Health economic evaluation of therapeutic strategies in patients with idiopathic achalasia: results of a randomized trial comparing pneumatic dilatation with laparoscopic cardiomyotomy
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We have prospectively collected information concerning the costs incurred during the management of patients allocated to either forceful dilatation or to an immediate laparoscopic operation because of newly diagnosed achalasia.
Fifty-one patients with newly diagnosed achalasia were randomized to either pneumatic dilatation to a diameter of 30–40 mm or to a laparoscopic myotomy to which was added a posterior partial fundoplication. Follow-ups were scheduled at 1, 3, 6, and 12 months after inclusion. At each follow-up visit a study nurse interviewed the patients regarding symptoms and their quality of life (QoL) and a health economic questionnaire was completed. In the latter questionnaire, patients were asked to report the presence and character of contacts with the healthcare system since the last visit.
In the dilatation group six patients (23%), including the patient who was operated on because of perforation, were classified as failures during the first 12 months of follow-up compared to one (4%) in the myotomy group (p = 0.047). Five of those classified as failures in the dilatation group subsequently had a surgical myotomy and the sixth patient was treated with repeated dilatations. The patient classified as failure in the myotomy group was treated with endoscopic dilatation. The initial treatment cost and the total costs were significantly higher for laparoscopic myotomy compared to a pneumatic dilatation-based strategy (p = 0.0002 and p = 0.0019, respectively) When the total costs were subdivided into the different resources used, we found that the single largest cost item for pneumatic dilatation was that for hospital stay and that for laparoscopic myotomy was the actual operative treatment (operating room time) The cost-effectiveness analysis, relating to the actual treatment failures, revealed that the cost to avoid one treatment failure (incremental cost-effectiveness ratio) amounted to €9239.
The current prospective, controlled clinical trial shows that despite a higher level of clinical efficacy of laparoscopic myotomy to prevent treatment failure in newly diagnosed achalasia, the cost effectiveness of pneumatic dilatation is superior, at least when a reasonable time horizon is applied.
KeywordsAchalasia Balloon dilatation Myotomy Symptoms Treatment failure Health economic evaluation Laparoscopy
- 8.Vantrappen G, Hellemans J, Deloof W, Valembois P, Vandenbroucke J (1971) Treatment of achalasia with pneumatic dilatations. Gut 121:268–275Google Scholar
- 12.Dimenas E (1993) Methological aspects of evaluation of quality of life in upper gastrointestinal diseases. Scan J Gastroenterol Suppl 199:18–21Google Scholar
- 14.Dupuy HJ (1984) The Psychological General Well-Being (PGWB) index. In: Wenger NK, Mattson ME, Furberg CF (eds) Assessment of Quality of Life in Clinical Trials of Cardiovascular Therapies. LeJacq Publishing Inc., New York, pp 170–183Google Scholar
- 17.Korolija D, Sauerland S, Wood-Dauphinee S, Abbou CC, Eypasch E, Gareia Caballero M, Lumsden MA, Millat B, Monson JRT, Nilsson G, Pointer R, Schwenk W, Shamiyeh A, Szold A, Targarona E, Ure B, Neugebauer E (2004) Surg Endosc 18:879–897Google Scholar
- 22.Myrvold HE, Lundell L, Miettinen P, Pedersen SA, Liedman B, Hatlebakk J, Julkunen R, Levander K, Lamm M, Mattson C, Carlsson J, Stahlhammar NO (2001) The cost of long term therapy for gastro-oesophageal reflux disease: a randomised trial comparing omeprazole and open antireflux surgery. Gut 49:488–494PubMedCrossRefGoogle Scholar
- 28.Van Den Boom G, Go PM, Hameeteman W, Dallemagne B, Ament AJ (1996) Cost effectiveness of medical versus surgical treatment in patients with severe or refractory gastroesophageal reflux disease in the Netherlands. Scand J Gastroenterol 31:1–9Google Scholar