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Improving cost-effectiveness of endoscopic surveillance for Barrett’s esophagus by reducing low-value care: a review of economic evaluations

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Individuals with Barrett’s esophagus are believed to be at 30–120× risk of developing esophageal adenocarcinoma (EAC). Early detection and endoscopic treatment of dysplasia/early cancer confers a significant advantage to patients under surveillance; however, most do not progress past the non-dysplastic state of Barrett’s esophagus (NDBE), which is potentially an inefficient distribution of health care resources.


This article aimed to review the outcomes of cost-effectiveness studies reducing low-value care in the context of endoscopic surveillance for non-dysplastic Barrett’s esophagus (NDBE).


A systematic search was conducted by two reviewers in accordance with PRISMA guidelines. Inclusion criteria: cost-utility analyses of endoscopic surveillance of NDBE patients with at least one treatment strategy focused on reduction of surveillance. A narrative synthesis of economic evaluations was undertaken, along with an in-depth analysis of input parameters contributing to stated Incremental cost-effectiveness ratios (ICER). Study appraisal was performed using the consolidated health economic evaluation reporting standards (CHEERS) tool.


10 Studies met inclusion criteria. There was significant variation in cost-model structures, input parameters, ICER values, and willingness-to-pay thresholds between studies. All studies except one concluded guideline-specified endoscopic surveillance for NDBE patients was not cost-effective. Studies that explored a modified surveillance by deselection of low-risk NDBE patients found it to be a cost-effective strategy.


Guideline specified endoscopic surveillance for NDBE was not found to be cost-effective in the studies examined. A modified endoscopic surveillance strategy removing individuals with the lowest risk for progression from NDBE to adenocarcinoma is likely to be cost-effective but is dependent on risk profile of patients excluded from surveillance.

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Dr. Vissapragada is sponsored by a Ph.D. grant from The Hospital Research Foundation. Professor Watson received a Beat Cancer Hospital Research Package Grant which was funded by the Cancer Council of South Australia’s Beat Cancer Project on behalf of its donors and the State Government of South Australia Department of Health, together with the support of the Flinders Medical Centre Foundation, its donors and partners. This grant funded Dr. Norma Bulamu’s salary.

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Correspondence to David I. Watson.

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Drs. Vissapragada, Bulamu, Brumfitt, Yazbeck, Profs. Karnon and Watson have no conflicts of interest to or other financial ties to disclose.

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Vissapragada, R., Bulamu, N.B., Brumfitt, C. et al. Improving cost-effectiveness of endoscopic surveillance for Barrett’s esophagus by reducing low-value care: a review of economic evaluations. Surg Endosc 35, 5905–5917 (2021).

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