Center for Healthcare Policy and Research, University of California Davis, Davis, California.
Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California; Center for Health Policy/Primary Care Outcomes Research, Stanford University, Palo Alto, California.
Clin Gastroenterol Hepatol. 2014 Feb;12(2):253-62.e2. doi: 10.1016/j.cgh.2013.06.028. Epub 2013 Jul 21.
BACKGROUND & AIMS: The level of fecal calprotectin (FC) can predict the onset of inflammatory bowel disease (IBD) with high accuracy and precision. We evaluated the cost-effectiveness of using measurements of FC to identify adults and children who require endoscopic confirmation of IBD. METHODS: We constructed a decision analytic tree to compare the cost-effectiveness of measuring FC before endoscopy examination with that of direct endoscopic evaluation alone. A second decision analytic tree was constructed to evaluate the cost-effectiveness of FC cutoff levels of 100 μg/g vs 50 μg/g (typically used to screen for intestinal inflammation). The primary outcome measure was the incremental cost required to avoid 1 false-negative result by using FC level to diagnose new-onset IBD. RESULTS: In adults, FC screening saved $417/patient but delayed diagnosis for 2.2/32 patients with IBD among 100 screened patients. In children, FC screening saved $300/patient but delayed diagnosis for 4.8/61 patients with IBD among 100 screened patients. If endoscopic biopsy analysis remained the standard for diagnosis, direct endoscopic evaluation would cost an additional $18,955 in adults and $6250 in children to avoid 1 false-negative result from FC screening. Sensitivity analyses showed that cost-effectiveness of FC screening varied with the sensitivity of the test and the pre-test probability of IBD in adults and children. Pre-test probabilities for IBD of ≤75% in adults and ≤65% in children made FC screening cost-effective, but it was cost-ineffective if the probabilities were ≥85% and ≥78% in adults and children, respectively. Compared with the FC cutoff level of 100 μg/g, the cutoff level of 50 μg/g cost an additional $55 and $43 for adults and children, respectively, but it yielded 2.4 and 6.1 additional accurate diagnoses of IBD per 100 screened adults and children, respectively. CONCLUSIONS: Screening adults and children to measure fecal levels of calprotectin is effective and cost-effective in identifying those with IBD on a per-case basis when the pre-test probability is ≤75% for adults and ≤65% for children. The utility of the test is greater for adults than children. Increasing the FC cutoff level to ≥50 μg/g increases diagnostic accuracy without substantially increasing total cost.
背景与目的：粪便钙卫蛋白（FC）的水平可以高精度和高精准度地预测炎症性肠病（IBD）的发病。我们评估了使用 FC 测量来识别需要内镜确认 IBD 的成人和儿童的成本效益。
方法：我们构建了一个决策分析树，比较了在进行内镜检查之前测量 FC 与单独进行直接内镜评估的成本效益。构建了第二个决策分析树来评估 FC 截断值为 100μg/g 与 50μg/g（通常用于筛查肠道炎症）的成本效益。主要观察指标是使用 FC 水平诊断新发病例 IBD 时，避免 1 例假阴性结果所需的增量成本。
结果：在成人中，FC 筛查为每位患者节省了 417 美元，但在 100 名筛查患者中，有 2.2/32 名 IBD 患者的诊断被延迟。在儿童中，FC 筛查为每位患者节省了 300 美元，但在 100 名筛查患者中，有 4.8/61 名 IBD 患者的诊断被延迟。如果内镜活检分析仍然是诊断标准，那么在成人中，直接进行内镜评估将额外增加 18,955 美元，在儿童中增加 6250 美元，以避免 FC 筛查的 1 例假阴性结果。敏感性分析表明，FC 筛查的成本效益取决于测试的敏感性和成人及儿童中 IBD 的预测试概率。成人 IBD 的预测试概率≤75%，儿童 IBD 的预测试概率≤65%，使得 FC 筛查具有成本效益，但如果成人和儿童的概率分别≥85%和≥78%，则 FC 筛查不具有成本效益。与 100μg/g 的 FC 截断值相比，成人和儿童的 50μg/g 截断值分别增加了 55 美元和 43 美元，但分别增加了 2.4 例和 6.1 例成人和儿童 IBD 的准确诊断。
结论：在成人和儿童中，测量粪便钙卫蛋白水平进行筛查，可以有效且具有成本效益地识别出那些预测试概率≤75%的成人和≤65%的儿童患有 IBD。该测试对成人的效果优于儿童。将 FC 截断值提高到≥50μg/g 不会显著增加总费用，但可以提高诊断准确性。
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