Double-Balloon Enteroscopy Cost-Effective for Obscure GI Bleeding

STANFORD, Calif., Nov. 26 -- For patients with difficult-to-detect gastrointestinal bleeding, an initial double-balloon enteroscopy is a cost-effective approach for diagnosis and treatment, researchers here said.

Compared with four other treatment modalities and no treatment, the procedure was associated with the greatest gain in number of quality-adjusted life years, Lauren Gerson, M.D., and Ahmad Kamal, M.D., of Stanford University, reported in the November issue of Gastrointestinal Endoscopy.

Over one year, the bleeding cessation rate was 86.5% with double-balloon enteroscopy, 76% for small-bowel capsule endoscopy -- the procedure most commonly used -- and 59% with no therapy.

The other modalities studied -- push enteroscopy, intraoperative enteroscopy, and angiography -- were all less effective than double-balloon enteroscopy.

Not only was double-balloon enteroscopy more effective and less expensive than small-bowel capsule endoscopy, the researchers said, it can also deliver treatment in the same procedure.

"Capsule-directed double-balloon enteroscopy may be associated with better long-term outcomes because of the potential for fewer complications and decreased utilization of endoscopic resources," the researchers said

In about 5% of patients with GI bleeding, the source is difficult to identify. Most of them will eventually be diagnosed with a small-bowel source, according to the researchers.

Capsule endoscopy has disadvantages for management of obscure GI bleeds, they said, including the lack of therapeutic potential, the possibility of missed lesions, and a limited field of view.

Double-balloon endoscopy, introduced in the U.S. in 2004, allows for visualization of the entire small intestine and can be performed in an endoscopy suite.

Using decision analysis software, the researchers evaluated the cost-effectiveness of various modalities to diagnose the problem in a hypothetical 50-year-old patient with obscure GI bleeding.

The patient had a prior endoscopic examination and required about two units of packed red blood cells per month for six months because of ongoing bleeding.

The researchers calculated total costs and quality-adjusted life years over a one-year time period.

The model was constructed using data from the scientific literature on small-bowel lesions and endoscopic procedures and information on Medicare payments.

Not surprisingly, the no-therapy approach was the least expensive, costing $532, but it was also the least effective, yielding 0.870 quality-adjusted life years per year.

Double-balloon enteroscopy was the most effective, garnering 0.956 quality-adjusted life years per year, but it was also more expensive, costing $2,407.

The other procedures were all less effective than double-balloon enteroscopy and more expensive (except for push enteroscopy at $1,025 per patient).

Compared with no therapy, the procedure resulted in an incremental cost-effectiveness ratio of $20,833 per quality-adjusted life year gained.

Values less than $50,000 indicate a procedure that is worth the health investment, the researchers said.

Although the procedure is cost-effective, a capsule endoscopy may still be the preferred initial option, the researchers said.

In a hypothetical cohort of 1,000 patients receiving an initial double-balloon enteroscopy, 130 would require a second procedure.

In comparison, in a hypothetical cohort of 1,000 patients receiving an initial capsule endoscopy, 237 would require at least one double-balloon endoscopy, and 47 would require a second.

"Therefore," the researchers said, "an initial capsule endoscopy was associated with a decreased double-balloon endoscopy workload and potential for endoscopic complications, since only patients with ongoing bleeding would undergo subsequent double-balloon enteroscopy examination."

The authors acknowledged some limitations of the study, including the short one-year time horizon of the model. The model was limited to this length because long-term data about the natural history of re-bleeding from small-intestine lesions are lacking.

Also, they said, assumptions in the model were based on data from clinical trials with small numbers of patients, the prevalence of small-bowel lesions is likely to vary depending on the age of the patient, little information is available about quality of life with GI bleeding, and indirect costs were not calculated.

They also pointed out the current lack of availability of double-balloon enteroscopy in most centers and a significantly increased endoscopy workload and potentially a higher rate of endoscopic complications.

Dr. Gerson has received research support, equipment, and honorarium from Fujinon and honorarium from Given Imaging.

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