The cost-effectiveness of radiofrequency ablation for Barrett's esophagus with low-grade dysplasia: results from a randomized controlled trial (SURF trial)

Abstract

Background and Aims: The Surveillance versus Radiofrequency Ablation (SURF) trial randomized 136 patients with Barrett's esophagus (BE) containing low-grade dysplasia (LGD), to receive radiofrequency ablation (ablation, n Z 68) or endoscopic surveillance (control, n Z 68). Ablation reduced the risk of neoplastic progression to highgrade dysplasia and esophageal adenocarcinoma (EAC) by 25% over 3 years (1.5% for ablation vs 26.5% for control). We performed a cost-effectiveness analysis from a provider perspective alongside this trial.Methods: Patients were followed for 3 years to quantify their use of health care services, including therapeutic and surveillance endoscopies, treatment of adverse events, and medication. Costs for treatment of progression were analyzed separately. Incremental cost-effectiveness ratios (ICER) were calculated by dividing the difference in costs (excluding and including the downstream costs for treatment of progression) by the difference in prevented events of progression. Bootstrap analysis (1000 samples) was used to construct 95% confidence intervals (CIs).Results: Patients who underwent ablation generated mean costs of U.S.$13,503 during the trial versus $2236 for controls (difference $11,267; 95% CI, $9996-$12,378), with an ICER per prevented event of progression of $45,066. Including the costs for treatment of progression, ablation patients generated mean costs of $13,523 versus $4,930 for controls (difference $8593; 95% CI, $6881-$10,153) with an ICER of $34,373. Based on the various ICER estimates derived from the bootstrap analysis, one can be reasonably certain (>75%) that ablation is efficient at a willingness to pay of $51,664 per prevented event of progression or $40,915 including downstream costs of progression.Conclusions: Ablation for patients with confirmed BE-LGD is more effective and more expensive than endoscopic surveillance in reducing the risk of progression to high-grade dysplasia/EAC. The increase in costs of ablation can be justified to avoid a serious event such as neoplastic progression. At a willingness to pay of $40,915 per prevented event of progression, one can be reasonably certain that ablation is efficient. (www.trialregister.nl number: NTR 1198.) (Gastrointest Endosc 2017;-:1-10.)

A cost-effectiveness analysis of endoscopic eradication therapy for management of dysplasia arising in patients with Barrett’s oesophagus in the United Kingdom

“…The results of this study align with the previous literature which has shown RFA to be cost effective for LGD and HGD separately [22,25,39]. Although the previous analysis of RFA for only HGD patients resulted in a marginally lower ICER (£1,272) [39], the current analysis highlights that use of RFA for both LGD and HGD patients remains significantly cost-effective (ICER: £3,006).…”

“…LGD patients with a confirmed diagnosis on two separate occasions [17,21] as studies suggest that surveillance is less effective than RFA in preventing disease progression [22].…”

Endoscopic eradication therapy for patients with Barrett’s esophagus–associated dysplasia and intramucosal cancer

“…The previously described data on costeffectiveness also factored into this risk-to-benefit assessment. 30,31 There are limited to no data addressing the issue of patient preferences and burden and inconvenience associated with either of these treatment approaches.…”

“…Data from a recent RCT showed that ablation with RFA for patients with confirmed LGD is more effective and more expensive than surveillance in reducing the risk of progression to the endpoint of HGD/EAC. 31 Similarly, a decision analysis that compared cost-effectiveness of esophagectomy and EET in the treatment of early EAC showed that EET was more effective and less expensive than esophagectomy. 32 EET was also a cost-effective alternative in patients with submucosal cancer, especially in patients with high operative risk.…”

Economic evaluation of endoscopic radiofrequency ablation for the treatment of dysplastic Barrett’s esophagus in Spain

“…However, recent evidence has confirmed the long-term efficacy and safety of RFA for the treatment of LGD (14,31,32) and this has been acknowledged by health technology evaluation agencies (3). The analysis presented here used a different pattern of clinical practice but was similar to studies carried out in the USA (27,29) and Europe (30,33). These studies have shown that RFA-EMR with SoC was a cost-effective strategy compared to SoC alone in BE patients with…”