Antithrombotic Agents and Bleeding Risk After Endoscopic Submucosal Dissection in Patients With Gastric Neoplasms: A Meta-Analysis

Background: Recently published data from a European randomized trial (SURF) showed that radiofrequency ablation (RFA) for Barrett's esophagus (BE) with confirmed low-grade dysplasia (LGD) significantly reduced the risk of progression to high-grade dysplasia and esophageal adenocarcinoma with 25%.Ablation for BE-LGD may therefore be of clinical utility if the risk of neoplastic progression is reduced at an acceptable cost profile.Modeling studies have previously suggested that RFA might be a cost-effective management strategy for confirmed and stable BE-LGD, but these studies were limited by the available data on the natural history of BE-LGD.This is the first trial-based cost-effectiveness analysis of ablation versus endoscopic surveillance in the management of BE patients with a confirmed diagnosis of LGD.Methods: This cost-effectiveness analysis was built from the trial data from randomization to end of follow-up (median 36 months, IQR 30-36), and was developed from a Dutch hospital perspective.Radiofrequency ablation and endoscopic surveillance were performed according to current international guidelines for the management of BE patients.Direct medical costs generated during the treatment (including management of complications) and follow-up period of the trial, and the direct medical costs related to endoscopic or surgical management of neoplastic progression, were estimated using hospital unit costs or Dutch reference costs for health care research.95% confidence intervals of generated costs in each group were constructed using 1000 bootstrap samples.Incremental cost-effectiveness ratios were defined as the costs of ablation to prevent one case of neoplastic progression.Results: Neoplastic progression occurred in 1/68 patients in ablation vs. 18/68 patients in surveillance (p<0.001).Mean total costs per patient during the trial (until the primary endpoint of progression was reached) were €10,464 (95%CI: 9,469-11,399) for ablation and €1902 (95%CI: 1,722-2,068) for surveillance.For subsequent treatment of progression mean total costs per patient were €16 (95%CI: 0-33) for ablation and € 2208 (95%CI: 1,399-3,163) for surveillance.To prevent one case of progression the amount to pay for ablation is €504 based on trial costs.When taking into account the additional costs for treatment of progression, the net costs per prevented case of progression reduces to €375 for ablation.The main cost drivers were therapeutic endoscopies and esophagectomy.Conclusions: Based on data from a randomized controlled trial, the costs of ablation treatment were only marginally higher than for endoscopic surveillance in preventing one case of neoplastic progression among BE patients with confirmed low-grade dysplasia.Implementation of ablation as the first management strategy for confirmed BE-LGD may therefore be acceptable from a provider perspective.