COMMENTARY

Cost Analysis Supports Radiofrequency Ablation for Barrett Esophagus With Low-Grade Dysplasia

David A. Johnson, MD

Disclosures

April 06, 2017

The Cost-Effectiveness of Radiofrequency Ablation for Barrett's Esophagus With Low-Grade Dysplasia: Results From a Randomized Controlled Trial (SURF Trial)

Phoa KN, Rosmolen WD, Weusten BL, et al
Gastrointest Endosc. 2016 Dec 9. [Epub ahead of print]

Study Summary

The crude incidence rate of esophageal adenocarcinoma in patients with Barrett esophagus (BE) has been reported in European and US cohort studies to range from 0.12% to 0.4%.[1,2]

Although there is nearly universal consensus on endoscopic ablation of BE for high-grade dysplasia (HGD), the evidence supporting it for low-grade dysplasia (LGD) has been mixed. LGD decision-making models are constructed using assumptions derived by extrapolations from databases rather than specific prospective studies.

This is the first trial-based cost-effectiveness analysis of radiofrequency ablation (RFA) in BE with LGD. It uses data obtained from the Surveillance vs Radiofrequency Ablation (SURF) trial,[3] a multiyear, prospective, randomized, controlled study from Europe that demonstrated a risk reduction for the progression of LGD to HGD or esophageal adenocarcinoma following ablation (from 26.5% to 1.5% and 8.8% to 1.5%, respectively).

In the current analysis, the costs for use of endoscopy (therapeutic and surveillance) and related healthcare resources were determined, with the price indexed annually. In an effort to express variability in the original trial, a so-called bootstrap analysis was performed mimicking results as if 1000 trials identical to SURF had been performed.

The difference in cost of RFA vs controls was $11,267 ($13,503 vs $2236, respectively). Incremental cost-effectiveness ratios (costs of RFA/prevented events for progression) showed a cost of $45,066 per prevented event and of $40,915 per the bootstrap analysis (>75% certainty).

Viewpoint

This analysis puts real data (rather than cost-modeling estimates) into the cost-effectiveness assessment for RFA. These costs are well within standard cost thresholds (typically ≤$50,000 used; for example, the cost of a dialysis program in the United States) for payments that are appropriate and justify their benefit.

It is important to recognize that all cases of LGD must be confirmed by expert pathologists before justifying intervention. Of note, only 52% of the initial patients with reported LGD in SURF were excluded after expert pathologist review.

Abstract

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