A Cost-Minimization Analysis of Alternative Treatment Strategies for Achalasia

Imperiale, Thomas F.; O'Connor, J. Barry; Vaezi, Michael F.; Richter, Joel E.
October 2000
American Journal of Gastroenterology;Oct2000, Vol. 95 Issue 10, p2737
Academic Journal
OBJECTIVE: The aim of this study is to compare the costs per cure of alternative strategies for the treatment of achalasia. METHODS: A cost-minimization model compared three strategies for otherwise healthy adults of any age with achalasia: I) laparoscopic Heller myotomy with fundoplication (LHM); 2) pneumatic dilation (PD), with LHM reserved for treatment failures; 3) hotulinum toxin (Botox) injection of the lower esophageal sphincter, with PD reserved for treatment failures. Probabilities of short- and long-term efficacy, treatment failure, symptomatic recurrence rates, and complications were derived from the published literature. Only direct costs were considered during the 5-yr time horizon. RESULTS: Respective reference case costs per cure of PD. Botox. and LHM strategies were $3,111. $3,723. and $10,792. Despite short- and long-term efficacy of 96% and 94%, respectively, the LHM strategy was most costly. Initial PD remained less costly than initial Botox, provided that rates of PD efficacy and perforation were ≥70% and <9.5%, respectively. and cost of a Botox session was ≥$450. The results were not sensitive to the probabilities of short- and long term response to Botox, recurrence after PD. LHM efficacy, and post-LHM gastroesophageal reflux disease, nor to the costs of LHM and PD. CONCLUSIONS: For otherwise healthy patients with achalasia. initial PD is the least costly strategy provided that the PD perforation rate remains <10%. Initial Botox is less costly only when nonendoscopic-related costs decrease by 25%. Initial LHM is the most costly strategy under all clinically plausible scenarios. Subsequent analyses should include a longer time horizon and an assessment of patient preference for each strategy.


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