Screening for high-grade dysplasia in gastroesophageal reflux disease: Is it cost-effective?

OBJECTIVE: The present study aimed to assess the cost-effectiveness of endo scopic screening in patients with gastroesophageal reflux disease (GERD) to rule our high-grade dysplasia of Barrett's esophagus. METHODS: Using an incremental cost-effectiveness ratio as outcome measure, the cost-effectiveness of endoscopic screening was compared to not screenin g in a decision tree. It was assumed that GERD patients at age 60 yr underg o a one-time endoscopy with esophageal biopsies, targeting abnormal-appeari ng epithelium. Positive biopsies with respect to high-grade dysplasia or ea rly esophageal adenocarcinoma result in esophagectomy. Transition rates wer e estimated from U.S. cancer statistics, as well as published data of endos copic sensitivity, specificity, and surgical outcome. Costs of screening an d cancer care were estimated from Medicare reimbursement data from the pers pective of a third-party-payor. RESULTS: Compared with no screening, screening endoscopy cost $24,700 per l ife-year saved. The cost-effectiveness of screening is quite sensitive to t he prevalence of Barrett's esophagus, high-grade dysplasia, and adenocarcin oma, as well as the sensitivity, specificity, and cost of screening endosco py. A small drop in the health-related quality of life associated with post surgical states markedly reduced the effectiveness of screening. Simultaneo us variations of the prevalence, specificity, and health-related quality of life can easily change screening endoscopy from a life-saving into a life- losing strategy. CONCLUSIONS: Under favorable conditions, general screening by endoscopy of all patients with reflux symptoms to prevent death from esophageal adenocar cinoma may represent a cost-effective strategy; however, such conditions ma y be difficult to meet. (C) 2000 by Am. Cell. of Gastroenterology.