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Valuing innovative endoscopic techniques: per-oral endoscopic myotomy for the management of achalasia
Gastrointestinal Endoscopy ( IF 6.7 ) Pub Date : 2018-04-21 , DOI: 10.1016/j.gie.2018.04.2341
Eric D. Shah , Andrew C. Chang , Ryan Law

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 1 year of follow-up (0.91 QALY). Maximum cost-effective reimbursement for POEM was $8033.37 to $8223.14, including all professional and facility fees. This compares favorably with contemporary total reimbursement of 10 to 15 total relative value units for advanced endoscopic procedures. Rates of postprocedural GERD did not affect the preference for POEM compared with LHM, assuming at least 10% cost savings with POEM compared with LHM in cost-minimization analysis, or at least 44% cost savings in cost-effectiveness analysis (WTP = $100,000/QALY). LHM was only preferred over POEM if both procedures were reimbursed similarly, and these findings were primarily driven by lower rates of postprocedural GERD. 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.

Discussion

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:

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

我们构建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1年中(0.91 QALY)相似。POEM的最高成本效益补偿额为$ 8033.37至$ 8223.14,包括所有专业和设施费用。这与先进的内窥镜检查程序的总总相对价值单位为10到15的当代总报销相比具有优势。与LHM相比,术后GERD率没有影响POEM的偏好,假设在成本最小化分析中与LHM相比,POEM节省至少10%的成本,或在成本效益分析中节省至少44%的成本(WTP = $ 100,000 / QALY)。如果两种方法的报销类似,LHM仅比POEM更可取,并且这些发现主要是由于术后GERD发生率降低所致。

讨论

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。

更新日期:2018-04-21
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