Yang Janie J, Thanataveerat Anusorn, Green Peter H R, Lebwohl Benjamin
Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York.
Department of Biostatistics, Columbia University Mailman School of Public Health, New York, New York.
Clin Gastroenterol Hepatol. 2015 Aug;13(8):1437-43. doi: 10.1016/j.cgh.2015.03.022. Epub 2015 Mar 25.
BACKGROUND & AIMS: Some patients with refractory gastroesophageal reflux disease (GERD) actually have undiagnosed celiac disease. These patients often undergo an esophagogastroduodenoscopy (EGD) to determine the etiology and severity of GERD. Performing routine duodenal biopsy analysis during an EGD could identify patients with celiac disease. We evaluated the cost effectiveness of this approach.
We performed a systematic search of the MEDLINE database to identify publications through March 2014 on patients who underwent a duodenal biopsy analysis during an EGD for GERD. Data collected were used to construct a decision tree to calculate the cost effectiveness of an EGD with and without celiac disease tests.
Among 10,000 patients with refractory GERD who underwent an EGD, we predicted a biopsy strategy would detect 70% of patients with celiac disease if the prevalence of celiac disease was 1% in this cohort. Biopsy analysis at the start of the EGD procedure would increase the remaining quality-adjusted life years (QALYs) by 0.0032, and increase the lifetime cost by $389/patient. Compared with no biopsy, the biopsy strategy cost $55,692.86/case of celiac disease detected, and $121,875/QALY gained. The incremental cost-effectiveness ratio for the biopsy strategy met the threshold of less than $50,000/QALY when 1 of the following parameters was met: when the utility of living with GERD was less than 0.88, when the prevalence of celiac disease in patients with refractory GERD was greater than 1.8%, when biopsy analysis detected celiac disease with more than 98.1% specificity, when the cost of a gluten-free diet was less than $645.85/y, or if the cost of proton pump inhibitor therapy was more than $5874.01/y.
Based on base-case values, it is not cost effective to perform a biopsy analysis to detect celiac disease in patients undergoing an EGD for refractory GERD. However, the approach becomes cost effective when the prevalence of celiac disease in this population is 1.8% or greater.
一些难治性胃食管反流病（GERD）患者实际上患有未被诊断出的乳糜泻。这些患者常接受食管胃十二指肠镜检查（EGD）以确定GERD的病因和严重程度。在EGD检查期间进行常规十二指肠活检分析可识别出乳糜泻患者。我们评估了这种方法的成本效益。
我们对MEDLINE数据库进行了系统检索，以确定截至2014年3月关于在EGD检查期间因GERD接受十二指肠活检分析的患者的出版物。收集的数据用于构建决策树，以计算进行或不进行乳糜泻检测的EGD检查的成本效益。
在10000例接受EGD检查的难治性GERD患者中，我们预测如果该队列中乳糜泻患病率为1%，活检策略将检测出70%的乳糜泻患者。在EGD检查开始时进行活检分析将使剩余的质量调整生命年（QALY）增加0.0032，并使每位患者的终身成本增加389美元。与不进行活检相比，活检策略每检测出一例乳糜泻病例的成本为55692.86美元，每获得一个QALY的成本为121875美元。当满足以下参数之一时，活检策略的增量成本效益比达到低于50000美元/QALY的阈值：当GERD患者的生活效用小于0.88时；当难治性GERD患者中乳糜泻的患病率大于1.8%时；当活检分析检测乳糜泻的特异性大于98.1%时；当无麸质饮食的成本低于每年645.85美元时；或者如果质子泵抑制剂治疗的成本高于每年5874.01美元时。
基于基础病例值，对于因难治性GERD接受EGD检查的患者，进行活检分析以检测乳糜泻不具有成本效益。然而，当该人群中乳糜泻的患病率为1.8%或更高时，该方法具有成本效益。
