NEW YORK (Reuters Health) - POEM (per-oral endoscopic myotomy) is increasingly being used to manage achalasia, but reimbursement is spotty, and healthcare utilization and costs should be compared with other treatment options, researchers say.
"Our findings do not address the efficacy of POEM in relieving achalasia symptoms, though this has been well-supported in several recent clinical trials," Dr. Alex Lois of the University of Washington in Seattle told Reuters Health by email. However, he said, he is concerned about the gastroesophageal reflux (GER) that can develop after the procedure.
"While we did not feel we could accurately assess the burden of post-procedural reflux using claims data, we measure the utilization-related consequences of said reflux in subsequent diagnostic testing and reintervention," he noted. "It is critical for clinicians incorporating POEM into their practice to be transparent with patients about the tradeoffs between the available treatment options - not only the risks and benefits, but also the potential need for additional treatment to treat new symptoms that may develop."
"As there is now a new CPT code," he added, "this should streamline the prior authorization process and improve future ability to track outcome data."
"Several professional practice guidelines recommend (POEM) as a potential first-line therapy for the management of achalasia, yet payers remain hesitant to reimburse for the procedure owing to unanswered questions regarding safety," Dr. Lois and colleagues write in JAMA Surgery.
To investigate, the team analyzed claims data from 1,921 patients (median age, about 50; about half, men) who underwent their first intervention for achalasia with either laparoscopic Heller myotomy (LHM), pneumatic dilation (PD), or POEM in the U.S. between 2010 and 2017.
The main outcome was the frequency of severe procedure-related adverse events, including perforation, pneumothorax, bleeding, and death, among the three interventions.
The use of POEM increased 19-fold during the study period, from 1.1% of procedures in 2010 to 18.9% in 2017. Adverse events were rare and did not differ between procedures.
Compared with LHM, POEM was associated with more subsequent diagnostic testing (incidence rate ratio, 2.2) and reinterventions (IRR, 1.9).
Compared with PD, POEM was associated with more subsequent diagnostic testing (IRR, 1.5) but fewer reinterventions (IRR, 0.4). Total one-year healthcare costs were similar between POEM and LHM, but significantly lower for PD (mean cost difference, $7674).
Dr. Marco Patti of the University of Virginia in Charlottesville, coauthor of a related editorial, commented in an email to Reuters Health, "Patients should be treated in centers of excellence by a multidisciplinary team composed of radiologists, gastroenterologists, and surgeons."
Regarding available treatments for achalasia, he said, "PD (by blunt disruption of the muscle fibers) and POEM (by transection of the muscle fibers) eliminate the resistance caused by the lower esophageal sphincter, but allow GER. In contrast, LHM limits GER because of the partial fundoplication."
"Expertise being equal, a LHM should be used as primary form of treatment, particularly in young patients, to limit the risk of decades of GER with severe sequelae such as Barrett's esophagus and strictures," he said. "POEM should be used primarily in patients with type III achalasia, as it seems to be very effective, and for patients who have recurrent dysphagia after LHM.
Dr. Henry Jen, a gastroenterologist at Long Island Jewish Forest Hills, part of Northwell Health in New York City, also commented by email. "A caveat to this study is that post-procedural costs and length of stay are likely to change as POEM continues to evolve. In fact, recent data suggest that POEM is already shifting to an outpatient procedure."
"Also, the advent of combining the endoscopic anti-reflux procedure, transoral incisionless fundoplication (TIF), in conjunction with POEM is likely to decrease the burden of post-procedural reflux and pH testing in the future," he added. "Standardizing practice guidelines for POEM can also help to obviate the need for frequent post procedural testing."
SOURCE: https://bit.ly/3kpDhgt and https://bit.ly/3OLWIxV JAMA Surgery, online April 20, 2022.
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