Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
Am J Gastroenterol. 2020 Jul;115(7):1026-1035. doi: 10.14309/ajg.0000000000000578.
Clinical guidelines recommend surveillance of patients with Barrett's esophagus (BE). However, the surveillance intervals in practice are shorter than policy recommendations. We aimed to determine how this policy-practice gap affects the costs and benefits of BE surveillance.
We used the Netherlands as an exemplary Western country and simulated a cohort of 60-year-old patients with BE using the Microsimulation Screening Analysis model-esophageal adenocarcinoma (EAC) microsimulation model. We evaluated surveillance according to the Dutch guideline and more intensive surveillance of patients without dysplastic BE and low-grade dysplasia. For each strategy, we computed the quality-adjusted life years (QALYs) gained and costs compared with no surveillance. We also performed a budget impact analysis to estimate the increased costs of BE management in the Netherlands for 2017.
Compared with no surveillance, the Dutch guideline incurred an additional &OV0556;5.0 ($5.7) million per 1,000 patients with BE for surveillance and treatment, whereas 57 esophageal adenocarcinoma (EAC) cases (>T1a) were prevented. With intensive and very intensive surveillance strategies for both nondysplastic BE and low-grade dysplasia, the net costs increased by another &OV0556;2.5-5.6 ($2.8-6.5) million while preventing 10-19 more EAC cases and gaining 33-60 more QALYs. On a population level, this amounted to &OV0556;21-47 ($24-54) million (+32%-70%) higher healthcare costs in 2017.
The policy-practice gap in BE surveillance intervals results in 50%-114% higher net costs for BE management for only 10%-18% increase in QALYs gained, depending on actual intensity of surveillance. Incentives to eliminate this policy-practice gap should be developed to reduce the burden of BE management on patients and healthcare resources.
临床指南建议对 Barrett 食管（BE）患者进行监测。然而，实际中的监测间隔时间短于政策建议。我们旨在确定这种政策与实践之间的差距如何影响 BE 监测的成本和效益。
我们选择荷兰作为西方的典型代表国家，使用 Microsimulation Screening Analysis model-esophageal adenocarcinoma (EAC) microsimulation model 模拟了 60 岁 BE 患者队列。我们根据荷兰指南和对无异型增生 BE 和低级别异型增生患者更密集的监测来评估监测策略。对于每种策略，我们计算了与不监测相比获得的质量调整生命年（QALYs）和成本。我们还进行了预算影响分析，以估计 2017 年荷兰 BE 管理成本的增加。
与不监测相比，荷兰指南对每 1000 例 BE 患者进行监测和治疗的额外费用为 505 万欧元（570 万美元），同时预防了 57 例食管腺癌（EAC）（>T1a）病例。对于无异型增生 BE 和低级别异型增生患者进行更密集和非常密集的监测策略，净成本又增加了 250 万至 560 万欧元，同时预防了 10 至 19 例更多的 EAC 病例，并获得了 33 至 60 个更多的 QALYs。在人群水平上，这相当于 2017 年医疗保健成本增加了 2100 万至 4700 万欧元（32%至 70%）。
BE 监测间隔的政策与实践差距导致 BE 管理的净成本增加了 50%至 114%，而获得的 QALYs 仅增加了 10%至 18%，具体取决于实际监测的强度。应制定激励措施以消除这种政策与实践之间的差距，以减轻患者和医疗资源的 BE 管理负担。
