13.5GRADE table of ablative cost effectiveness studies

StudyPopulationComparatorsCosts (£)QALYSIncremental QALYSIncremental costsICER (incremental)UncertaintyLimitationsApplicability
A Das et al 2009Non dysplastic Barrett’s oesophagus, 50 year old malesNatural history (no surveillance)1898.5117.959ReferenceUnder a willingness to pay threshold of £39360 no surveillance is most cost effective treatment option. At thresholds greater than £60,000 ablation is most cost effective.Potentially serious limitationsNot applicable
Endoscopic (surveillance)8538.518.0760.117664056700.7
Ablate (HALO ablation system) (surveillance)14378.918.2590.312480.441600.9 ( 31898.7)
Comments: US based study. Did not include patients with dysplasia, EMR and surgery were not considered as comparators, 3% discount rate used for costs. Estimates for efficacy are not based on a systematic review of the data.
Inadomi et al 2009Patients with Barrett’s oesophagus, with low grade dysplasia (LGD) and high grade dysplasia (HGD). Only HGD results reportedNatural history (no surveillance)1219.512.43ReferenceAblation is preferred option at WTP thresholds over £32800. Under £19680 no surveillance is preferred.Very serious limitationsNot applicable
RFA with surveillance13629.115.673.2412409.63830.4
APC with surveillance14508.815.623.1913289.2dominated
PDT with surveillance22684.515.673.241490521377826.4
Endoscopic (surveillance)31720.214.822.3930500.7dominated
Comments: US based study; certain clinical parameters were calculated by pooling data from a number of studies and weighting by sample size. EMR not included.
Pohl H et al 200965-year old men with early Barrett’s oesophagus carcinoma,Endoscopic therapy11419.74.88ReferenceDeterministic sensitivity analysis undertaken surgery is only preferred when percentage of dysphagia after endoscopic treatment is over 74% or is lymph node invasion percentage is over 69%Very serious limitationsNot applicable
Surgical resection18256.54.59−0.2968396.6dominated
Comments: US study, does not include ablation, time horizon too short (5 years)
Comay D, et al 200750 year old men with Barrett’s oesophagus and newly diagnosed HGD,Endoscopic surveillance1168811.85ReferencePDT had highest prob. of being cost effective for WTP threshold over £656/QALY and a prob. 0.99 at £16400/QALY.Potentially serious limitationsNot applicable
Comments: Canadian based study, 5 year time horizon is insufficient for life time condition and QALY estimates are counter intuitive for example 15.85 QALYs over 5 years.
Shaheen et al 200450 year-old males with HGDNo surveillance490.713.90ReferenceAblative therapy had a 95% chance of being cost effective at under £32800 WTP.Potentially serious limitationsNot applicable
Endoscopic surveillance22778.914.961.0622288.321026.8 (extended dominated)
Comments: US based study, EMR not included, 3% discount rate used for costs, unclear from paper how parameters were chosen.
Chin Hur et al 200355 year old HGD patientsSurveillance18236.89.96ReferenceIf long term utility after PDT lower than post-surgery utility surveillance was preferred option.Very serious limitationsNot applicable
Comments: US based study. EMR not included. 3% and 30% discount rates mentioned in paper. No systematic review for selection of parameters. Utilities elicited from patients using visual analogue scale, which is prone to bias over a choice based instrument.
Vij et al 200455 year old males with HGDSurgery15773.511.819ReferenceSeveral deterministic analyses undertaken indicated that surgery is preferred option if operative mortality is below 2%, as it increased surveillance and PDT become more cost effective options.Very serious limitationsNot applicable
Surveillance18925.6Incorrect number reportedIncorrect number reported3152.1Extended dominated
PDT and surveillance29864.412.2430.42414090.9Extended dominated
PDT followed by surgery for HGD31028.812.3070.48815255.331101
Comments: US based study. EMR not included. 3% discount rate for costs. Estimates for health outcomes were derived from random effects model, considered inappropriate due to quality of data.
Ragunath et al 200413 patients with Barrett’s oesophagus, LGD and HGDArgon plasma coagulation,NoneNoneNoneNoneNoneNoneVery serious limitationsNot applicable
Comments: No appropriate comparators, no incremental analysis. No health related quality of life considerations.

Converted to UK pounds from US dollars using a PPP exchange rate of 0.656 (www​.oecd.org/std/ppp)

From: Appendix 6, Cost effectiveness analysis for Barrett’s oesophagus

Cover of Barrett’s Oesophagus
Barrett’s Oesophagus: Ablative Therapy for the Treatment of Barrett’s Oesophagus.
NICE Clinical Guidelines, No. 106.
Centre for Clinical Practice at NICE (UK).
Copyright © 2010, National Institute for Health and Clinical Excellence.

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