A cost-minimization analysis of alternative treatment strategies for achalasia.

Abstract

The aim of this study is to compare the costs per cure of alternative strategies for the treatment of achalasia. A cost-minimization model compared three strategies for otherwise healthy adults of any age with achalasia: 1) laparoscopic Heller myotomy with fundoplication (LHM); 2) pneumatic dilation (PD), with LHM reserved for treatment failures; 3) botulinum toxin (Botox) injection of the lower esophageal sphincter, with PD reserved for treatment failures. Probabilities of short- and long-term efficacy, treatment failure, symptomatic recurrence rates, and complications were derived from the published literature. Only direct costs were considered during the 5-yr time horizon. Respective reference case costs per cure of PD, Botox, and LHM strategies were $3,111, $3,723, and $10,792. Despite short- and long-term efficacy of 96% and 94%, respectively, the LHM strategy was most costly. Initial PD remained less costly than initial Botox, provided that rates of PD efficacy and perforation were > or = 70% and < 9.5%, respectively, and cost of a Botox session was > or = $450. The results were not sensitive to the probabilities of short- and long-term response to Botox, recurrence after PD, LHM efficacy, and post-LHM gastroesophageal reflux disease, nor to the costs of LHM and PD. For otherwise healthy patients with achalasia, initial PD is the least costly strategy provided that the PD perforation rate remains < 10%. Initial Botox is less costly only when nonendoscopic-related costs decrease by 25%. Initial LHM is the most costly strategy under all clinically plausible scenarios. Subsequent analyses should include a longer time horizon and an assessment of patient ference for each strategy.