Advertisement

Digestive Diseases and Sciences

, Volume 53, Issue 3, pp 680–688 | Cite as

Cost-effectiveness Analysis of Strategies for Diagnosing Celiac Disease

  • Spencer D. DornEmail author
  • David B. Matchar
Original Paper

Abstract

Objective To compare strategies for diagnosing celiac disease (CD). Methods A decision analytic model was used to compare five strategies on diagnostic performance and costs. Results First, tTG screening alone is the least costly strategy ($22/individual). While the NPV is high (99.8%), the PPV is low (63.4%). Second, if tTG-positive patients undergo esophagogastroduodenoscopy (EGD) to confirm CD, the PPV increases to 100% ($2,237/false-positive diagnosis avoided). Third, if EGDs are restricted to only those who are both tTG and HLA DQ2/8 positive, costs are slightly reduced ($59 vs. $63/individual), while PPV and NPV remain unchanged. Fourth, screening tTG-negative patients for IgA deficiency increases the NPV to 99.9% ($32,605/false-negative diagnosis avoided). Sensitivity analyses revealed that as the prevalence of CD increases, the cost of avoiding a false-positive diagnosis by adding EGD to the tTG alone strategy increases considerably. Conclusions When the pre-test probability of CD is low, patients with positive tTG serology should undergo EGD with biopsy—either directly or after positive screening for HLA DQ2/8—to confirm CD. As the pre-test probability of CD increases, the added cost of EGD should be weighed against the consequences of a false-positive diagnosis. Routinely screening for IgA deficiency in order to avoid a false-negative diagnosis is quite costly.

Keywords

Cost effectiveness Celiac disease Diagnosis 

Notes

Acknowledgement

Grant support: supported by NIH grant T32DK7634

References

  1. 1.
    James SP (2005) This month at the NIH: final statement of NIH consensus conference on celiac disease. Gastroenterology 128:6PubMedCrossRefGoogle Scholar
  2. 2.
    Green PH, Jabri B (2003) Coeliac disease. Lancet 362:383–391PubMedCrossRefGoogle Scholar
  3. 3.
    Rostom A, Murray JA, Kagnoff MF (2006) American Gastroenterological Association (AGA) Institute technical review on the diagnosis and management of celiac disease. Gastroenterology 131:1981–2002PubMedCrossRefGoogle Scholar
  4. 4.
    Cataldo F, Lio D, Marino V, Picarelli A, Ventura A, Corazza GR (2000) IgG(1) antiendomysium and IgG antitissue transglutaminase (anti-tTG) antibodies in coeliac patients with selective IgA deficiency. Working Groups on Celiac Disease of SIGEP and Club del Tenue. Gut 47:366–369PubMedCrossRefGoogle Scholar
  5. 5.
    Zarkadas M, Cranney A, Case S et al (2006) The impact of a gluten-free diet on adults with coeliac disease: results of a national survey. J Hum Nutr Diet 19:41–49PubMedCrossRefGoogle Scholar
  6. 6.
    Burgin-Wolff A, Hadziselimovic F (2003) Coeliac disease. Lancet 362:1418–1419PubMedCrossRefGoogle Scholar
  7. 7.
    Valdimarsson T, Franzen L, Grodzinsky E, Skogh T, Strom M (1996) Is small bowel biopsy necessary in adults with suspected celiac disease and IgA anti-endomysium antibodies? 100% positive predictive value for celiac disease in adults. Dig Dis Sci 41:83–87PubMedCrossRefGoogle Scholar
  8. 8.
    Viljamaa M, Collin P, Huhtala H, Sievanen H, Maki M, Kaukinen K (2005) Is coeliac disease screening in risk groups justified? A 14-year follow-up with special focus on compliance and quality of life. Aliment Pharmacol Ther 22:317–324PubMedCrossRefGoogle Scholar
  9. 9.
    Drummond MF, Sculpher MJ, Torrance GW, O’Brien BJ, Stoddart DL (2005) Methods for the economic evaluation of health care programmes. Oxford University Press, New YorkGoogle Scholar
  10. 10.
    Dube C, Rostom A, Sy R et al (2005) The prevalence of celiac disease in average-risk and at-risk Western European populations: a systematic review. Gastroenterology 128:S57–S67PubMedCrossRefGoogle Scholar
  11. 11.
    Hill ID (2005) What are the sensitivity and specificity of serologic tests for celiac disease? Do sensitivity and specificity vary in different populations? Gastroenterology 128:S25–S32PubMedCrossRefGoogle Scholar
  12. 12.
    Rostom A, Dube C, Cranney A et al (2005) The diagnostic accuracy of serologic tests for celiac disease: a systematic review. Gastroenterology 128:S38–S46PubMedCrossRefGoogle Scholar
  13. 13.
    Rostom A, Dube C, Cranney A et al (2004) Celiac disease. Evid Rep Technol Assess (Summ) 104:1–6Google Scholar
  14. 14.
    Abrams JA, Brar P, Diamond B, Rotterdam H, Green PH (2006) Utility in clinical practice of immunoglobulin a anti-tissue transglutaminase antibody for the diagnosis of celiac disease. Clin Gastroenterol Hepatol 4:726–730PubMedCrossRefGoogle Scholar
  15. 15.
    Collin P, Kaukinen K, Vogelsang H et al (2005) Antiendomysial and antihuman recombinant tissue transglutaminase antibodies in the diagnosis of coeliac disease: a biopsy-proven European multicentre study. Eur J Gastroenterol Hepatol 17:85–91PubMedCrossRefGoogle Scholar
  16. 16.
    Lock RJ, Stevens S, Pitcher MC, Unsworth DJ (2004) Is immunoglobulin a anti-tissue transglutaminase antibody a reliable serological marker of coeliac disease? Eur J Gastroenterol Hepatol 16:467–470PubMedCrossRefGoogle Scholar
  17. 17.
    Van Meensel B, Hiele M, Hoffman I et al (2004) Diagnostic accuracy of ten second-generation (human) tissue transglutaminase antibody assays in celiac disease. Clin Chem 50:2125–2135PubMedCrossRefGoogle Scholar
  18. 18.
    Zintzaras E, Germenis AE (2006) Performance of antibodies against tissue transglutaminase for the diagnosis of celiac disease: meta-analysis. Clin Vaccine Immunol 13:187–192PubMedCrossRefGoogle Scholar
  19. 19.
    Picarelli A, Sabbatella L, Di TM et al (2000) Celiac disease diagnosis in misdiagnosed children. Pediatr Res 48:590–592PubMedCrossRefGoogle Scholar
  20. 20.
    Clark JA, Callicoat PA, Brenner NA, Bradley CA, Smith DM Jr (1983) Selective IgA deficiency in blood donors. Am J Clin Pathol 80:210–213PubMedGoogle Scholar
  21. 21.
    Pereira LF, Sapina AM, Arroyo J, Vinuelas J, Bardaji RM, Prieto L (1997) Prevalence of selective IgA deficiency in Spain: more than we thought. Blood 90:893PubMedGoogle Scholar
  22. 22.
    Strothman R, White MB, Testin J, Chen SN, Ball MJ HLA (1986) and IgA deficiency in blood donors. Hum Immunol 16:289–294PubMedCrossRefGoogle Scholar
  23. 23.
    Ulfarsson J, Gudmundsson S, Birgisdottir B, Kjeld JM, Jensson O (1982) Selective serum IgA deficiency in Icelanders. Frequency, family studies and Ig levels. Acta Med Scand 211:481–487PubMedCrossRefGoogle Scholar
  24. 24.
    Koistinen J (1975) Selective IgA deficiency in blood donors. Vox Sang 29:192–202PubMedCrossRefGoogle Scholar
  25. 25.
    Weber-Mzell D, Kotanko P, Hauer AC et al (2004) Gender, age and seasonal effects on IgA deficiency: a study of 7293 Caucasians. Eur J Clin Invest 34:224–228PubMedCrossRefGoogle Scholar
  26. 26.
    Holt PD, Tandy NP, Anstee DJ (1977) Screening of blood donors for IgA deficiency: a study of the donor population of south-west England. J Clin Pathol 30:1007–1010PubMedCrossRefGoogle Scholar
  27. 27.
    Gudmundsson S, Jensson O (1977) Frequency of IgA deficiency in blood donors and Rh negative women in Iceland. Acta Pathol Microbiol Scand [C] 85:87–89Google Scholar
  28. 28.
    Litzman J, Sevcikova I, Stikarovska D, Pikulova Z, Pazdirkova A, Lokaj J (2000) IgA deficiency in Czech healthy individuals and selected patient groups. Int Arch Allergy Immunol 123:177–180PubMedCrossRefGoogle Scholar
  29. 29.
    Perez Vaquero MA, Vesga Carasa MA, Lopez UA (2000) Frequency of selective IgA deficiency in Basque Country. Med Clin (Barc) 115:339–440Google Scholar
  30. 30.
    Silvis SE, Nebel O, Rogers G, Sugawa C, Mandelstam P (1976) Endoscopic complications. Results of the 1974 American society for gastrointestinal endoscopy survey. JAMA 235:928–930PubMedCrossRefGoogle Scholar
  31. 31.
    Newcomer MK, Brazer SR (1994) Complications of upper gastrointestinal endoscopy and their management. Gastrointest Endosc Clin N Am 4:551–570PubMedGoogle Scholar
  32. 32.
    Chan MF (1996) Complications of upper gastrointestinal endoscopy. Gastrointest Endosc Clin N Am 6:287–303PubMedGoogle Scholar
  33. 33.
    Quine MA, Bell GD, McCloy RF, Matthews HR (1995) Prospective audit of perforation rates following upper gastrointestinal endoscopy in two regions of England. Br J Surg 82:530–533PubMedCrossRefGoogle Scholar
  34. 34.
    Eisen GM, Baron TH, Dominitz JA et al (2002) Complications of upper GI endoscopy. Gastrointest Endosc 55:784–793PubMedCrossRefGoogle Scholar
  35. 35.
    Hennekens CH, Buring JE, Mayrent SL (1987) Epidemiology in clinical medicine. Lippincott, Williams & Wilkins, PhiladelphiaGoogle Scholar
  36. 36.
    Austin GL, Shaheen NJ, Sandler RS (2006) Positive and negative predictive values: use of inflammatory bowel disease serologic markers. Am J Gastroenterol 101:413–416PubMedCrossRefGoogle Scholar
  37. 37.
    Ramsey SD (1999) Evaluating evidence from a decision analysis. J Am Board Fam Pract 12:395–402PubMedGoogle Scholar
  38. 38.
    Murray JA, Green PH (1999) Biopsy is the gold standard of diagnosis of celiac sprue. Gastroenterology 116:1273–1274PubMedCrossRefGoogle Scholar
  39. 39.
    Trier JS (1998) Diagnosis of celiac sprue. Gastroenterology 115:211–216PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  1. 1.Division of Gastroenterology and HepatologyUniversity of North CarolinaChapel HillUSA
  2. 2.Center for Clinical Health Policy ResearchDuke UniversityDurhamUSA
  3. 3.Department of MedicineDuke University Medical CenterDurhamUSA
  4. 4.Durham VA Medical CenterDurhamUSA

Personalised recommendations