John B Kisiel1, Gauree G Konijeti2, Andrew J Piscitello3, Tarun Chandra3, Thomas F Goss4, David A Ahlquist5, Francis A Farraye6, Ashwin N Ananthakrishnan7. 1. Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota. Electronic address: kisiel.john@mayo.edu. 2. Division of Gastroenterology, Scripps Clinic, La Jolla, California; Scripps Translational Science Institute, La Jolla, California. 3. EmpiraQA LLC, Long Grove, Illinois. 4. Boston Healthcare Associates, Boston, Massachusetts. 5. Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota. 6. Center for Digestive Disorders, Boston Medical Center, Section of Gastroenterology, Boston University School of Medicine, Boston, Massachusetts. 7. Division of Gastroenterology and Hepatology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
Abstract
BACKGROUND & AIMS: Patients with chronic ulcerative colitis are at increased risk for colorectal neoplasia (CRN). Surveillance by white-light endoscopy (WLE) or chromoendoscopy may reduce risk of CRN, but these strategies are underused. Analysis of DNA from stool samples (sDNA) can detect CRN with high levels of sensitivity, but it is not clear if this approach is cost-effective. We simulated these strategies for CRN detection to determine which approach is most cost-effective. METHODS: We adapted a previously published Markov model to simulate the clinical course of chronic ulcerative colitis, the incidence of cancer or dysplasia, and costs and benefits of care with 4 surveillance strategies: (1) analysis of sDNA and diagnostic chromoendoscopy for patients with positive results, (2) analysis of sDNA with diagnostic WLE for patients with positive results, (3) chromoendoscopy with targeted collection of biopsies, or (4) WLE with random collection of biopsies. Costs were based on 2014 Medicare reimbursement. The primary outcome was the incremental cost-effectiveness ratio (incremental cost/incremental difference in quality-adjusted life-years) compared with no surveillance and a willingness-to-pay threshold of $50,000. RESULTS: All strategies fell below the willingness-to-pay threshold at 2-year intervals. Incremental cost-effectiveness ratios were $16,362 per quality-adjusted life-year for sDNA analysis with diagnostic chromoendoscopy; $18,643 per quality-adjusted life-year for sDNA analysis with diagnostic WLE; $23,830 per quality-adjusted life-year for chromoendoscopy alone; and $27,907 per quality-adjusted life-year for WLE alone. In sensitivity analyses, sDNA analysis with diagnostic chromoendoscopy was more cost-effective than chromoendoscopy alone, up to a cost of $1135 per sDNA test. sDNA analysis remained cost-effective at all rates of compliance; when combined with diagnostic chromoendoscopy, this approach was preferred over chromoendoscopy alone, when the specificity of the sDNA test for CRN was >65%. CONCLUSIONS: Based on a Markov model, surveillance for CRN is cost-effective for patients with chronic ulcerative colitis. Analysis of sDNA with chromoendoscopies for patients with positive results was more cost-effective than chromoendoscopy or WLE alone.
BACKGROUND & AIMS:Patients with chronic ulcerative colitis are at increased risk for colorectal neoplasia (CRN). Surveillance by white-light endoscopy (WLE) or chromoendoscopy may reduce risk of CRN, but these strategies are underused. Analysis of DNA from stool samples (sDNA) can detect CRN with high levels of sensitivity, but it is not clear if this approach is cost-effective. We simulated these strategies for CRN detection to determine which approach is most cost-effective. METHODS: We adapted a previously published Markov model to simulate the clinical course of chronic ulcerative colitis, the incidence of cancer or dysplasia, and costs and benefits of care with 4 surveillance strategies: (1) analysis of sDNA and diagnostic chromoendoscopy for patients with positive results, (2) analysis of sDNA with diagnostic WLE for patients with positive results, (3) chromoendoscopy with targeted collection of biopsies, or (4) WLE with random collection of biopsies. Costs were based on 2014 Medicare reimbursement. The primary outcome was the incremental cost-effectiveness ratio (incremental cost/incremental difference in quality-adjusted life-years) compared with no surveillance and a willingness-to-pay threshold of $50,000. RESULTS: All strategies fell below the willingness-to-pay threshold at 2-year intervals. Incremental cost-effectiveness ratios were $16,362 per quality-adjusted life-year for sDNA analysis with diagnostic chromoendoscopy; $18,643 per quality-adjusted life-year for sDNA analysis with diagnostic WLE; $23,830 per quality-adjusted life-year for chromoendoscopy alone; and $27,907 per quality-adjusted life-year for WLE alone. In sensitivity analyses, sDNA analysis with diagnostic chromoendoscopy was more cost-effective than chromoendoscopy alone, up to a cost of $1135 per sDNA test. sDNA analysis remained cost-effective at all rates of compliance; when combined with diagnostic chromoendoscopy, this approach was preferred over chromoendoscopy alone, when the specificity of the sDNA test for CRN was >65%. CONCLUSIONS: Based on a Markov model, surveillance for CRN is cost-effective for patients with chronic ulcerative colitis. Analysis of sDNA with chromoendoscopies for patients with positive results was more cost-effective than chromoendoscopy or WLE alone.
Authors: Gauree Gupta Konijeti; Mark G Shrime; Ashwin N Ananthakrishnan; Andrew T Chan Journal: Gastrointest Endosc Date: 2013-11-18 Impact factor: 9.427
Authors: Ashwin N Ananthakrishnan; Andrew Cagan; Tianxi Cai; Vivian S Gainer; Stanley Y Shaw; Susanne Churchill; Elizabeth W Karlson; Shawn N Murphy; Isaac Kohane; Katherine P Liao Journal: Clin Gastroenterol Hepatol Date: 2014-07-17 Impact factor: 11.382
Authors: Shanika de Silva; Christopher Ma; Marie-Claude Proulx; Marcelo Crespin; Belle S Kaplan; James Hubbard; Martin Prusinkiewicz; Andrew Fong; Remo Panaccione; Subrata Ghosh; Paul L Beck; Anthony Maclean; Donald Buie; Gilaad G Kaplan Journal: Clin Gastroenterol Hepatol Date: 2011-07-30 Impact factor: 11.382
Authors: Kathleen Lang; Lisa M Lines; David W Lee; Jonathan R Korn; Craig C Earle; Joseph Menzin Journal: Clin Gastroenterol Hepatol Date: 2008-09-04 Impact factor: 11.382
Authors: Thomas F Imperiale; David F Ransohoff; Steven H Itzkowitz; Theodore R Levin; Philip Lavin; Graham P Lidgard; David A Ahlquist; Barry M Berger Journal: N Engl J Med Date: 2014-03-19 Impact factor: 91.245
Authors: John B Kisiel; Pasquale Klepp; Hatim T Allawi; William R Taylor; Maria Giakoumopoulos; Tamara Sander; Tracy C Yab; Bjorn A Moum; Graham P Lidgard; Stephan Brackmann; Douglas W Mahoney; Arne Roseth; David A Ahlquist Journal: Clin Gastroenterol Hepatol Date: 2018-05-15 Impact factor: 11.382