P1706 - Cost-Effectiveness of Endoscopic Balloon Dilation versus Resection Surgery for Crohn’s Disease Strictures

Kate E. Lee, BA¹, Francesca Lim, MS², Adam S. Faye, MD, MS³, Bo Shen, MD², Chin Hur, MD, MPH^2
1Columbia University College of Physicians and Surgeons, New York, NY; ²Columbia University Medical Center, New York, NY; ³New York University School of Medicine, New York, NY

Introduction: Crohn’s disease (CD) carries a major healthcare burden, costing over $10 billion a year in the United States. Strictures are a common complication of CD, emerging in over half of patients after 20 years from diagnosis, and requiring invasive interventions such as surgery which further increases healthcare costs. Endoscopic balloon dilation (EBD) has emerged as an alternative intervention in managing CD strictures. We determined the cost-effectiveness of EBD versus resection surgery for patients with short (< 4-5cm) anastomotic or primary small or large bowel strictures.

Methods: A microsimulation state-transition model simulated the benefits and risks of EBD and bowel resection surgery for patients with primary or anastomotic strictures due to CD. Our base case was a 40-year-old patient with CD who developed a stricture. Strategies included EBD or surgery as a patient’s first procedure, after which they were allowed to receive either procedure based on probabilities of subsequent intervention derived from the literature. Our primary outcome was quality-adjusted life years (QALYs) over ten years, and strategies were compared using a willingness to pay of $100,000/QALY from a societal perspective. Costs (in 2021 $US) and incremental cost-effectiveness ratios (ICER) were calculated. Deterministic 1-way and probabilistic analyses assessed model uncertainty.

Results: The EBD strategy cost $19,822 and resulted in 6.18 QALYs while the surgery strategy cost $41,358 and resulted in 6.37 QALYs. Surgery had an ICER of $113,332 per QALY, making EBD a cost-effective strategy. The median number of EBDs was 6 in the EBD strategy and 0 in the surgery strategy. The median number of surgeries was 2 in the surgery strategy and 1 in the EBD strategy. Of individuals who initially received EBD, 50.4% underwent subsequent surgery. One-way sensitivity analyses showed that the probabilities of requiring repeated interventions, surgery mortality (< 0.6%), and quality of life after interventions were the most influential parameters in our model. Probabilistic sensitivity analyses favored EBD in 50.9% of iterations.

Discussion: EBD, when feasible, is a cost-effective strategy for managing CD primary or anastomotic strictures. Sensitivity analyses show that differences in patient risk and quality of life after intervention can impact cost-effectiveness. The decision between EBD or surgery should be made considering cost-effectiveness, patient risks, and quality of life preferences.


Figure: Figure. Tornado diagram showing main drivers (variables and sensitivity ranges) of the incremental cost-effectiveness ratio (ICER).
* Values represent threshold values that reduce the ICER to < $100,000/QALY.
Abbreviations: EBD (Endoscopic Balloon Dilation), CD (Crohn's Disease), ICER (Incremental Cost-Effectiveness Ratio), WTP (Willingness To Pay)

	Cost ($)	Incremental cost ($)	Effectiveness (QALY)	Incremental effectiveness	ICER ($/QALY)
Endoscopic Balloon Dilation	19,822		6.18
Resection Surgery	41,358	21,535	6.37	19 QALYs per 100 persons	113,332.35

Table: Table 2. Base case cost-effectiveness analysis results.
Abbreviations: QALY (Quality-Adjusted Life Years), ICER (Incremental Cost-Effectiveness Ratio)


Disclosures:
Kate Lee indicated no relevant financial relationships.
Francesca Lim indicated no relevant financial relationships.
Adam Faye indicated no relevant financial relationships.
Bo Shen indicated no relevant financial relationships.
Chin Hur indicated no relevant financial relationships.


Kate E. Lee, BA¹, Francesca Lim, MS², Adam S. Faye, MD, MS³, Bo Shen, MD², Chin Hur, MD, MPH². P1706 - Cost-Effectiveness of Endoscopic Balloon Dilation versus Resection Surgery for Crohn’s Disease Strictures, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.