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Management of obscure occult gastrointestinal bleeding: a cost-minimization analysis
Ma Somsouk1, Ian M Gralnek, John M Inadomi
1Department of Gastrointestinal Health Outcomes, Policy and Economics Research Program, University of California, San Francisco, 513 Parnassus Avenue, Box 0538, San Francisco, California 94143, USA. ma.somsouk@ucsf.edu
Insights
For obscure occult gastrointestinal bleeding (OGIB), initial double-balloon enteroscopy (DBE) is most cost-effective when treatment is needed. Capsule endoscopy (CE) is preferred if only visual diagnosis is sufficient or DBE is unavailable.
Area of Science:
- Gastroenterology
- Medical Economics
- Diagnostic Imaging
Background:
- Capsule endoscopy (CE) and double-balloon enteroscopy (DBE) enable complete small-bowel examination but incur significant healthcare costs.
- Obscure occult gastrointestinal bleeding (OGIB) presents a diagnostic challenge requiring effective and resource-conscious management strategies.
Purpose of the Study:
- To determine the optimal initial management strategy for obscure occult gastrointestinal bleeding (OGIB) using a cost-minimization analysis.
- To compare the cost-effectiveness of various small-bowel examination techniques for diagnosing OGIB.
Main Methods:
- A cost-minimization analysis compared five strategies: small-bowel follow-through, enteroclysis, push enteroscopy (PE), CE, and DBE.
- Models considered medically refractory disease with endpoints requiring treatment/diagnosis or where visual diagnosis sufficed.
- Sensitivity analyses explored parameter variations, Monte Carlo simulation, and scenarios excluding initial DBE.
Main Results:
- When treatment or definitive diagnosis was necessary, initial DBE was the optimal strategy ($3824).
- Initial CE incurred an incremental cost of $440 and was preferred if DBE costs exceeded $1849 or sensitivity dropped below 68%.
- If DBE was unavailable initially, CE was preferred over PE unless specific cost or diagnostic yield thresholds were met. Initial CE was favored when visual diagnosis was sufficient.
Conclusions:
- For OGIB, initial DBE is the most cost-effective strategy when treatment or definitive diagnosis is required.
- Initial CE is the preferred strategy when only visual identification is sufficient or when DBE is not available as an initial option.
Background & Aims:
Capsule endoscopy (CE) and double-balloon enteroscopy (DBE) allow complete small-bowel examination but consume additional health care resources. A cost-minimization analysis determined the optimal initial management strategy for obscure occult gastrointestinal bleeding (OGIB).
Methods:
We compared 5 strategies: initial small-bowel follow-through, enteroclysis, push enteroscopy (PE), CE, or DBE. Incorporation of multiple tests was allowed with costs taken from a third-party payer perspective. We modeled medically refractory disease with 2 separate model end points in which treatment or definitive diagnosis was necessary and in which visual diagnosis was sufficient to suspend testing. Sensitivity analyses included variations in parameter estimates, Monte Carlo simulation, and structural variations in the model in which DBE was not available as an initial strategy.
Results:
When treatment or definitive diagnosis was necessary, the optimal strategy was initial DBE at a cost of $3824. An initial CE strategy costs an incremental $440. CE was preferred when DBE exceeded $1849 or when the sensitivity of DBE decreased to less than 68%. If DBE was unavailable as an initial test then CE was preferred to PE unless CE exceeded $1190, capsule retention was greater than 3%, or 64% of lesions were within reach of PE. When visual diagnosis was sufficient, initial CE was preferred.
Conclusions:
For OGIB, initial DBE may be the least expensive strategy when treatment or definitive diagnosis is necessary and initial CE may be preferred when visual identification is sufficient. In settings where DBE is not available as an initial test, initial CE may be the preferred strategy.
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