which the optimal strategy changes. This change is demonstrated by the lines on either side being different colors. eVOC, exhaled volatile organic compounds; GERD, gastroesophageal reflux disease; hTNE, hospital transnasal endoscopy; mTNE, mobile van transnasal endoscopy; sEGD, sedated endoscopy; SoS, sponge on a string test (EsophaCap + MDMs); TFF3, trefoil factor 3.
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