Cost-utility advantage of interventional endoscopy

Background: Gastroenterologists frequently face the dilemma of how to choose among different management options.

Aim: To develop a tool of medical decision analysis that helps choosing between competing management options of interventional endoscopy and surgery.

Methods: Carcinoma-in-situ of the esophagus, large colonic polyps, and ampullary adenoma serve as three examples for disorders being managed by both techniques. A threshold analysis using a decision tree was modeled to compare the costs and utility values associated with managing the three examples. If the expected healing or success rate of interventional endoscopy exceeds a threshold calculated as the ratio of endoscopy costs over surgery costs, endoscopy becomes the preferred management option. A low threshold speaks in favor of endoscopic intervention as initial management strategy.

Results: If the decision in favor of surgery is focused exclusively on preventing death from a given disease, surgical intervention may seem to provide the best treatment option. However, interventional endoscopy becomes a viable alternative, if the comparison is based on a broader perspective that includes adverse events and long-term disability, as well as the healthcare costs of both procedures. For carcinoma-in-situ of the esophagus, the threshold for the expected success rate is 24% (range in the sensitivity analysis: 7-29%); for large colonic polyps it is 10% (5-12%), and for duodenal papillary adenoma it is 17% (5-21%).

Conclusions: Even if a management strategy surpasses its alternative with respect to one important outcome parameter, there is often still room for the lesser alternative to be considered as viable option.