Abstract
Health care costs are an increasingly important study outcome. Endoscopic practice consumes a large proportion of gastroenterology-related health expenses. An economic comparison of several currently accepted endoscopic practices was performed, ranking them according their cost-effectiveness, as viewed from the payer perspective. The cost-effectiveness of four currently accepted standard endoscopic practices was examined: small bowel biopsy to assess for celiac sprue, colonoscopic biopsy to assess for microscopic colitis, surveillance of Barrett’s esophagus, and surveillance of chronic ulcerative colitis (CUC). Parameter estimates were obtained from the published literature. Charges were based on Medicare professional plus facility/technical fees. Performing colonoscopic biopsies for microscopic colitis in the setting of chronic nonbloody diarrhea was the most cost-effective practice ($2447/case detected), while small bowel biopsy for sprue in the setting of a patient with a first−degree relative with sprue ($3042/case detected) or with anemia ($2982/case detected) was also a cost−effective approach. Small bowel biopsy in the setting of diarrhea ($3900/case detected) was less cost-effective, while CUC surveillance ($14,119/detection of dysplasia) and performance of small bowel biopsy in an asymptomatic patient ($15,209/case detected) were clearly the least economical. As efforts are made to reduce the costs of health care, more attention will be focused on the cost-effectiveness of routine endoscopic practices. Although, our findings put endoscopic practices into economic perspective, future perspective, future prospective trials are required to confirm the validity of these findings.
Similar content being viewed by others
References
Brook RH: Appropriateness: The next frontier. BMJ 308(6923):218–219, 1994
Brook RH, Park RE, Chassin MR, Solomon DH, Keesey J, Kosecoff J: Predicting the appropriate use of carotid endarterectomy, upper gastrointestinal endoscopy, and coronary angiography. N Engl J Med 323(17):1173–1177, 1990
Quine MA, Bell GD, McCloy RF, Devlin HB, Hopkins A: Appropriate use of upper gastrointestinal endoscopy—A prospective audit. Steering Group of the Upper Gastrointestinal Endoscopy Audit Committee. Gut 35(9):1209–1214, 1994
Karasick S, Ehrlich SM, Levin DC, et al.: Trends in use of barium enema examination, colonoscopy, and sigmoidoscopy: Is use commensurate with risk of disease? Radiology 195(3):777–784, 1995
Scott B: Endoscopic demands in the 90’s. Gut 31(2):125–126, 1990
Arrowsmith JB, Gerstman BB, Fleischer DE, Benjamin SB: Results from the American Society for Gastrointestinal Endoscopy/U.S. Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy. Gastrointest Endosc 37(4):421–427, 1991
Kornbluth A, Sachar DB: Ulcerative colitis practice guidelines in adults. American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol 92(2):204–211, 1997
Averill RF, Goldfield NI, Wynn ME, et al.: Design of a prospective payment patient classification system for ambulatory care. Health Care Financ Rev 15(1):71–100, 1993
Sieg A, Hachmoeller-Eisenbach U, Eisenbach T: Prospective evaluation of complications in outpatient GI endoscopy: A survey among German gastroenterologists. Gastrointest Endosc 53(6):620–627, 2001
Newcomer MK, Brazer SR: Complications of upper gastrointestinal endoscopy and their management. Gastrointest Endosc Clin North Am 4(3):551–570, 1994
Miros M, Kerlin P, Walker N: Only patients with dysplasia progress to adenocarcinoma in Barrett’s oesophagus. Gut 32(12):1441–1446, 1991
O’Connor JB, Falk GW, Richter JE: The incidence of adenocarcinoma and dysplasia in Barrett’s esophagus: Report on the Cleveland Clinic Barrett’s Esophagus Registry. Amj Gastroenterol 94(8):2037–2042, 1999
Connell WR, Lennard-Jones JE, Williams CB, Talbot IC, Price AB, Wilkinson KH: Factors affecting the outcome of endoscopic surveillance for cancer in ulcerative colitis. Gastroenterology 107(4):934–944, 1994
Lennard-Jones JE, Melville DM, Morson BC, Ritchie JK, Williams CB: Precancer and cancer in extensive ulcerative colitis: Findings among 401 patients over 22 years. Gut 31(7):800–806, 1990
Lofberg R, Brostrom O, Karlen P, Tribukait B, Ost A: Colonoscopic surveillance in long-standing total ulcerative colitis—A 15-year follow-up study. Gastroenterology 99(4):1021–1031, 1990
Lynch DA, Lobo AJ, Sobala GM, Dixon MF, Axon AT: Failure of colonoscopic surveillance in ulcerative colitis. Gut 34(8):1075–1080, 1993
Fasano A, Berti I, Gerarduzzi T, et al.: Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: A large multicenter study. Arch Intern Med 163(3):286–292, 2003
Hin H, Bird G, Fisher P, Mahy N, Jewell D: coeliac disease in primary care: case finding study. BMJ 318(7177):164–167, 1999
Ransford RA, Hayes M, Palmer M, Hall MJ: A controlled, prospective screening study of celiac disease presenting as iron deficiency anemia. J Clin Gastroenterol 35(3):228–233, 2002
Murray JA, Van Dyke C, Plevak MF, Dierkhising RA, Zinsmeister AR, Melton LJ: Trends in the incidence and clinical features of celiac disease in a North American community, 1950–2001. Clin Gastroenterol Hepatol 1:19–27, 2003
Fine KD, Seidel RH, Do K: The prevalence, anatomic distribution, and diagnosis of colonic causes of chronic diarrhea. Gastrointest Endosc 51(3):318–326, 2000
Yusoff IF, Ormonde DG, Hoffman NE: Routine colonic mucosal biopsy and ileoscopy increases diagnostic yield in patients undergoing colonoscopy for diarrhea. J Gastroenterol Hepatol 17(3):276–280, 2002
Pardi DS, Ramnath VR, Loftus EV, Jr, Tremaine WJ, Sandborn WJ: Lymphocytic colitis: Clinical features, treatment, and outcomes. Am J Gastroenterol 97(11):2829–2833, 2002
Conio M, Cameron AJ, Romero Y, et al.: Secular trends in the epidemiology and outcome of Barrett’s oesophagus in Olmsted County, Minnesota. Gut 48(3):304–309, 2001
Toruner M, Harewood GC, Loftus EV Jr, Sandborn WJ, Tremaine WJ, Schroeder KW, Egan LJ: Endoscopic factors in the diagnosis of colorectal dysplasia in chronic inflammatory bowel disease (manuscript in preparation)
Brook RH: Practice guidelines and practicing medicine. Are they compatible? JAMA 262(21):3027–3030, 1989 [see comment]
Oxentenko AS, Grisolano SW, Murray JA, Burgart LJ, Dierkhising RA, Alexander JA: The insensitivity of endoscopic markers in celiac disease. Am J Gastroenterol 97(4):933–938, 2002
Greenstein AJ, Sachar DB, Smith H, et al.: Cancer in universal and left-sided ulcerative colitis: Factors determining risk. Gastroenterology 77(2):290–294, 1979
Sugita A, Sachar DB, Bodian C, Ribeiro MB, Aufses AH Jr, Greenstein AJ: Colorectal cancer in ulcerative colitis. Influence of anatomical extent and age at onset on colitis-cancer interval. Gut 32(2):167–169, 1991
Vemulapalli R, Lance P: Cancer surveillance in ulcerative colitis: More of the same or progress? Gastroenterology 107(4):1196–1199, 1994
Streitz JM Jr, Andrews CW Jr, Ellis FH Jr: Endoscopic surveillance of Barrett’s esophagus. Does it help? J Thorac Cardiovasc Surg 105(3):383–387 (discussion 387–388), 1993
Peters JH, Clark GW, Ireland AP, Chandrasoma P, Smyrk TC, DeMeester TR: Outcome of adenocarcinoma arising in Barrett’s esophagus in endoscopically surveyed and nonsurveyed patients. J Thorac Cardiovasc Surg 108(5):813–821 (discussion 821–822), 1994
Van Sandick JW, Van Lanschot JJ, Kuiken BW, Tytgat GN, Offerhaus GJ, Obertop H: Impact of endoscopic biopsy surveillance of Barrett’s oesophagus on pathological stage and clinical outcome of Barrett’s carcinoma. Gut 43(2):216–222, 1998
Sampliner RE, Practice Parameters Committee of the American College of Gastroenterology: Updated guidelines for the diagnosis, surveillance, and therapy of Barrett’s esophagus. Am J Gastroenterol 97(8):1888–1895, 2002
Green PH, Murray JA: Routine duodenal biopsies to exclude celiac disease? Gastrointest Endosc 58(1):92–95, 2003
West J, Logan RF, Hill PG, et al.: Seroprevalence, correlates, and characteristics of undetected coeliac disease in England. Gut 52(7):960–965, 2003
Lindberg BU, Broome U, Persson B: Proximal colorectal dysplasia or cancer in ulcerative colitis. The impact of primary sclerosing cholangitis and sulfasalazine: Results from a 20-year surveillance study. Dis Colon Rect 44(1):77–85, 2001
Soetikno RM, Lin OS, Heidenreich PA, Young HS, Blackstone MO: Increased risk of colorectal neoplasia in patients with primary sclerosing cholangitis and ulcerative colitis: A meta-analysis. Gastrointest Endosc 56(1):48–54, 2002
Pardi DS: Microscopic colitis. Mayo Clin Proc 78(5):614–616 (quiz 616–617), 2003
Rudolph RE, Vaughan TL, Storer BE, et al.: Effect of segment length on risk for neoplastic progression in patients with Barrett esophagus. Ann Intern Med 132(8):612–620, 2000
Sharma P, Morales TG, Bhattacharyya A, Garewal HS, Sampliner RE: Dysplasia in short-segment Barrett’s esophagus: A prospective 3-year follow-up. Am J Gastroenterol 92(11):2012–2016, 1997
Bernstein CN, Shanahan F, Weinstein WM: Are we telling patients the truth about surveillance colonoscopy in ulcerative colitis? Lancet 343(8889):71–74, 1994
Woolrich AJ, DaSilva MD, Korelitz BI: Surveillance in the routine management of ulcerative colitis: The predictive value of low-grade dysplasia. Gastroenterology 103(2):431–438, 1992
Hopper AD, Cross SS, McAlindon ME, Sanders DS: Symptomatic giardiasis without diarrhea: Further evidence to support the routine duodenal biopsy? Gastrointest Endosc 58(1):120–122, 2003
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Harewood, G.C. Economic Comparison of Current Endoscopic Practices: Barrett’s Surveillance vs. Ulcerative Colitis Surveillance vs. Biopsy for Sprue vs. Biopsy for Microscopic Colitis. Dig Dis Sci 49, 1808–1814 (2004). https://doi.org/10.1007/s10620-004-9575-2
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10620-004-9575-2