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Observational Study
. 2023 Aug;21(9):2378-2388.e28.
doi: 10.1016/j.cgh.2023.01.003. Epub 2023 Jan 13.

Up-Front Endoscopy Maximizes Cost-Effectiveness and Cost-Satisfaction in Uninvestigated Dyspepsia

Emily V Wechsler  1 , Nitin K Ahuja  2 , Darren Brenner  3 , Walter Chan  4 , Lin Chang  5 , William D Chey  6 , Anthony J Lembo  7 , Baha Moshiree  8 , Judy Nee  7 , Shailja C Shah  9 , Kyle Staller  10 , Eric D Shah  11
Affiliations
Observational Study

Up-Front Endoscopy Maximizes Cost-Effectiveness and Cost-Satisfaction in Uninvestigated Dyspepsia

Emily V Wechsler et al. Clin Gastroenterol Hepatol. 2023 Aug.

Abstract

Background & aims: Practice guidelines promote a routine noninvasive, non-endoscopic initial approach to investigating dyspepsia without alarm features in young patients, yet many patients undergo prompt upper endoscopy. We aimed to assess tradeoffs among costs, patient satisfaction, and clinical outcomes to inform discrepancy between guidelines and practice.

Methods: We constructed a decision-analytic model and performed cost-effectiveness/cost-satisfaction analysis over a 1-year time horizon on patients with uninvestigated dyspepsia without alarm features referred to gastroenterology. A RAND/UCLA expert panel informed model design. Four competing diagnostic/management strategies were evaluated: prompt endoscopy, testing for Helicobacter pylori and eradicating if present (test-and-treat), testing for H pylori and performing endoscopy if present (test-and-scope), and empiric acid suppression. Outcomes were derived from systematic reviews of clinical trials. Costs were informed by prospective observational cohort studies and national commercial/federal cost databases. Health gains were represented using quality-adjusted life years.

Results: From the patient perspective, costs and outcomes were similar for all strategies (maximum out-of-pocket difference of $30 and <0.01 quality-adjusted life years gained/year regardless of strategy). Prompt endoscopy maximized cost-satisfaction and health system reimbursement. Test-and-scope maximized cost-effectiveness from insurer and patient perspectives. Results remained robust on multiple one-way sensitivity analyses on model inputs and across most willingness-to-pay thresholds.

Conclusions: Noninvasive management strategies appear to result in inferior cost-effectiveness and patient satisfaction outcomes compared with strategies promoting up-front endoscopy. Therefore, additional studies are needed to evaluate the drivers of patient satisfaction to facilitate inclusion in value-based healthcare transformation efforts.

Keywords: Comparative Effectiveness Research; Costs and Cost Analysis; Endoscopy; Insurance.

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Conflict of interest statement

These authors disclose the following: Dr Ahuja consulted for GI Supply, Takeda, Medtronic, and GlaxoSmithKline Consumer Healthcare and has received research support from Vanda Pharmaceuticals and Nestle. Dr Brenner consulted, advised, or spoke for AbbVie, Arena, Alnylam, AlphaSigma, Ardelyx Ironwood, Laborie, Mahana, Salix, Takeda, and Board of Directors of the IFFGD. Dr Chan consulted/advised for Ironwood, Takeda, and Phathom. Dr Chey consulted for AbbVie, Allakos, Alnylam, Arena, Biomerica, Comvita, Everlywell, Gemelli, Ironwood, Isothrive, QOL Medical, Nestle, Phathom, Progenity, Quest, Redhill, Salix, Urovant, and Vibrant. Dr Lembo has consulted for Allakos, Ironwood, Takeda, Bayer, Vibrant, Aeon, Mylan, Shire, Bellatrix, Arena, and OrphoMed. Dr Moshiree has advised Progenity, Intrinsic Sciences, Iron-wood, Allergan, Takeda, Nestle, and Bausch Pharmaceuticals. Dr S. Shah has consulted for Phathom Pharmaceuticals. Dr Staller has consulted for Anji, Arena, Gelesis, GI Supply, Sanofi, and Shire/Takeda and has received research support from Ironwood and Urovant. Dr E. Shah consulted for GI Supply, Ardelyx, Bausch Health, Takeda, and Mahana. The remaining authors disclose no conflicts.

Figures

Figure 1.
Figure 1.
Model design.
Figure 2.
Figure 2.
Cost-effectiveness and cost-satisfaction of discrete management strategies for patients with uninvestigated dyspepsia without alarm features in gastroenterology care. Treat-and-scope was the preferred cost-effective strategy from (A) insurer and (B) patient perspectives. Prompt endoscopy was the preferred strategy to maximize cost-satisfaction strategy from (C) insurer and (D) patient perspectives. QALY, quality-adjusted life year.
Figure 3.
Figure 3.
Probabilistic sensitivity analyses demonstrate treat-and-scope as the preferred cost-effective strategy from (A) insurer and (B) patient perspectives. Prompt endoscopy was the preferred strategy to maximize cost-satisfaction from (C) insurer and (D) patient perspectives. QALY, quality-adjusted life year.
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References

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