Cost-effectiveness of endoscopic surveillance of gastric ulcers to improve survival

BackgroundEndoscopic surveillance of presumed-benign gastric ulcers may detect missed malignancy, but its impact on long-term outcomes is uncertain.ObjectiveTo estimate the clinical benefits and cost-effectiveness of follow-up surveillance.DesignState-transition model.SettingTo simulate the clinical course of presumed-benign gastric ulcers, we estimated prevalence and incidence of undetected gastric cancer, surveillance effectiveness, stage-specific disease mortality rates, and costs from clinical studies and databases.PatientsThis study involved 60-year-old men diagnosed with presumed-benign gastric ulcers.InterventionFollow-up endoscopic surveillance.Main Outcome MeasurementsLifetime gastric cancer risk, life expectancy, quality-adjusted life expectancy, lifetime costs, and incremental cost-effectiveness ratios.ResultsFor a cohort of 60-year-old men with presumed-benign gastric ulcers and a 2.6% prevalence of undetected malignancy, the lifetime gastric cancer risk was 4.4%. Surveillance improved (undiscounted) life expectancy by 10.0 days and increased discounted quality-adjusted life expectancy by 3.4 days at a cost of $146,700 per quality-adjusted life year (QALY). Surveillance cost less than $50,000 per QALY if the undetected gastric cancer prevalence was 6.5%, and it cost less than $100,000 per QALY if the prevalence was greater than 3.5%, endoscopy costs were 40% lower, or the disutility associated with gastric cancer was 30% lower. Probabilistic sensitivity analysis suggested that at a willingness-to-pay threshold of $100,000 per QALY, the probability that surveillance was cost effective was 25.2%.LimitationsData from multiple sources with varied study designs were used.ConclusionEndoscopic surveillance of presumed-benign gastric ulcers may improve overall survival. However, unless the prevalence of having undetected malignancy exceeds 6%, surveillance is unlikely to be cost-effective.