Kisiel John B, Konijeti Gauree G, Piscitello Andrew J, Chandra Tarun, Goss Thomas F, Ahlquist David A, Farraye Francis A, Ananthakrishnan Ashwin N
Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
Division of Gastroenterology, Scripps Clinic, La Jolla, California; Scripps Translational Science Institute, La Jolla, California.
Clin Gastroenterol Hepatol. 2016 Dec;14(12):1778-1787.e8. doi: 10.1016/j.cgh.2016.07.018. Epub 2016 Jul 25.
BACKGROUND & AIMS: Patients with chronic ulcerative colitis are at increased risk for colorectal neoplasia (CRN). Surveillance by white-light endoscopy (WLE) or chromoendoscopy may reduce risk of CRN, but these strategies are underused. Analysis of DNA from stool samples (sDNA) can detect CRN with high levels of sensitivity, but it is not clear if this approach is cost-effective. We simulated these strategies for CRN detection to determine which approach is most cost-effective.
We adapted a previously published Markov model to simulate the clinical course of chronic ulcerative colitis, the incidence of cancer or dysplasia, and costs and benefits of care with 4 surveillance strategies: (1) analysis of sDNA and diagnostic chromoendoscopy for patients with positive results, (2) analysis of sDNA with diagnostic WLE for patients with positive results, (3) chromoendoscopy with targeted collection of biopsies, or (4) WLE with random collection of biopsies. Costs were based on 2014 Medicare reimbursement. The primary outcome was the incremental cost-effectiveness ratio (incremental cost/incremental difference in quality-adjusted life-years) compared with no surveillance and a willingness-to-pay threshold of $50,000.
All strategies fell below the willingness-to-pay threshold at 2-year intervals. Incremental cost-effectiveness ratios were $16,362 per quality-adjusted life-year for sDNA analysis with diagnostic chromoendoscopy; $18,643 per quality-adjusted life-year for sDNA analysis with diagnostic WLE; $23,830 per quality-adjusted life-year for chromoendoscopy alone; and $27,907 per quality-adjusted life-year for WLE alone. In sensitivity analyses, sDNA analysis with diagnostic chromoendoscopy was more cost-effective than chromoendoscopy alone, up to a cost of $1135 per sDNA test. sDNA analysis remained cost-effective at all rates of compliance; when combined with diagnostic chromoendoscopy, this approach was preferred over chromoendoscopy alone, when the specificity of the sDNA test for CRN was >65%.
Based on a Markov model, surveillance for CRN is cost-effective for patients with chronic ulcerative colitis. Analysis of sDNA with chromoendoscopies for patients with positive results was more cost-effective than chromoendoscopy or WLE alone.
慢性溃疡性结肠炎患者患结直肠肿瘤（CRN）的风险增加。白光内镜检查（WLE）或色素内镜检查进行监测可能会降低CRN风险，但这些策略未得到充分利用。对粪便样本（sDNA）的DNA分析可以高度灵敏地检测CRN，但尚不清楚这种方法是否具有成本效益。我们模拟了这些CRN检测策略，以确定哪种方法最具成本效益。
我们采用了之前发表的马尔可夫模型来模拟慢性溃疡性结肠炎的临床病程、癌症或发育异常的发生率以及4种监测策略的护理成本和效益：（1）对结果呈阳性的患者进行sDNA分析和诊断性色素内镜检查；（2）对结果呈阳性的患者进行sDNA分析和诊断性WLE；（3）色素内镜检查并针对性采集活检样本；或（4）WLE并随机采集活检样本。成本基于2014年医疗保险报销标准。主要结局是与不进行监测相比的增量成本效益比（增量成本/质量调整生命年的增量差异）以及50,000美元的支付意愿阈值。
所有策略在2年间隔时均低于支付意愿阈值。对于诊断性色素内镜检查的sDNA分析，每质量调整生命年的增量成本效益比为16,362美元；对于诊断性WLE的sDNA分析，每质量调整生命年为18,643美元；单独色素内镜检查每质量调整生命年为23,830美元；单独WLE每质量调整生命年为27,907美元。在敏感性分析中，诊断性色素内镜检查的sDNA分析比单独色素内镜检查更具成本效益，最高可达每次sDNA检测1135美元的成本。在所有依从率下，sDNA分析均具有成本效益；当与诊断性色素内镜检查结合使用时，当sDNA检测CRN的特异性>65%时，这种方法比单独色素内镜检查更受青睐。
基于马尔可夫模型，对慢性溃疡性结肠炎患者进行CRN监测具有成本效益。对结果呈阳性的患者进行sDNA分析和色素内镜检查比单独进行色素内镜检查或WLE更具成本效益。
