Endoscopic ultrasound gastroenterostomy vs duodenal stenting for malignant gastric outlet obstruction: Cost-effectiveness study

Abstract

Background and study aims: Enteral stenting has been traditionally employed for managing malignant gastric outlet obstruction (GOO). However, concerns regarding high reintervention rates have brought into question its cost-effectiveness. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) with a lumen-apposing metal stent (LAMS) provides an alternative to luminal stenting. The goal of this study was to assess the cost-effectiveness of EUS-GE relative to duodenal stenting.

Patients and methods: A decision analysis was performed to analyze costs and survival in patients with unresectable or metastatic GOO. The model was designed with two treatment arms: self-expanding metal stent (SEMS) placement and EUS-GE with LAMS. Costs were derived from Medicare reimbursement rates (US$) while effectiveness was measured by quality-adjusted life years (QALYs). The primary outcome measure was the incremental cost-effectiveness ratio (ICER). Probabilistic sensitivity analyses were performed.

Results: Endoscopic stenting resulted in an average cost of $22,748 and 0.31 QALYs whereas EUS-GE cost $32,254 and yielded 0.53 QALYs, which yielded a difference of $9,507 in cost and 0.23 in QALY. EUS-GE was found to be a cost-effective strategy over duodenal stenting (ICER, $41994/QALY) at a willingness-to-pay of $100,000/QALY. In 10,000 Monte-Carlo simulations, EUS-GE was favored 62% of the time. Using a tornado diagram, the model was most sensitive to the probability of mortality in patients with duodenal stents compared with EUS-GE.

Conclusions: In patients with malignant GOO, EUS-GE is a cost-effective palliative intervention compared with duodenal stenting.

Keywords: Endoscopic ultrasonography; Endoscopy Lower GI Tract; Endoscopy Upper GI Tract; Stenting.

Fig. 1

Decision tree. Shown is the simulation model used to estimate costs, clinical outcomes, and quality-adjusted life-years of patients undergoing duodenal stenting or EUS-GE for malignant gastric outlet obstruction (GOO). a Duodenal stenting and EUS-GE and the health states of the patients. b Three categories of subsequent clinical events: mortality at 1 month, survival, stent patency, and stent failure. The blue square indicates the decision node, the point at which a treatment strategy is chosen; the blue encircled letter “M” indicates the Markov node, with branches indicating the health states in transition every 1 month; the green circle indicates the chance node, after which there is a probability of the occurrence of each event; and the red triangle indicates the terminal node, the end of a pathway within a 12-month cycle.

Fig. 2

Tornado diagram showing the model is sensitive to the probability of mortality in patients with duodenal stents and failure of duodenal stents compared with endoscopic ultrasound gastroenterostomy (EUS-GE). WTP, willingness to pay; ICER, incremental cost-effectiveness ratio.

Fig. 3

Scatter plot of probabilistic sensitivity analysis. The incremental cost-effectiveness scatter plot for each of the two studied treatment strategies showing the iterations occurring either above (duodenal stenting) or below (EUS-GE) the willingness-to-pay (WTP) threshold of $100,000/quality-adjusted life-year (QALY), with the oval showing the 95% confidence interval. This visually represents what was found in the cost-effectiveness acceptability curve.