Cost-effectiveness of regular surveillance versus endoscopy at need for patients with Barrett’s esophagus: economic evaluation alongside the BOSS randomized controlled trial

Introduction

The Barrett’s esophagus surveillance study (BOSS) was the first randomized study of surveillance. This study reports the costs and quality of life outcomes from the BOSS trial and models the outcomes and cost-effectiveness of surveillance beyond the follow up period of the BOSS study. This trial showed similar stages and rates of esophageal cancer in both arms, but the regular surveillance arm did identify more high-grade dysplasia after a median of 12.8 years follow up.

Methods

We used a decision tree model based on results from BOSS to conduct a cost-effectiveness analysis of costs and quality adjusted life years (QALYs). A Markov model was used to extrapolate costs and outcomes over a further 10 years after the trial had ended representing a 22.8 year time horizon. The proportion with high grade dysplasia and QALYs were derived from the randomized trial.

Results

The total costs associated with two yearly surveillance was $5,309 vs. $3,182 in the at need arm. Total QALY in the two-yearly endoscopy arm were 8.647 as compared to 8.629 in the at need arm. Compared with at need endoscopy, two-yearly surveillance costs $115,563/QALY gained. In the sensitivity analyses around assumptions on the proportion of high-grade dysplasia that is undetected in the at need endoscopy arm, surveillance had an incremental cost effectiveness ratio of $94,513/QALY for the best-case and $146,272/QALY for the worst-case scenario.

Conclusion

BE surveillance every 2-3 years is unlikely to be a cost-effective strategy. Guidelines should take this into account when deciding surveillance intervals