OBJECTIVE: The aim of this study is to compare the costs per cure of alternative strategies for the treatment of achalasia. METHODS: A cost-minimization model compared three strategies for otherwise healthy adults of any age with achalasia: 1) laparoscopic Heller myotomy with fundoplication (LHM); 2) pneumatic dilation (PD), with LHM reserved for treatment failures; 3) botulinum toxin (Botox) injection of the lower esophageal sphincter, with PD reserved for treatment failures. Probabilities of short- and long-term efficacy, treatment failure, symptomatic recurrence rates, and complications were derived from the published literature. Only direct costs were considered during the 5-yr time horizon. RESULTS: Respective reference case costs per cure of PD, Botox, and LHM strategies were $3,111, $3,723, and $10,792. Despite short- and long-term efficacy of 96% and 94%, respectively, the LHM strategy was most costly. Initial PD remained less costly than initial Botox, provided that rates of PD efficacy and perforation were > or = 70% and < 9.5%, respectively, and cost of a Botox session was > or = $450. The results were not sensitive to the probabilities of short- and long-term response to Botox, recurrence after PD, LHM efficacy, and post-LHM gastroesophageal reflux disease, nor to the costs of LHM and PD. CONCLUSIONS: For otherwise healthy patients with achalasia, initial PD is the least costly strategy provided that the PD perforation rate remains < 10%. Initial Botox is less costly only when nonendoscopic-related costs decrease by 25%. Initial LHM is the most costly strategy under all clinically plausible scenarios. Subsequent analyses should include a longer time horizon and an assessment of patient ference for each strategy.
OBJECTIVE: The aim of this study is to compare the costs per cure of alternative strategies for the treatment of achalasia. METHODS: A cost-minimization model compared three strategies for otherwise healthy adults of any age with achalasia: 1) laparoscopic Heller myotomy with fundoplication (LHM); 2) pneumatic dilation (PD), with LHM reserved for treatment failures; 3) botulinum toxin (Botox) injection of the lower esophageal sphincter, with PD reserved for treatment failures. Probabilities of short- and long-term efficacy, treatment failure, symptomatic recurrence rates, and complications were derived from the published literature. Only direct costs were considered during the 5-yr time horizon. RESULTS: Respective reference case costs per cure of PD, Botox, and LHM strategies were $3,111, $3,723, and $10,792. Despite short- and long-term efficacy of 96% and 94%, respectively, the LHM strategy was most costly. Initial PD remained less costly than initial Botox, provided that rates of PD efficacy and perforation were > or = 70% and < 9.5%, respectively, and cost of a Botox session was > or = $450. The results were not sensitive to the probabilities of short- and long-term response to Botox, recurrence after PD, LHM efficacy, and post-LHM gastroesophageal reflux disease, nor to the costs of LHM and PD. CONCLUSIONS: For otherwise healthy patients with achalasia, initial PD is the least costly strategy provided that the PD perforation rate remains < 10%. Initial Botox is less costly only when nonendoscopic-related costs decrease by 25%. Initial LHM is the most costly strategy under all clinically plausible scenarios. Subsequent analyses should include a longer time horizon and an assessment of patient ference for each strategy.
Authors: Paul J Karanicolas; Shona E Smith; Richard I Inculet; Richard A Malthaner; Richard P Reynolds; Ron Goeree; Amiram Gafni Journal: Surg Endosc Date: 2007-05-04 Impact factor: 4.584
Authors: J Barry O'Connor; Mendel E Singer; Thomas F Imperiale; Michael F Vaezi; Joel E Richter Journal: Dig Dis Sci Date: 2002-07 Impact factor: 3.199
Authors: G Zaninotto; V Vergadoro; V Annese; M Costantini; M Costantino; D Molena; C Rizzetto; M Epifani; A Ruol; L Nicoletti; E Ancona Journal: Surg Endosc Date: 2004-03-19 Impact factor: 4.584