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Cost Utility Analysis of Topical Steroids Compared With Dietary Elimination for Treatment of Eosinophilic Esophagitis

  • Cary C. Cotton
    Affiliations
    Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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  • Daniel Erim
    Affiliations
    Department of Health Policy and Management, Gillings School of Public Heath, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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  • Swathi Eluri
    Affiliations
    Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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  • Sarah H. Palmer
    Affiliations
    Department of Health Policy and Management, Gillings School of Public Heath, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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  • Daniel J. Green
    Affiliations
    Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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  • W. Asher Wolf
    Affiliations
    Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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  • Thomas M. Runge
    Affiliations
    Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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  • Stephanie Wheeler
    Affiliations
    Department of Health Policy and Management, Gillings School of Public Heath, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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  • Nicholas J. Shaheen
    Affiliations
    Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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  • Evan S. Dellon
    Correspondence
    Reprint requests Address requests for reprints to: Evan S. Dellon, MD, MPH, CB #7080, Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, North Carolina 27599-7080. fax: 919-843-2508.
    Affiliations
    Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Published:December 07, 2016DOI:https://doi.org/10.1016/j.cgh.2016.11.032

      Background & Aims

      Topical corticosteroids or dietary elimination are recommended as first-line therapies for eosinophilic esophagitis, but data to directly compare these therapies are scant. We performed a cost utility comparison of topical corticosteroids and the 6-food elimination diet (SFED) in treatment of eosinophilic esophagitis, from the payer perspective.

      Methods

      We used a modified Markov model based on current clinical guidelines, in which transition between states depended on histologic response simulated at the individual cohort-member level. Simulation parameters were defined by systematic review and meta-analysis to determine the base-case estimates and bounds of uncertainty for sensitivity analysis. Meta-regression models included adjustment for differences in study and cohort characteristics.

      Results

      In the base-case scenario, topical fluticasone was about as effective as SFED but more expensive at a 5-year time horizon ($9261.58 vs $5719.72 per person). SFED was more effective and less expensive than topical fluticasone and topical budesonide in the base-case scenario. Probabilistic sensitivity analysis revealed little uncertainty in relative treatment effectiveness. There was somewhat greater uncertainty in the relative cost of treatments; most simulations found SFED to be less expensive.

      Conclusions

      In a cost utility analysis comparing topical corticosteroids and SFED for first-line treatment of eosinophilic esophagitis, the therapies were similar in effectiveness. SFED was on average less expensive, and more cost effective in most simulations, than topical budesonide and topical fluticasone, from a payer perspective and not accounting for patient-level costs or quality of life.

      Keywords

      Abbreviations used in this paper:

      EoE (eosinophilic esophagitis), hpf (high-power field), PPI (proton pump inhibitor), PSA (probabilistic sensitivity analysis), QALY (quality-adjusted life-year), SFED (6-food elimination diet), tCS (topical corticosteroids)
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