The Impact of the Policy-Practice Gap on Costs and Benefits of Barrett's Esophagus Management

• Published in: The American journal of gastroenterology Vol. 115; no. 7; pp. 1026 - 1035
• Main Authors: Omidvari, Amir-Houshang, Roumans, Carlijn A.M., Naber, Steffie K., Kroep, Sonja, Wijnhoven, Bas P.L., Gaast, Ate van der, de Jonge, Pieter-Jan, Spaander, Manon C.W., Lansdorp-Vogelaar, Iris
• Format: Journal Article
• Language: English
• Published: United States Wolters Kluwer 01.07.2020; Wolters Kluwer Health Medical Research, Lippincott Williams & Wilkins
• Subjects: Biopsy; Cost analysis; Cost estimates; Endoscopy; Esophageal cancer; Esophagus; Gastroenterology; Gastroesophageal reflux; Health surveillance; Impact analysis; Patients; Population; Netherlands
• ISSN: 0002-9270; 1572-0241
• 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 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 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 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.