Background and Aims

Unclear reimbursement for new and innovative endoscopic procedures can limit adoption in clinical practice despite effectiveness in clinical trials. The aim of this study was to determine maximum cost-effective reimbursement for per-oral endoscopic myotomy (POEM) in treating achalasia.

Methods

We constructed a decision analytic model assessing POEM versus laparoscopic Heller myotomy with Dor fundoplication (LHM) in managing achalasia from a payer perspective over a 1-year time horizon. Reimbursement data were derived from 2017 Medicare data. Responder rates were based on clinically meaningful improvement in validated Eckardt scores. Validated health utility values were assigned to terminal health states based on data previously derived with a standard gamble technique. Contemporary willingness-to-pay (WTP) levels per quality-adjusted life year (QALY) were used to estimate maximum reimbursement for POEM using threshold analysis.

Results

Effectiveness of POEM and LHM was similar at one year of follow-up (0.91 QALY). Maximum cost-effective reimbursement for POEM was $1,200.07 to $1,389.85 (33.4-38.7 total 2017 RVUs). This compares to contemporary total reimbursement of 10-15 total RVU for advanced endoscopic procedures. The model was most sensitive to the probability of GERD after procedure. The rate of conversion to open laparotomy due to perforation or bleeding was infrequent in published clinical practice experience, thus did not significantly affect reimbursement.

Conclusion

POEM is an example of an innovative and potentially disruptive endoscopic technique offering greater cost-effective value and similar outcomes to the established surgical standard at contemporary reimbursement levels.

中文翻译：

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重视创新的内镜技术：经口内镜下肌切开术治疗门失弛缓症

背景和目标

尽管临床试验有效，但对新的和创新的内窥镜手术的报销不清楚会限制其在临床实践中的采用。这项研究的目的是确定经口内镜下肌切开术（POEM）治疗门失弛缓症的最大成本效益补偿。

方法

我们建立了一个决策分析模型，从付款人的角度出发，在1年的时间范围内评估POEM与腹腔镜Heller子宫切开术与Dor胃底折叠术（LHM）在管理门失弛缓症中的关系。报销数据来自2017年Medicare数据。响应者比率基于经过验证的Eckardt分数的临床意义上的改善。根据以前使用标准赌博技术得出的数据，将经过验证的健康效用值分配给终端健康状态。每个质量调整生命年（QALY）的当代支付意愿（WTP）水平用于使用阈值分析来估计POEM的最大报销。

结果

POEM和LHM的有效性在随访的一年中相似（0.91 QALY）。POEM的最高成本效益补偿为1,200.07美元至1,389.85美元（2017年RVU总数为33.4-38.7）。与此相比，先进的内窥镜检查程序目前的总偿还额为10-15 RVU。该模型对手术后发生GERD的可能性最敏感。在公开的临床实践经验中，由于穿孔或出血而导致开腹剖腹手术的转换率很低，因此对报销没有明显影响。

结论

POEM是一种创新且具有潜在破坏性的内窥镜技术的示例，在现代报销水平上，它具有更高的性价比，并且与既定的手术标准具有相似的结果。