Optimizing Approach to Nonobstructive Dysphagia: A Cost-Minimization Analysis

Dysphagia affects over 15 million US adults. The initial workup often involves performing an esophagogastroduodenoscopy (EGD), and in 32% of cases, the EGD is normal, prompting further evaluation. This study aimed to identify the most cost-effective approach for diagnosing and managing nonobstructive dysphagia (NOD).

We compared the cost of multiple scenarios in the initial workup of NOD: (1) esophageal high-resolution manometry (HRM); (2) esophageal impedance planimetry (EndoFLIP); or (3) empiric dilation followed by HRM or EndoFLIP if dilation fails. Distributions of HRM and EndoFLIP diagnoses in NOD were determined from prior published large cohorts, which were then cross-referenced to determine the costs of different clinical scenarios.

Approaches using EndoFLIP compared with HRM with or without empiric dilation had notably higher average per-patient costs of ∼$300 to $430. HRM-first strategies remained more cost-effective in all scenarios unless the HRM failure rates exceeded 48.8%.

Our study found potential savings of $1 to $2 billion when performing HRM instead of EndoFLIP in the initial workup of NOD. The difference is attributed to the relatively higher cost of EndoFLIP and the more frequent need for follow-up testing, which often includes HRM. However, the cost of EndoFLIP, particularly when normal during the initial EGD, may be justified as patient comfort and tolerability are critical unmeasured components of patient care.