Intrasphincteric botulinum toxin versus pneumatic dilatation for achalasia: a cost minimization analysis

Background: Pneumatic dilatation or intrasphincteric botulinum toxin inject ion provide effective symptom relief for patients with achalasia. Although intrasphincteric botulinum toxin injection is simple and safe, its efficacy may be short-lived. Pneumatic dilatation lasts longer, but esophageal perf oration is a risk. We compared treatment costs for pneumatic dilatation and intrasphincteric botulinum toxin injection using a decision analysis model to determine whether the practical advantages of intrasphincteric botulinu m toxin injection outweigh the economic impact of the need for frequent re- treatment. Methods: Probability estimates for intrasphincteric botulinum toxin injecti on were derived from published reports. Probability estimates for the pneum atic dilatation strategy were obtained by retrospective review of our 10-ye ar experience using the Rigiflex dilator. Direct, "third-party payer" costs were determined in Canadian dollars. Results: Intrasphincteric botulinum toxin injection was significantly more costly at $5033 compared with $3608 for the pneumatic dilatation strategy, yielding an incremental cost of $1425 over the 10-year period considered. S ensitivity analysis showed that pneumatic dilatation is less expensive acro ss all probable ranges of costs and probability estimates. The intrasphinct eric botulinum toxin injection strategy is less costly ii life-expectancy i s less than 2 years. Conclusions: Intrasphincteric botulinum toxin injection is more costly than pneumatic dilatation for the treatment of achalasia. The added expense of frequent re-treatment with intrasphincteric botulinum toxin injection outwe ighs the potential economic benefits of the safety of the procedure, unless life-expectancy is 2 years or less.