Inflammatory Bowel Disease
Subject Category: Inflammatory Bowel Disease
Am J Gastroenterol 2009; 104:2222–2232; doi:10.1038/ajg.2009.264; published online 2 June 2009
Cost Effectiveness of Ulcerative Colitis Surveillance in the Setting of 5-Aminosalicylates
Joel H Rubenstein MD, MSc1,2, Akbar K Waljee MD1, Joanne M Jeter MD, MSc3, Fernando S Velayos MD4, Uri Ladabaum MD, MSc4 and Peter D R Higgins MD, PhD, MSc1
- 1The Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Michigan, USA
- 2Department of Internal Medicine, Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan, USA
- 3Division of Hematology-Oncology, Department of Internal Medicine, Arizona Cancer Center, University of Arizona College of Medicine, Tucson, Arizona, USA
- 4Division of Gastroenterology, Department of Internal Medicine, University of California San Francisco Medical School, San Francisco, California, USA
Correspondence: Joel H. Rubenstein, MD, MSc, VA Medical Center (111-D), 2215 Fuller Road, Ann Arbor, Michigan 48105, USA. E-mail: jhr@umich.edu
Received 31 October 2008; Accepted 26 March 2009; Published online 2 June 2009.
Abstract
OBJECTIVES:
Colorectal cancer (CRC) is a feared complication of chronic ulcerative colitis (UC). Annual endoscopic surveillance is recommended for the detection of early neoplasia. 5-Aminosalicylates (5-ASAs) may prevent some UC-associated CRC. Therefore, in patients prescribed 5-ASAs for maintenance of remission, annual surveillance might be overly burdensome and inefficient. We aimed to determine the ideal frequency of surveillance in patients with UC maintained on 5-ASAs.
METHODS:
We performed systematic reviews of the literature, and created a Markov computer model simulating a cohort of 35-year-old men with chronic UC, followed until the age of 90 years. Twenty-two strategies were modeled: natural history (no 5-ASA or surveillance), surveillance without 5-ASA at intervals of 1–10 years, 5-ASA plus surveillance every 1–10 years, and 5-ASA alone. The primary outcome was the ideal interval of surveillance in the setting of 5-ASA maintenance, assuming a third-party payer was willing to pay $100,000 for each quality-adjusted life-year (QALY) gained.
RESULTS:
In the natural history strategy, the CRC incidence was 30%. Without 5-ASA, annual surveillance was the ideal strategy, preventing 89% of CRC and costing $69,100 per QALY gained compared with surveillance every 2 years. 5-ASA alone prevented 49% of CRC. In the setting of 5-ASA, surveillance every 3 years was ideal, preventing 87% of CRC. 5-ASA with surveillance every 2 years cost an additional $147,500 per QALY gained, and 5-ASA with annual surveillance cost nearly $1 million additional per QALY gained compared with every 2 years. In Monte Carlo simulations, surveillance every 2 years or less often was ideal in 95% of simulations.
CONCLUSIONS:
If 5-ASA is efficacious chemoprevention for UC-associated CRC, endoscopic surveillance might be safely performed every 2 years or less often. Such practice could decrease burdens to patients and on endoscopic resources with a minimal decrease in quality-adjusted length of life, because 5-ASA with annual surveillance may cost nearly $1 million per additional QALY gained.
