Up-Front Endoscopy Maximizes Cost-Effectiveness and Cost-Satisfaction in Uninvestigated Dyspepsia

Emily V. Wechsler; Nitin K. Ahuja; Darren Brenner; Walter Chan; Lin Chang; William D. Chey; Anthony J. Lembo; Baha Moshiree; Judy Nee; Shailja C. Shah; Kyle Staller; Eric D. Shah

doi:10.1016/j.cgh.2023.01.003

Up-Front Endoscopy Maximizes Cost-Effectiveness and Cost-Satisfaction in Uninvestigated Dyspepsia

Emily V. Wechsler, Nitin K. Ahuja, Darren Brenner, Walter Chan, Lin Chang, William D. Chey, Anthony J. Lembo, Baha Moshiree, Judy Nee, Shailja C. Shah, Kyle Staller, Eric D. Shah^*

^*Corresponding author for this work

Medicine, Gastroenterology Division

Research output: Contribution to journal › Article › peer-review

14 Scopus citations

Abstract

Background & Aims: Practice guidelines promote a routine noninvasive, non-endoscopic initial approach to investigating dyspepsia without alarm features in young patients, yet many patients undergo prompt upper endoscopy. We aimed to assess tradeoffs among costs, patient satisfaction, and clinical outcomes to inform discrepancy between guidelines and practice. Methods: We constructed a decision-analytic model and performed cost-effectiveness/cost-satisfaction analysis over a 1-year time horizon on patients with uninvestigated dyspepsia without alarm features referred to gastroenterology. A RAND/UCLA expert panel informed model design. Four competing diagnostic/management strategies were evaluated: prompt endoscopy, testing for Helicobacter pylori and eradicating if present (test-and-treat), testing for H pylori and performing endoscopy if present (test-and-scope), and empiric acid suppression. Outcomes were derived from systematic reviews of clinical trials. Costs were informed by prospective observational cohort studies and national commercial/federal cost databases. Health gains were represented using quality-adjusted life years. Results: From the patient perspective, costs and outcomes were similar for all strategies (maximum out-of-pocket difference of $30 and <0.01 quality-adjusted life years gained/year regardless of strategy). Prompt endoscopy maximized cost-satisfaction and health system reimbursement. Test-and-scope maximized cost-effectiveness from insurer and patient perspectives. Results remained robust on multiple one-way sensitivity analyses on model inputs and across most willingness-to-pay thresholds. Conclusions: Noninvasive management strategies appear to result in inferior cost-effectiveness and patient satisfaction outcomes compared with strategies promoting up-front endoscopy. Therefore, additional studies are needed to evaluate the drivers of patient satisfaction to facilitate inclusion in value-based healthcare transformation efforts.

Original language	English (US)
Pages (from-to)	2378-2388.e28
Journal	Clinical Gastroenterology and Hepatology
Volume	21
Issue number	9
DOIs	https://doi.org/10.1016/j.cgh.2023.01.003
State	Published - Aug 2023

Funding

Funding Dr Chang is supported by a grant from AnX Robotica. Dr Chey has research grants from Commonwealth Diagnostics International, QOL Medical, Salix, and stock options from GI on Demand, Isothrive, and Modify Health. Dr Moshiree is supported by grant support from Bausch Pharmaceuticals and Progenity. Dr Staller is supported by NIDDK K23 DK120945. Dr E. Shah was supported by the AGA Research Foundation’s 2019 American Gastroenterological Association-Shire Research Scholar Award in Functional GI and Motility Disorders.

Keywords

Comparative Effectiveness Research
Costs and Cost Analysis
Endoscopy
Insurance

ASJC Scopus subject areas

Hepatology
Gastroenterology

Access to Document

10.1016/j.cgh.2023.01.003

Cite this

@article{e6bf3073345049ab90c29baed1642d8f,

title = "Up-Front Endoscopy Maximizes Cost-Effectiveness and Cost-Satisfaction in Uninvestigated Dyspepsia",

abstract = "Background & Aims: Practice guidelines promote a routine noninvasive, non-endoscopic initial approach to investigating dyspepsia without alarm features in young patients, yet many patients undergo prompt upper endoscopy. We aimed to assess tradeoffs among costs, patient satisfaction, and clinical outcomes to inform discrepancy between guidelines and practice. Methods: We constructed a decision-analytic model and performed cost-effectiveness/cost-satisfaction analysis over a 1-year time horizon on patients with uninvestigated dyspepsia without alarm features referred to gastroenterology. A RAND/UCLA expert panel informed model design. Four competing diagnostic/management strategies were evaluated: prompt endoscopy, testing for Helicobacter pylori and eradicating if present (test-and-treat), testing for H pylori and performing endoscopy if present (test-and-scope), and empiric acid suppression. Outcomes were derived from systematic reviews of clinical trials. Costs were informed by prospective observational cohort studies and national commercial/federal cost databases. Health gains were represented using quality-adjusted life years. Results: From the patient perspective, costs and outcomes were similar for all strategies (maximum out-of-pocket difference of $30 and <0.01 quality-adjusted life years gained/year regardless of strategy). Prompt endoscopy maximized cost-satisfaction and health system reimbursement. Test-and-scope maximized cost-effectiveness from insurer and patient perspectives. Results remained robust on multiple one-way sensitivity analyses on model inputs and across most willingness-to-pay thresholds. Conclusions: Noninvasive management strategies appear to result in inferior cost-effectiveness and patient satisfaction outcomes compared with strategies promoting up-front endoscopy. Therefore, additional studies are needed to evaluate the drivers of patient satisfaction to facilitate inclusion in value-based healthcare transformation efforts.",

keywords = "Comparative Effectiveness Research, Costs and Cost Analysis, Endoscopy, Insurance",

author = "Wechsler, {Emily V.} and Ahuja, {Nitin K.} and Darren Brenner and Walter Chan and Lin Chang and Chey, {William D.} and Lembo, {Anthony J.} and Baha Moshiree and Judy Nee and Shah, {Shailja C.} and Kyle Staller and Shah, {Eric D.}",

note = "Funding Information: Funding Dr Chang is supported by a grant from AnX Robotica. Dr Chey has research grants from Commonwealth Diagnostics International, QOL Medical, Salix, and stock options from GI on Demand, Isothrive, and Modify Health. Dr Moshiree is supported by grant support from Bausch Pharmaceuticals and Progenity. Dr Staller is supported by NIDDK K23 DK120945. Dr E. Shah was supported by the AGA Research Foundation{\textquoteright}s 2019 American Gastroenterological Association-Shire Research Scholar Award in Functional GI and Motility Disorders. Publisher Copyright: {\textcopyright} 2023 AGA Institute",

year = "2023",

month = aug,

doi = "10.1016/j.cgh.2023.01.003",

language = "English (US)",

volume = "21",

pages = "2378--2388.e28",

journal = "Clinical Gastroenterology and Hepatology",

issn = "1542-3565",

publisher = "W.B. Saunders",

number = "9",

}

TY - JOUR

T1 - Up-Front Endoscopy Maximizes Cost-Effectiveness and Cost-Satisfaction in Uninvestigated Dyspepsia

AU - Wechsler, Emily V.

AU - Ahuja, Nitin K.

AU - Brenner, Darren

AU - Chan, Walter

AU - Chang, Lin

AU - Chey, William D.

AU - Lembo, Anthony J.

AU - Moshiree, Baha

AU - Nee, Judy

AU - Shah, Shailja C.

AU - Staller, Kyle

AU - Shah, Eric D.

N1 - Funding Information: Funding Dr Chang is supported by a grant from AnX Robotica. Dr Chey has research grants from Commonwealth Diagnostics International, QOL Medical, Salix, and stock options from GI on Demand, Isothrive, and Modify Health. Dr Moshiree is supported by grant support from Bausch Pharmaceuticals and Progenity. Dr Staller is supported by NIDDK K23 DK120945. Dr E. Shah was supported by the AGA Research Foundation’s 2019 American Gastroenterological Association-Shire Research Scholar Award in Functional GI and Motility Disorders. Publisher Copyright: © 2023 AGA Institute

PY - 2023/8

Y1 - 2023/8

N2 - Background & Aims: Practice guidelines promote a routine noninvasive, non-endoscopic initial approach to investigating dyspepsia without alarm features in young patients, yet many patients undergo prompt upper endoscopy. We aimed to assess tradeoffs among costs, patient satisfaction, and clinical outcomes to inform discrepancy between guidelines and practice. Methods: We constructed a decision-analytic model and performed cost-effectiveness/cost-satisfaction analysis over a 1-year time horizon on patients with uninvestigated dyspepsia without alarm features referred to gastroenterology. A RAND/UCLA expert panel informed model design. Four competing diagnostic/management strategies were evaluated: prompt endoscopy, testing for Helicobacter pylori and eradicating if present (test-and-treat), testing for H pylori and performing endoscopy if present (test-and-scope), and empiric acid suppression. Outcomes were derived from systematic reviews of clinical trials. Costs were informed by prospective observational cohort studies and national commercial/federal cost databases. Health gains were represented using quality-adjusted life years. Results: From the patient perspective, costs and outcomes were similar for all strategies (maximum out-of-pocket difference of $30 and <0.01 quality-adjusted life years gained/year regardless of strategy). Prompt endoscopy maximized cost-satisfaction and health system reimbursement. Test-and-scope maximized cost-effectiveness from insurer and patient perspectives. Results remained robust on multiple one-way sensitivity analyses on model inputs and across most willingness-to-pay thresholds. Conclusions: Noninvasive management strategies appear to result in inferior cost-effectiveness and patient satisfaction outcomes compared with strategies promoting up-front endoscopy. Therefore, additional studies are needed to evaluate the drivers of patient satisfaction to facilitate inclusion in value-based healthcare transformation efforts.

AB - Background & Aims: Practice guidelines promote a routine noninvasive, non-endoscopic initial approach to investigating dyspepsia without alarm features in young patients, yet many patients undergo prompt upper endoscopy. We aimed to assess tradeoffs among costs, patient satisfaction, and clinical outcomes to inform discrepancy between guidelines and practice. Methods: We constructed a decision-analytic model and performed cost-effectiveness/cost-satisfaction analysis over a 1-year time horizon on patients with uninvestigated dyspepsia without alarm features referred to gastroenterology. A RAND/UCLA expert panel informed model design. Four competing diagnostic/management strategies were evaluated: prompt endoscopy, testing for Helicobacter pylori and eradicating if present (test-and-treat), testing for H pylori and performing endoscopy if present (test-and-scope), and empiric acid suppression. Outcomes were derived from systematic reviews of clinical trials. Costs were informed by prospective observational cohort studies and national commercial/federal cost databases. Health gains were represented using quality-adjusted life years. Results: From the patient perspective, costs and outcomes were similar for all strategies (maximum out-of-pocket difference of $30 and <0.01 quality-adjusted life years gained/year regardless of strategy). Prompt endoscopy maximized cost-satisfaction and health system reimbursement. Test-and-scope maximized cost-effectiveness from insurer and patient perspectives. Results remained robust on multiple one-way sensitivity analyses on model inputs and across most willingness-to-pay thresholds. Conclusions: Noninvasive management strategies appear to result in inferior cost-effectiveness and patient satisfaction outcomes compared with strategies promoting up-front endoscopy. Therefore, additional studies are needed to evaluate the drivers of patient satisfaction to facilitate inclusion in value-based healthcare transformation efforts.

KW - Comparative Effectiveness Research

KW - Costs and Cost Analysis

KW - Endoscopy

KW - Insurance

UR - http://www.scopus.com/inward/record.url?scp=85149827951&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85149827951&partnerID=8YFLogxK

U2 - 10.1016/j.cgh.2023.01.003

DO - 10.1016/j.cgh.2023.01.003

M3 - Article

C2 - 36646234

AN - SCOPUS:85149827951

SN - 1542-3565

VL - 21

SP - 2378-2388.e28

JO - Clinical Gastroenterology and Hepatology

JF - Clinical Gastroenterology and Hepatology

IS - 9

ER -

Up-Front Endoscopy Maximizes Cost-Effectiveness and Cost-Satisfaction in Uninvestigated Dyspepsia

Abstract

Funding

Keywords

ASJC Scopus subject areas

Access to Document

Other files and links

Fingerprint

Cite this