Abstract
Introduction
Published reports have demonstrated that many Barrett’s esophagus patients are over-diagnosed as low-grade dysplasia (BE-LGD). We performed an analysis of the surveillance and treatment costs associated with the over-diagnosis of BE-LGD.
Methods
As the principal cost variables, we used endoscopic and histologic procedures performed during the recommended surveillance intervals for patients with BE-LGD, the national average Medicare reimbursement for the Current Procedural Terminology codes of the procedures performed, and a spreadsheet-based tool we created to determine the overall healthcare cost associated with the over-diagnosis of BE-LGD in the US population.
Results
The average excess cost (range) for every patient in the US who is over-diagnosed with BE-LGD is estimated to be $5557 ($3115 to $8072). The principal contributors to the excess cost of over-diagnosis of BE-LGD in these patients are: endoscopy ($2626 to $4639), pathologist biopsy review ($275 to $2185), and esophagogastroduodenoscopy-guided endoscopic ablation ($214 to $1249).
Conclusions
The healthcare cost of over-diagnosis of BE-LGD is significant. To reduce the overall healthcare cost impact of over-diagnosis of BE-LGD, strict adherence to the recommendations of the American Gastroenterological Association, American College of Gastroenterology, and American Society for Gastrointestinal Endoscopy that pathology review of all BE biopsy specimens be performed by a gastrointestinal pathologist is warranted.
Similar content being viewed by others
References
Organisation for Economic Co-operation and Development (OECD) website. http://www.oecd.org/els/health-systems/oecd-health-statistics-2014-frequently-requested-data.htm. Accessed Sept 2, 2014.
Brody H. Medicine’s ethical responsibility for health care reform—the top five list. N Engl J Med. 2010;362:283–5.
Welch G, Schwartz L, Woloshin S. Overdiagnosed: making people sick in the pursuit of health. Boston: Beacon Press; 2010. p. 180.
Weber LJ. The ethics of cost control: wasteful treatments undermine health care for all. Health Prog. 2011;92:68–74.
Booth CL, Thompson KS. Barrett’s esophagus: a review of diagnostic criteria, clinical surveillance practices and new developments. J Gastrointest Oncol. 2012;3:232–42.
Odze RD. Diagnosis and grading of dysplasia in Barrett’s oesophagus. J Clin Pathol. 2006;59:1029–38.
Montgomery E. Update on grading dysplasia in Barrett’s esophagus. Pathol Case Rev. 2002;7:35–42.
Corley DA, Kubo A, DeBoer J, et al. Diagnosing Barrett’s esophagus: reliability of clinical and pathologic diagnoses. Gastrointest Endosc. 2009;69:1004–10.
Curvers WL, Bohmer CJ, Mallant-Hent RC, et al. Mucosal morphology in Barrett’s esophagus: interobserver agreement and role of narrow band imaging. Endoscopy. 2008;40:799–805.
Montgomery E. Is there a way for pathologists to decrease interobserver variability in the diagnosis of dysplasia? Arch Pathol Lab Med. 2005;129:174–5.
Rex DK, Cummings OW, Shaw M, et al. Screening for Barrett’s esophagus in colonoscopy patients with and without heartburn. Gastroenterology. 2003;125:1670–7.
Gerson LB, Shetler K, Triadafilopoulus G. Prevalence of Barrett’s esophagus in asymptomatic individuals. Gastroenterology. 2002;123:1461–7.
Cameron AJ, Zinsmeister AR, Ballard DJ, et al. Prevalence of columnar-lined (Barrett’s) esophagus: comparison of population based clinical and autopsy findings. Gastroenterology. 1990;99:918–22.
Hayeck TJ, Kong CY, Spechler SJ, et al. The prevalence of Barrett’s esophagus in the US: estimated from a simulation model confirmed by SEER data. Dis Esophagus. 2010;23:451–7.
Fock KM, Ang TL. Global epidemiology of Barrett’s esophagus. Expert Rev Gastroenterol Hepatol. 2011;5:123–30.
Feig SA. Pitfalls in accurate estimation of overdiagnosis: implications for screening policy and compliance. Breast Cancer Res. 2013;15:105.
Bhardwaj A, Stairs DB, Mani H, et al. Barrett’s esophagus: emerging knowledge and management strategies. Pathol Res Int. 2012;2012:1–20.
US Census Bureau website: http://www.census.gov/popclock/. Accessed Sept 2, 2014.
Grotenhuis BA, van Heijl M, ten Kate FJW, et al. Inter- and intraobserver variation in the histopathological evaluation of oesophageal adenocarcinoma. J Clin Pathol. 2010;63:978–81.
Kerkhof M, van Dekken H, Steyerberg EW, et al. Grading of dysplasia in Barrett’s oesophagus: substantial interobserver variation between general and gastrointestinal pathologists. Histopathology. 2007;50:920–7.
Sharma P. Low-grade dysplasia in Barrett’s esophagus. Gastroenterology. 2004;127:1233–8.
Spechler SJ. Barrett’s esophagus. New Engl J Med. 2002;346:836–42.
Montgomery E, Bronner MP, Goldblum JR, et al. Reproducibility of the diagnosis of dysplasia in Barrett esophagus: a reaffirmation. Hum Pathol. 2001;32:368–78.
Reid BJ, Haggitt RC, Rubin CE, et al. Observer variation in the diagnosis of dysplasia in Barrett’s esophagus. Hum Pathol. 1988;19:166–78.
Silva FB, Dinis-Ribeiro M, Vieth M, et al. Endoscopic assessment and grading of Barrett’s esophagus using magnification endoscopy and narrow-band imaging: accuracy and interobserver agreement of different classification systems (with videos). Gastrointest Endosc. 2011;73:7–14.
Spechler SJ, Sharma P, Souza RF, et al. American Gastroenterological Association medical position statement on the management of Barrett’s esophagus. Gastroenterology. 2011;140:1084–91.
Wang KK, Sampliner RE. Updated guidelines 2008 for the diagnosis, surveillance, and therapy of Barrett’s esophagus. Am J Gastroenterol. 2008;103:788–97.
ASGE Standards of Practice Committee, Evans JA, Early DS, et al. ASGE guideline: the role of endoscopy in Barrett’s esophagus and other premalignant conditions of the esophagus. Gastrointest Endosc. 2012;76:1087–94.
Curvers WL, ten Kate FJ, Krishnadath KK, et al. Low-grade dysplasia in Barrett’s esophagus: overdiagnosed and underestimated. Am J Gastroenterol. 2010;105:1523–30.
Sharma P, Falk GW, Weston AP, et al. Dysplasia and cancer in a large multicenter cohort of patients with Barrett’s esophagus. Clin Gastroenterol Hepatol. 2008;4:566–72.
CMS Physician Fee Schedule Search Tool website: https://www.cms.gov/apps/physician-fee-schedule/overview.aspx. Accessed Jul 14, 2015.
Level I Healthcare Common Procedure Coding System (HCPCS) website. https://www.cms.gov/apps/physician-fee-schedule/overview.aspx. Accessed Jul 14, 2015.
Duits LC, Phoa N, Curvers WL, et al. Barrett’s oesophagus patients with low-grade dysplasia can be accurately risk-stratified after histological review by an expert pathology panel. Gut. 2015;64:700–6.
Wu X, Ajani JA, Gu J, et al. MicroRNA expression signatures during malignant progression from Barrett’s esophagus to esophageal adenocarcinoma. Cancer Prev Res. 2013;6:196–205.
Ong CA, Lao-Sirieix P, Fitzgerald RC. Biomarkers in Barrett’s esophagus and esophageal adenocarcinoma: predictors of progression and prognosis. World J Gastroenterol. 2010;16:5669–81.
Tischoff I, Tannapfel A. Barrett’s esophagus: can biomarkers predict progression to malignancy? Expert Rev Gastroenterol Hepatol. 2008;2:653–63.
Baak JPA, ten Kate FJW, Offerhaus GJA, et al. Routine morphometrical analysis can improve reproducibility of dysplasia grade in Barrett’s oesophagus surveillance biopsies. J Clin Pathol. 2002;55:910–6.
Ireland AP, Clark GWB, DeMeester TR. Barrett’s esophagus. The significance of p53 in clinical practice. Ann Surg. 1997;225:17–30.
Shi XY, Bhagwandeen B, Leong AS. P16, cyclin D1, Ki-67, and AMACR as markers for dysplasia Barrett esophagus. Appl Immunohistochem Mol Morphol. 2008;16:447–52.
Trimmer MR, Gun G, Gorospe EC, et al. Predictive biomarkers for Barrett’s esophagus: so near and yet so far. Dis Esophagus. 2013;26:574–81.
Acknowledgments
No funding or sponsorship was received for this study or publication of this article. The authors would like to acknowledge Suzanne Ridner for her editorial assistance. All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval for the version to be published.
Disclosures
Richard Lash MD is an employee of Miraca Life Sciences, a subspecialty pathology services company which may benefit from data that demonstrates cost savings for patients who receive subspecialty care. Frank Wians PhD was compensated for time spent designing the Excel spreadsheet, the “Healthcare Cost Impact Calculator.” Thomas Deas MD has nothing to disclose.
Compliance with Ethics Guidelines
This article does not contain any new studies with human or animal subjects performed by any of the authors.
Author information
Authors and Affiliations
Corresponding author
Additional information
Enhanced content To view enhanced content for this article go to http://www.medengine.com/Redeem/7844F0601CC7FA4E.
Rights and permissions
About this article
Cite this article
Lash, R.H., Deas, T.M. & Wians, F.H. Healthcare Cost of Over-Diagnosis of Low-Grade Dysplasia in Barrett’s Esophagus. Adv Ther 33, 684–697 (2016). https://doi.org/10.1007/s12325-016-0308-7
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12325-016-0308-7