Clinical Gastroenterology and Hepatology
Volume 8, Issue 3 , Pages 261-267.e4, March 2010

Cost Effectiveness of Alternative Imaging Strategies for the Diagnosis of Small-Bowel Crohn's Disease

  • Barrett G. Levesque

      Affiliations

    • Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine, California
    • Department of Medicine, Stanford University School of Medicine, California
    • Corresponding Author InformationReprint requests Address requests for reprints to: Barrett G. Levesque, MD, Department of Medicine, Stanford University School of Medicine, 117 Encina Commons, Stanford, California 94305. fax: (650) 723-1919
    • ,
  • Lauren E. Cipriano

      Affiliations

    • Department of Management Science and Engineering, Stanford University, California
    • ,
  • Steven L. Chang

      Affiliations

    • Department of Surgery, Stanford University School of Medicine, California
    • ,
  • Keane K. Lee

      Affiliations

    • Department of Medicine, Stanford University School of Medicine, California
    • ,
  • Douglas K. Owens

      Affiliations

    • Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine, California
    • VA Palo Alto Healthcare System, Palo Alto, California
    • ,
  • Alan M. Garber

      Affiliations

    • Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine, California
    • VA Palo Alto Healthcare System, Palo Alto, California

published online 06 November 2009.

Background & Aims

The cost effectiveness of alternative approaches to the diagnosis of small-bowel Crohn's disease is unknown. This study evaluates whether computed tomographic enterography (CTE) is a cost-effective alternative to small-bowel follow-through (SBFT) and whether capsule endoscopy is a cost-effective third test in patients in whom a high suspicion of disease remains after 2 previous negative tests.

Methods

A decision-analytic model was developed to compare the lifetime costs and benefits of each diagnostic strategy. Patients were considered with low (20%) and high (75%) pretest probability of small-bowel Crohn's disease. Effectiveness was measured in quality-adjusted life-years (QALYs) gained. Parameter assumptions were tested with sensitivity analyses.

Results

With a moderate to high pretest probability of small-bowel Crohn's disease, and a higher likelihood of isolated jejunal disease, follow-up evaluation with CTE has an incremental cost-effectiveness ratio of less than $54,000/QALY-gained compared with SBFT. The addition of capsule endoscopy after ileocolonoscopy and negative CTE or SBFT costs greater than $500,000 per QALY-gained in all scenarios. Results were not sensitive to costs of tests or complications but were sensitive to test accuracies.

Conclusions

The cost effectiveness of strategies depends critically on the pretest probability of Crohn's disease and if the terminal ileum is examined at ileocolonoscopy. CTE is a cost-effective alternative to SBFT in patients with moderate to high suspicion of small-bowel Crohn's disease. The addition of capsule endoscopy as a third test is not a cost-effective third test, even in patients with high pretest probability of disease.

View this article's video abstract at www.cghjournal.org.

Keywords: Crohn's Disease, Cost Effectiveness, Capsule Endoscopes

Abbreviations used in this paper: CTE, computed tomographic enterography, QALY, quality-adjusted life-year, SBFT, small-bowel follow-through

 

 View this article's video abstract at www.cghjournal.org.

 Conflicts of interest The authors disclose no conflicts.

 Funding Supported by a T-32 training grant from the Agency for Healthcare Research and Quality, Center for Primary Care and Outcomes Research, Stanford University (B.G.L.); and by the Social Science and Humanities Research Council of Canada (L.E.C.).

PII: S1542-3565(09)01135-5

doi:10.1016/j.cgh.2009.10.032

Clinical Gastroenterology and Hepatology
Volume 8, Issue 3 , Pages 261-267.e4, March 2010