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Screening and Surveillance for Barrett Esophagus in High-Risk Groups: A Cost–Utility Analysis

John M. Inadomi, MD; Richard Sampliner, MD; Jesper Lagergren, MD; David Lieberman, MD; A Mark Fendrick, MD; and Nimish Vakil, MD
[+] Article and Author Information

From Veterans Administration Center for Practice Management and Outcomes Research, University of Michigan, and the Consortium for Health Outcomes, Innovation, and Cost Effectiveness Studies, Ann Arbor, Michigan; Southern Arizona Veterans Affairs Healthcare System and University of Arizona, Tucson, Arizona; Karolinska Institute and Karolinska Hospital, Stockholm, Sweden; Oregon Health Sciences University, Portland, Oregon; and University of Wisconsin Medical School, Milwaukee, Wisconsin.


Grant Support: By Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service grant IIR 99-238-2 and an American College of Gastroenterology Faculty Development Award (Dr. Inadomi).

Potential Conflicts of Interest:Consultancies: A.M. Fendrick, N. Vakil; Honoraria: R. Sampliner, A.M. Fendrick, N. Vakil; Grants received: R. Sampliner, A.M. Fendrick, N. Vakil; Grants pending: R. Sampliner; Other: A.M. Fendrick.

Requests for Single Reprints: Nimish Vakil, MD, Division of Gastroenterology, University of Wisconsin Medical School, Aurora Sinai Medical Center, 945 North 12th Street, Room 4040, Milwaukee, WI 53233; e-mail, nvakil@wisc.edu.

Current Author Addresses: Dr. Inadomi: Veterans Affairs Ann Arbor Health Systems (111-D), 2215 Fuller Road, Ann Arbor, MI 48105.

Dr. Sampliner: Southern Arizona Veterans Affairs Healthcare System, 3601 South Sixth Avenue (111G-1), Tucson, AZ 85723.

Dr. Lagergren: Department of Medical Epidemiology, Karolinska Institute, Box 281, S-171 77 Stockholm, Sweden.

Dr. Lieberman: Portland Veterans Affairs Hospital (111A), 3710 Southwest U.S. Veterans Hospital Road, PO Box 1034, Portland, OR 97207.

Dr. Fendrick: University of Michigan Medical Center, 300 NIB, Room Ni7C27, 865 Brookside Drive, Ann Arbor, MI 48105.

Dr. Vakil: Division of Gastroenterology, Aurora Sinai Medical Center, 945 North 12th Street, Room 4040, Milwaukee, WI 53233.

Author Contributions: Conception and design: J.M. Inadomi, R. Sampliner, J. Lagergren, A.M. Fendrick, N. Vakil.

Analysis and interpretation of the data: J.M. Inadomi, J. Lagergren, D. Lieberman, A.M. Fendrick, N. Vakil.

Drafting of the article: J.M. Inadomi, J. Lagergren, D. Lieberman, A.M. Fendrick, N. Vakil.

Critical revision of the article for important intellectual content: J.M. Inadomi, R. Sampliner, J. Lagergren, D. Lieberman, A.M. Fendrick, N. Vakil.

Final approval of the article: J.M. Inadomi, R. Sampliner, J. Lagergren, D. Lieberman, A.M. Fendrick, N. Vakil.

Provision of study materials or patients: J.M. Inadomi, R. Sampliner, N. Vakil.

Statistical expertise: J.M. Inadomi, N. Vakil.

Obtaining of funding: J.M. Inadomi.

Administrative, technical, or logistic support: J.M. Inadomi, N. Vakil.

Collection and assembly of data: J.M. Inadomi, N. Vakil.


Ann Intern Med. 2003;138(3):176-186. doi:10.7326/0003-4819-138-3-200302040-00009
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This study demonstrates the potential benefit of strategies of screening and surveillance for Barrett esophagus and associated adenocarcinoma of the esophagus among white men with symptoms of GERD. Performing a single screening examination at 50 years of age and limiting surveillance to patients with Barrett esophagus with dysplasia is associated with an incremental cost-effectiveness ratio of $10 440 compared to no screening or surveillance. Surveillance for patients with Barrett esophagus without dysplasia may increase the total number of QALYs saved but is expensive ($300 000 to $600 000 per QALY saved). The majority of benefit provided by any strategy stems from the initial screening examination to detect asymptomatic cancers and subsequent surveillance for patients with dysplasia. Surveillance for high-grade dysplasia dominates esophagectomy unless the incidence of cancer in Barrett esophagus is greater than 1 per 122 to 133 patient-years of follow-up. The analysis is sensitive to the prevalence of Barrett esophagus and adenocarcinoma of the esophagus at the time when screening is performed, the incidence of cancer among patients with Barrett esophagus, the proportion of cases cured by early detection of cancer through screening and surveillance, and the utility experience by patients in whom esophagectomy is performed.

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Grahic Jump Location
Figure 1.
Markov model.

Patients in this analysis can reside in seven major states: Patients without Barrett esophagus; patients with Barrett esophagus, without dysplasia or cancer; low-grade dysplasia, in which patients have Barrett esophagus and low-grade dysplasia; high-grade dysplasia, in which patients have Barrett esophagus and high-grade dysplasia; cancer, in which patients have adenocarcinoma of the esophagus; status after surgery, in which patients have undergone esophagectomy for adenocarcinoma of the esophagus; and death from adenocarcinoma of the esophagus, complications of surgery or endoscopy, or other causes. Because there may be errors in diagnosis, the first five states also contain substates that refer to the diagnosed state of the patients in addition to the actual health state. The arrows indicate the possible transitions from one state to another in each cycle. The base-case analysis examined the effect of esophagectomy for detection of cancer only, whereas sensitivity analysis examined esophagectomy for cancer or high-grade dysplasia.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Cost and benefit of screening and surveillance compared to no screening or surveillance.
Grahic Jump Location

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Summary for Patients

Cost-Effectiveness of Screening and Surveillance for Barrett Esophagus

The summary below is from the full report titled “Screening and Surveillance for Barrett Esophagus in High-Risk Groups: A Cost–Utility Analysis.” It is in the 4 February 2003 issue of Annals of Internal Medicine (volume 138, pages 176-186). The authors are JM Inadomi, R Sampliner, J Lagergren, D Lieberman, AM Fendrick, and N Vakil.

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