Is endoscopic surveillance for non-dysplastic Barrett's esophagus cost-effective? Review of economic evaluations


  • Financial support: Nicholas Hirst is funded through a National Health and Medical Research Council Program Grant #552429. Louisa Gordon is funded through a National Health and Medical Research Council Public Health Postdoctoral Training Fellowship. David Whiteman is funded by an Australian Research Council Future Fellowship.

  • Potential competing interests: None.

Nicholas Hirst, Genetics and Population Health Division, Queensland Institute of Medical Research, PO Royal Brisbane Hospital, Brisbane Q4029, Qld. Australia.


Background and Aim:  Several health economic evaluations have explored the cost-effectiveness of endoscopic surveillance for patients with non-dysplastic Barrett's esophagus, with conflicting results. By comparing results across studies and highlighting key methodological and data limitations a platform for future, more rigorous analyses, can be developed.

Methods:  A systematic literature review was undertaken of studies evaluating cost-effectiveness of surveillance for non-dysplastic Barrett's esophagus. Articles were included if they assessed both cost and health outcomes for surveillance versus no surveillance. A descriptive review was undertaken and the quality of the studies appraised against best-practice recommendations for economic evaluations and modeling studies.

Results:  Seven publications met the inclusion criteria. All used decision-analytic Markov models. Half of the evaluations found surveillance was not cost-effective. At best, surveillance produced improved outcomes at a cost of US$16 640 per quality-adjusted life-year, and at worst it did more harm than good and at a greater cost. The quality of the evaluations and generalizability to the Asia-Pacific region was diminished as a result of inadequate or inconsistent evidence supporting parameter estimates, such as quality of life, endoscopic sensitivity and specificity and cancer recurrence rates.

Conclusions:  Unless newly emerging technologies improve the quality-adjusted survival benefit conferred by endoscopic surveillance, this strategy is unlikely to be cost-effective. Obsolete assumptions and incomplete analyses reduce the quality of published evaluations. For these reasons new evaluations are required that encompass the growing evidence base for new technologies, such as new endoscopic therapies for high-grade dysplasia and intramucosal cancer.