Critique of the Economic Study by Inadomi et al.
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Critique of the Economic Study by Inadomi et al.  From the Appendix 2 of Xie et al. 2009 The authors systematic

Critique of the Economic Study by Inadomi et al.

 From the Appendix 2 of Xie et al. 2009

The authors systematically reviewed the literature on the efficacy of different types of ablation technologies for eradication of metaplasia and dysplasia among BE patients. A complex Markov decision analysis model was created to examine 6 different treatment strategies for 50 year old BE patients(e.g. no intervention, surveillance alone, RFA with surveillance, argon plasma coagulation (APC) ablation with surveillance, PDT ablation with surveillance, esophagectomy). The authors analyzed patients with no dysplasia, low grade dysplasia and high grade dysplasia separately.


This study has some serious limitations. For instance, the authors assumed that the effectiveness of the RFA procedure (in terms of eradication of metaplasia) was the same for patients with low grade dysplasia and high grade dysplasia. This would imply that the efficacy for high grade patients was overestimated. The authors assumed a higher mortality rates following esophagectomy (5% to 8%) than  has been reported in the literature (approximately 1% for high-grade dysplasia)20, thus favoring alternatives to the surgical approach. The follow-up time for many interventions was not more than 3 years, but the authors extrapolated results to 30 years (life-time) by making assumptions, which would potentially overestimate the effectiveness of  all treatments. The model was too complicated to obtain reliable data of transition probabilities; some strategies were uncommon in practice for high-grade patients, i.e. APC ablation and no surveillance; and qualities of life, (the full health equaling 1) sound higher than those in reality21, i.e. postesophagectomy state of 0.97 and high grade patients of 1.


But, overall, the quality of this study is good and it provides a useful insight into the cost-effectiveness of different treatments for BE. The main results of base-case analysis by Inadomi et al. for high-grade patients are summarized in Table 6. Three ablation approaches (RFA, APC and PDT) showed very similar effectiveness (15.62 to 15.67 quality-adjusted life-years(QALYs)), but PDT was associated with a significantly higher cost of 34,580 US$, RFA of 20,776 US$ and  APC of 22,117 US$, respectively.  The esophagectomy strategy was dominated by ablation therapies for its higher costs (58,973 US$) and lower effectiveness (15.02 QALYs). Compared with no intervention, ablation strategies extend around 3 QALYs, and the incremental cost effectiveness ratio (ICER) is less than 6,000 US$. Authors concluded that “endoscopic ablation could be the preferred strategy for managing patients with BE with high-grade dysplasia (HGD)”.    


Inadomi JM, Somsouk M, Madanick RD, Thomas JP, Shaheen NJ. A cost‐utility analysis of ablative therapy for Barrett's esophagus. Gastroenterology 2009;136(7):2101‐2114.


Xie X, McGregor M, Dendukuri N. Radiofrequency ablation for treatment of Barrett’s esophagus: A systematic review and cost analysis. Montreal (Canada): Technology Assessment Unit (TAU) of the McGill University Health Centre (MUHC); 2009. Report no. 46. 37p. Available from:


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