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World J Gastroenterol. 2016 Sep 14;22(34):7813-23. doi: 10.3748/wjg.v22.i34.7813.

Cost effectiveness of routine duodenal biopsies in iron deficiency anemia.

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Efrat Broide, Shay Matalon, Ofra Kriger-Sharabi, Vered Richter, Haim Shirin, The Kamila Gonczarowski Institute of Gastroenterology, Assaf Harofeh Medical Center, Zerifin 70300, Israel.



To investigate the cost effectiveness of routine small bowel biopsies (SBBs) in patients with iron deficiency anemia (IDA) independent of their celiac disease (CD) serology test results.


We used a state transition Markov model. Two strategies were compared: routine SBBs during esophagogastroduodenoscopy (EGD) in all patients with IDA regardless their celiac serology status (strategy A) vs SBBs only in IDA patients with positive serology (strategy B). The main outcomes were quality adjusted life years (QALY), average cost and the incremental cost effectiveness ratio (ICER). One way sensitivity analysis was performed on all variables and two way sensitivity analysis on selected variables were done. In order to validate the results, a Monte Carlo simulation of 100 sample trials with 10, and an acceptability curve were performed.


Strategy A of routine SBBs yielded 19.888 QALYs with a cost of $218.10 compared to 19.887 QALYs and $234.17 in strategy B. In terms of cost-effectiveness, strategy A was the dominant strategy, as long as the cost of SBBs stayed less than $67. In addition, the ICER of strategy A was preferable, providing the cost of biopsy stays under $77. Monte Carlo simulation demonstrated that strategy A yielded the same QALY but with lower costs than strategy B.


Our model suggests that EGD with routine SBBs is a cost-effective approach with improved QALYs in patients with IDA when the prevalence of CD is 5% or greater. SBBs should be a routine screening tool for CD among patients with IDA, regardless of their celiac antibody status.


Celiac disease; Cost-effectiveness; Esophagogastroduodenoscopy; Iron deficiency anemia; Markov model

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