Research Article: Economic value of narrow-band imaging versus white light endoscopy for the diagnosis and surveillance of Barrett’s esophagus: Cost-consequence model

Date Published: March 13, 2019

Publisher: Public Library of Science

Author(s): Gianluca Furneri, Romy Klausnitzer, Laura Haycock, Zenichi Ihara, Benjamin Peter Geisler.


Barrett’s esophagus (BE) is an abnormality arising from gastroesophageal reflux disease that can progressively evolve into a sequence of dysplasia and adenocarcinoma. Progression of Barrett’s esophagus into dysplasia is monitored with endoscopic surveillance. The current surveillance standard requests random biopsies plus targeted biopsies of suspicious lesions under white-light endoscopy, known as the Seattle protocol. Recently, published evidence has shown that narrow-band imaging (NBI) can guide targeted biopsies to identify dysplasia and reduce the need for random biopsies. We aimed to assess the health economic implications of adopting NBI-guided targeted biopsy vs. the Seattle protocol from a National Health Service England perspective. A decision tree model was developed to undertake a cost-consequence analysis. The model estimated total costs (i.e. staff and overheads; histopathology; adverse events; capital equipment) and clinical implications of monitoring a cohort of patients with known/suspected BE, on an annual basis. In the simulation, BE patients (N = 161,657 at Year 1; estimated annual increase: +20%) entered the model every year and underwent esophageal endoscopy. After 7 years, the adoption of NBI with targeted biopsies resulted in cost reduction of £458.0 mln vs. HD-WLE with random biopsies (overall costs: £1,966.2 mln and £2,424.2 mln, respectively). The incremental investment on capital equipment to upgrade hospitals with NBI (+£68.3 mln) was offset by savings due to the reduction of histological examinations (-£505.2 mln). Reduction of biopsies also determined savings for avoided adverse events (-£21.1 mln). In the base-case analysis, the two techniques had the same accuracy (number of correctly identified cases: 1.934 mln), but NBI was safer than HD-WLE. Budget impact analysis and cost-effectiveness analyses confirmed the findings of the cost-consequence analysis. In conclusion, NBI-guided targeted biopsies was a cost-saving strategy for NHS England, compared to current practice for detection of dysplasia in patients with BE, whilst maintaining at least comparable health outcomes for patients.

Partial Text

Barrett’s esophagus (BE) is a condition in which the typical squamous epithelium of the esophageal mucosa is replaced with columnar intestinal epithelium [1,2]. The prevalence of BE ranges from 0.5% to 2% of the general adult population, with gastroesophageal reflux disease (GERD), obesity, cigarette smoking, alcohol, and Helicobacter pylori infection being the most common risk factors of development [3].

BE is a common condition, characterized by negative impact on patient prognosis and quality of life, plus significant economic burden for healthcare services. According to epidemiology estimates, there are at least 160,000 patients with BE in England (Table 2). This number may be underestimated, as a low-end prevalence assumption was applied (0.5%; range: 0.5%-2.0%), as well as a 75% diagnosis rate to take into account that: i) BE may be underdiagnosed; ii) a certain proportion of patients do not receive care during the year. Therefore, it is plausible that the BE population in England will increase over the coming years to be in the range of 250,000 to 300,000 interventions per year.

The results of our model suggest that NBI with targeted biopsies is a cost-saving strategy for NHS England compared to current practice, i.e. HD-WLE with random biopsies, for the detection of dysplasia in patients with BE, and may ensure at least comparable health outcomes for patients. However, since the constant evolution of diagnostic techniques will likely determine further improvements in the diagnosis and treatment of BE, it is highly recommended to review and update the available evidence, and conduct analyses reflecting such developments, including the selection of new comparators.




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