Sasha Taleban1,2, Martijn G H Van Oijen3,4, Eric A Vasiliauskas5, Phillip R Fleshner6,7, Bo Shen8, Andrew F Ippoliti9, Stephan R Targan10, Gil Y Melmed11. 1. F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, 8730 Alden Drive, Thalians Building, 2nd Floor East, Los Angeles, CA, 90048, USA. staleban@yahoo.com. 2. Division of Gastroenterology, Department of Medicine, University of Arizona Medical Center, 1501 N. Campbell Ave, Tucson, AZ, 85724, USA. staleban@yahoo.com. 3. Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. m.g.vanoijen@amc.uva.nl. 4. Department of Medical Oncology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. m.g.vanoijen@amc.uva.nl. 5. F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, 8730 Alden Drive, Thalians Building, 2nd Floor East, Los Angeles, CA, 90048, USA. Eric.Vasiliauskas@cshs.org. 6. F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, 8730 Alden Drive, Thalians Building, 2nd Floor East, Los Angeles, CA, 90048, USA. phillip.fleshner@cshs.org. 7. , 8737 W Beverly Blvd Ste. 101, West Hollywood, CA, 90048, USA. phillip.fleshner@cshs.org. 8. Department of Gastroenterology and Hepatology, Cleveland Clinic Main Campus, 9500 Euclid Avenue, Mail Code A30, Cleveland, OH, 44195, USA. shenb@ccf.org. 9. F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, 8730 Alden Drive, Thalians Building, 2nd Floor East, Los Angeles, CA, 90048, USA. andrew.ippoliti@cshs.org. 10. F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, 8730 Alden Drive, Thalians Building, 2nd Floor East, Los Angeles, CA, 90048, USA. stephan.targan@cshs.org. 11. F. Widjaja Foundation Inflammatory Bowel and Immunobiology Research Institute, Cedars-Sinai Medical Center, 8730 Alden Drive, Thalians Building, 2nd Floor East, Los Angeles, CA, 90048, USA. gil.melmed@cshs.org.
Abstract
BACKGROUND: Much of the economic burden of Crohn's disease (CD) is related to surgery. Twenty percent of patients with CD have isolated colonic disease. While permanent end ileostomy (EI) is generally the procedure of choice for patients with refractory CD colitis, single-center experiences suggest that restorative proctocolectomy (IPAA) is durable in select patients. AIMS: We assessed the cost-effectiveness of total colectomy with permanent EI versus IPAA in medically refractory colonic CD. METHODS: We used a lifetime Markov model with 6-month cycles to simulate quality-adjusted life years (QALYs) and cost. In each of the EI and IPAA strategies, patients could transition between multiple health states. One-way and multivariable sensitivity analysis and tornado analysis were performed to identify thresholds for factors influencing cost-effectiveness. RESULTS: IPAA was more effective than EI surgery with an incremental cost-effectiveness ratio of $70,715 per QALY gained. We identified the following variables of importance in our model: (1) the cost of the EI surgery, (2) the cost of infliximab, and (3) the cost of gastroenterology ambulatory visit and labs. Threshold analysis revealed that if the costs associated with EI surgery exceeded $20,167 or if the utility of IPAA with CD remission without medical therapy exceeded 0.37, IPAA became the more cost-effective strategy. CONCLUSIONS: In patients with medically refractory CD isolated to the colon, colectomy with permanent EI is more cost-effective than IPAA unless the costs associated with the EI surgery exceed $20,167 or if the utility associated with IPAA and CD remission exceeds 0.37.
BACKGROUND: Much of the economic burden of Crohn's disease (CD) is related to surgery. Twenty percent of patients with CD have isolated colonic disease. While permanent end ileostomy (EI) is generally the procedure of choice for patients with refractory CD colitis, single-center experiences suggest that restorative proctocolectomy (IPAA) is durable in select patients. AIMS: We assessed the cost-effectiveness of total colectomy with permanent EI versus IPAA in medically refractory colonic CD. METHODS: We used a lifetime Markov model with 6-month cycles to simulate quality-adjusted life years (QALYs) and cost. In each of the EI and IPAA strategies, patients could transition between multiple health states. One-way and multivariable sensitivity analysis and tornado analysis were performed to identify thresholds for factors influencing cost-effectiveness. RESULTS:IPAA was more effective than EI surgery with an incremental cost-effectiveness ratio of $70,715 per QALY gained. We identified the following variables of importance in our model: (1) the cost of the EI surgery, (2) the cost of infliximab, and (3) the cost of gastroenterology ambulatory visit and labs. Threshold analysis revealed that if the costs associated with EI surgery exceeded $20,167 or if the utility of IPAA with CD remission without medical therapy exceeded 0.37, IPAA became the more cost-effective strategy. CONCLUSIONS: In patients with medically refractory CD isolated to the colon, colectomy with permanent EI is more cost-effective than IPAA unless the costs associated with the EI surgery exceed $20,167 or if the utility associated with IPAA and CD remission exceeds 0.37.
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