Optimizing the Management Algorithm for Esophageal Dysphagia After Index Endoscopy: Cost-Effectiveness and...

Area of Science:

• Gastroenterology
• Medical Economics
• Diagnostic Algorithms

Background:

• Dysphagia evaluation guidelines recommend esophageal motility testing after structural disorders are excluded.
• Cost concerns often limit the adoption of esophageal motility testing.
• Optimizing the placement of these tests within diagnostic algorithms is crucial.

Purpose of the Study:

• To evaluate the cost-effectiveness of different strategies for esophageal motility testing in patients with dysphagia.
• To determine the optimal positioning of esophageal manometry and impedance planimetry within the dysphagia diagnostic pathway.

Main Methods:

• A decision analytic model compared three strategies: esophageal manometry alone, screening impedance planimetry followed by manometry, and usual care.
• Diagnostic accuracy data were applied to general gastroenterology populations.
• Cost outcomes were analyzed using national commercial and Medicare datasets, stratified by age and sex.
• Health outcomes were modeled for achalasia populations over a 1-year timeframe.

Main Results:

• Esophageal motility testing proved more cost-effective than usual care, primarily due to cost savings.
• Routine esophageal manometry was cost-saving for nonstructural/mechanical dysphagia below a reimbursed cost of $2,415.
• Screening impedance planimetry was cost-saving below a reimbursed cost of $1,130.
• Lower cost thresholds for patients over 65 were observed, mainly influenced by insurance.

Conclusions:

• Routine esophageal motility testing is cost-saving for patients and insurers compared to nonalgorithmic care for dysphagia.
• The choice of diagnostic strategy should be guided by the pre-test index of suspicion for conditions like achalasia.
• Screening impedance planimetry followed by manometry is preferred when the suspicion for achalasia is low (<6%).