Skip to main content

Healthcare Cost of Over-Diagnosis of Low-Grade Dysplasia in Barrett’s Esophagus

An Erratum to this article was published on 22 March 2016



Published reports have demonstrated that many Barrett’s esophagus patients are over-diagnosed as low-grade dysplasia (BE-LGD). We performed an analysis of the surveillance and treatment costs associated with the over-diagnosis of BE-LGD.


As the principal cost variables, we used endoscopic and histologic procedures performed during the recommended surveillance intervals for patients with BE-LGD, the national average Medicare reimbursement for the Current Procedural Terminology codes of the procedures performed, and a spreadsheet-based tool we created to determine the overall healthcare cost associated with the over-diagnosis of BE-LGD in the US population.


The average excess cost (range) for every patient in the US who is over-diagnosed with BE-LGD is estimated to be $5557 ($3115 to $8072). The principal contributors to the excess cost of over-diagnosis of BE-LGD in these patients are: endoscopy ($2626 to $4639), pathologist biopsy review ($275 to $2185), and esophagogastroduodenoscopy-guided endoscopic ablation ($214 to $1249).


The healthcare cost of over-diagnosis of BE-LGD is significant. To reduce the overall healthcare cost impact of over-diagnosis of BE-LGD, strict adherence to the recommendations of the American Gastroenterological Association, American College of Gastroenterology, and American Society for Gastrointestinal Endoscopy that pathology review of all BE biopsy specimens be performed by a gastrointestinal pathologist is warranted.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2


  1. Organisation for Economic Co-operation and Development (OECD) website. Accessed Sept 2, 2014.

  2. Brody H. Medicine’s ethical responsibility for health care reform—the top five list. N Engl J Med. 2010;362:283–5.

    CAS  Article  PubMed  Google Scholar 

  3. Welch G, Schwartz L, Woloshin S. Overdiagnosed: making people sick in the pursuit of health. Boston: Beacon Press; 2010. p. 180.

    Google Scholar 

  4. Weber LJ. The ethics of cost control: wasteful treatments undermine health care for all. Health Prog. 2011;92:68–74.

    PubMed  Google Scholar 

  5. Booth CL, Thompson KS. Barrett’s esophagus: a review of diagnostic criteria, clinical surveillance practices and new developments. J Gastrointest Oncol. 2012;3:232–42.

    PubMed  PubMed Central  Google Scholar 

  6. Odze RD. Diagnosis and grading of dysplasia in Barrett’s oesophagus. J Clin Pathol. 2006;59:1029–38.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  7. Montgomery E. Update on grading dysplasia in Barrett’s esophagus. Pathol Case Rev. 2002;7:35–42.

    Article  Google Scholar 

  8. Corley DA, Kubo A, DeBoer J, et al. Diagnosing Barrett’s esophagus: reliability of clinical and pathologic diagnoses. Gastrointest Endosc. 2009;69:1004–10.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Curvers WL, Bohmer CJ, Mallant-Hent RC, et al. Mucosal morphology in Barrett’s esophagus: interobserver agreement and role of narrow band imaging. Endoscopy. 2008;40:799–805.

    CAS  Article  PubMed  Google Scholar 

  10. Montgomery E. Is there a way for pathologists to decrease interobserver variability in the diagnosis of dysplasia? Arch Pathol Lab Med. 2005;129:174–5.

    PubMed  Google Scholar 

  11. Rex DK, Cummings OW, Shaw M, et al. Screening for Barrett’s esophagus in colonoscopy patients with and without heartburn. Gastroenterology. 2003;125:1670–7.

    Article  PubMed  Google Scholar 

  12. Gerson LB, Shetler K, Triadafilopoulus G. Prevalence of Barrett’s esophagus in asymptomatic individuals. Gastroenterology. 2002;123:1461–7.

    Article  Google Scholar 

  13. Cameron AJ, Zinsmeister AR, Ballard DJ, et al. Prevalence of columnar-lined (Barrett’s) esophagus: comparison of population based clinical and autopsy findings. Gastroenterology. 1990;99:918–22.

    CAS  PubMed  Google Scholar 

  14. Hayeck TJ, Kong CY, Spechler SJ, et al. The prevalence of Barrett’s esophagus in the US: estimated from a simulation model confirmed by SEER data. Dis Esophagus. 2010;23:451–7.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  15. Fock KM, Ang TL. Global epidemiology of Barrett’s esophagus. Expert Rev Gastroenterol Hepatol. 2011;5:123–30.

    Article  PubMed  Google Scholar 

  16. Feig SA. Pitfalls in accurate estimation of overdiagnosis: implications for screening policy and compliance. Breast Cancer Res. 2013;15:105.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Bhardwaj A, Stairs DB, Mani H, et al. Barrett’s esophagus: emerging knowledge and management strategies. Pathol Res Int. 2012;2012:1–20.

    Article  Google Scholar 

  18. US Census Bureau website: Accessed Sept 2, 2014.

  19. Grotenhuis BA, van Heijl M, ten Kate FJW, et al. Inter- and intraobserver variation in the histopathological evaluation of oesophageal adenocarcinoma. J Clin Pathol. 2010;63:978–81.

    Article  PubMed  Google Scholar 

  20. Kerkhof M, van Dekken H, Steyerberg EW, et al. Grading of dysplasia in Barrett’s oesophagus: substantial interobserver variation between general and gastrointestinal pathologists. Histopathology. 2007;50:920–7.

    CAS  Article  PubMed  Google Scholar 

  21. Sharma P. Low-grade dysplasia in Barrett’s esophagus. Gastroenterology. 2004;127:1233–8.

    Article  PubMed  Google Scholar 

  22. Spechler SJ. Barrett’s esophagus. New Engl J Med. 2002;346:836–42.

    Article  PubMed  Google Scholar 

  23. Montgomery E, Bronner MP, Goldblum JR, et al. Reproducibility of the diagnosis of dysplasia in Barrett esophagus: a reaffirmation. Hum Pathol. 2001;32:368–78.

    CAS  Article  PubMed  Google Scholar 

  24. Reid BJ, Haggitt RC, Rubin CE, et al. Observer variation in the diagnosis of dysplasia in Barrett’s esophagus. Hum Pathol. 1988;19:166–78.

    CAS  Article  PubMed  Google Scholar 

  25. Silva FB, Dinis-Ribeiro M, Vieth M, et al. Endoscopic assessment and grading of Barrett’s esophagus using magnification endoscopy and narrow-band imaging: accuracy and interobserver agreement of different classification systems (with videos). Gastrointest Endosc. 2011;73:7–14.

    Article  PubMed  Google Scholar 

  26. Spechler SJ, Sharma P, Souza RF, et al. American Gastroenterological Association medical position statement on the management of Barrett’s esophagus. Gastroenterology. 2011;140:1084–91.

    Article  PubMed  Google Scholar 

  27. Wang KK, Sampliner RE. Updated guidelines 2008 for the diagnosis, surveillance, and therapy of Barrett’s esophagus. Am J Gastroenterol. 2008;103:788–97.

    Article  PubMed  Google Scholar 

  28. ASGE Standards of Practice Committee, Evans JA, Early DS, et al. ASGE guideline: the role of endoscopy in Barrett’s esophagus and other premalignant conditions of the esophagus. Gastrointest Endosc. 2012;76:1087–94.

    Article  Google Scholar 

  29. Curvers WL, ten Kate FJ, Krishnadath KK, et al. Low-grade dysplasia in Barrett’s esophagus: overdiagnosed and underestimated. Am J Gastroenterol. 2010;105:1523–30.

    Article  PubMed  Google Scholar 

  30. Sharma P, Falk GW, Weston AP, et al. Dysplasia and cancer in a large multicenter cohort of patients with Barrett’s esophagus. Clin Gastroenterol Hepatol. 2008;4:566–72.

    Article  Google Scholar 

  31. CMS Physician Fee Schedule Search Tool website: Accessed Jul 14, 2015.

  32. Level I Healthcare Common Procedure Coding System (HCPCS) website. Accessed Jul 14, 2015.

  33. Duits LC, Phoa N, Curvers WL, et al. Barrett’s oesophagus patients with low-grade dysplasia can be accurately risk-stratified after histological review by an expert pathology panel. Gut. 2015;64:700–6.

    Article  PubMed  Google Scholar 

  34. Wu X, Ajani JA, Gu J, et al. MicroRNA expression signatures during malignant progression from Barrett’s esophagus to esophageal adenocarcinoma. Cancer Prev Res. 2013;6:196–205.

    CAS  Article  Google Scholar 

  35. Ong CA, Lao-Sirieix P, Fitzgerald RC. Biomarkers in Barrett’s esophagus and esophageal adenocarcinoma: predictors of progression and prognosis. World J Gastroenterol. 2010;16:5669–81.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Tischoff I, Tannapfel A. Barrett’s esophagus: can biomarkers predict progression to malignancy? Expert Rev Gastroenterol Hepatol. 2008;2:653–63.

    CAS  Article  PubMed  Google Scholar 

  37. Baak JPA, ten Kate FJW, Offerhaus GJA, et al. Routine morphometrical analysis can improve reproducibility of dysplasia grade in Barrett’s oesophagus surveillance biopsies. J Clin Pathol. 2002;55:910–6.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  38. Ireland AP, Clark GWB, DeMeester TR. Barrett’s esophagus. The significance of p53 in clinical practice. Ann Surg. 1997;225:17–30.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  39. Shi XY, Bhagwandeen B, Leong AS. P16, cyclin D1, Ki-67, and AMACR as markers for dysplasia Barrett esophagus. Appl Immunohistochem Mol Morphol. 2008;16:447–52.

    CAS  Article  PubMed  Google Scholar 

  40. Trimmer MR, Gun G, Gorospe EC, et al. Predictive biomarkers for Barrett’s esophagus: so near and yet so far. Dis Esophagus. 2013;26:574–81.

    Article  Google Scholar 

Download references


No funding or sponsorship was received for this study or publication of this article. The authors would like to acknowledge Suzanne Ridner for her editorial assistance. All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval for the version to be published.


Richard Lash MD is an employee of Miraca Life Sciences, a subspecialty pathology services company which may benefit from data that demonstrates cost savings for patients who receive subspecialty care. Frank Wians PhD was compensated for time spent designing the Excel spreadsheet, the “Healthcare Cost Impact Calculator.” Thomas Deas MD has nothing to disclose.

Compliance with Ethics Guidelines

This article does not contain any new studies with human or animal subjects performed by any of the authors.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Richard H. Lash.

Additional information

Enhanced content To view enhanced content for this article go to

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Lash, R.H., Deas, T.M. & Wians, F.H. Healthcare Cost of Over-Diagnosis of Low-Grade Dysplasia in Barrett’s Esophagus. Adv Ther 33, 684–697 (2016).

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI:


  • Barrett’s esophagus
  • Endoscopic surveillance
  • Health economic impact
  • Low-grade dysplasia
  • Over-diagnosis