Cost-effectiveness of upper gastrointestinal endoscopy according to the appropriateness of the indication

Application of appropriate indications for upper endoscopy (EGD) should conserve limited endoscopic resources. The cost-effectiveness of current guidelines for the detection of gastro-oesophageal cancer is unknown. The aim of this study was to assess the clinical and economic impact of ASGE and EPAGE guidelines in selecting patients referred for upper endoscopy relative to the detection of gastro-oesophageal cancer.

A decision analysis model was constructed to compare a strategy of not referring patients for EGD (with either an appropriate or inappropriate indication) with a policy of carrying out the requested EGD. Cancer prevalence in appropriate and inappropriate EGDs was estimated using a systematic review of the literature. Costs of EGD and cancer care were estimated from Medicare reimbursement data.

The number of appropriate and inappropriate EGDs required to detect one case of cancer was 41 and 753, respectively, and to prevent one gastro-oesophageal cancer-related death the numbers were 571 and 11,111, respectively. The incremental cost-effectiveness ratios of appropriate and inappropriate EGDs as compared to a policy of not referring patients for endoscopy were $16,577 and $301,203, respectively, per life-year gained.

For inappropriate EGD, the very low likelihood of cancer and the relatively high costs associated with this procedure argue against endoscopic referral.