Evidence-Based Medicine
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Sep 14, 2016; 22(34): 7813-7823
Published online Sep 14, 2016. doi: 10.3748/wjg.v22.i34.7813
Cost effectiveness of routine duodenal biopsies in iron deficiency anemia
Efrat Broide, Shay Matalon, Ofra Kriger-Sharabi, Vered Richter, Haim Shirin, Moshe Leshno
Efrat Broide, Shay Matalon, Ofra Kriger-Sharabi, Vered Richter, Haim Shirin, The Kamila Gonczarowski Institute of Gastroenterology, Assaf Harofeh Medical Center, Zerifin 70300, Israel
Moshe Leshno, Faculty of Business Administration, Tel-Aviv University, Tel-Aviv 39040, Israel
Author contributions: Broide E and Matalon S contributed equally to this work; Broide E is the guarantor of article; Leshno M, Broide E and Matalon S performed the research, collected and analyzed the data; Shirin H and Leshno M designed the research study; Broide E, Matalon S, Richter V and Kriger-Sharabi O wrote the paper; Matalon S, Richter V and Kriger-Sharabi O contributed to the design of the study.
Conflict-of-interest statement: No potential conflicts of interest relevant to this article were reported.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Efrat Broide, MD, Professor of Pediatrics Gastroenterology, The Kamila Gonczarowski Institute of Gastroenterology, Assaf Harofeh Medical Center, Beer Ya'akov, Zerifin 70300, Israel. efibroide@yahoo.com
Telephone: +972-54419077 Fax: +972-89779727
Received: May 5, 2016
Peer-review started: May 6, 2016
First decision: June 20, 2016
Revised: July 11, 2016
Accepted: July 31, 2016
Article in press: August 1, 2016
Published online: September 14, 2016
Processing time: 125 Days and 11.9 Hours
Abstract
AIM

To investigate the cost effectiveness of routine small bowel biopsies (SBBs) in patients with iron deficiency anemia (IDA) independent of their celiac disease (CD) serology test results.

METHODS

We used a state transition Markov model. Two strategies were compared: routine SBBs during esophagogastroduodenoscopy (EGD) in all patients with IDA regardless their celiac serology status (strategy A) vs SBBs only in IDA patients with positive serology (strategy B). The main outcomes were quality adjusted life years (QALY), average cost and the incremental cost effectiveness ratio (ICER). One way sensitivity analysis was performed on all variables and two way sensitivity analysis on selected variables were done. In order to validate the results, a Monte Carlo simulation of 100 sample trials with 10, and an acceptability curve were performed.

RESULTS

Strategy A of routine SBBs yielded 19.888 QALYs with a cost of $218.10 compared to 19.887 QALYs and $234.17 in strategy B. In terms of cost-effectiveness, strategy A was the dominant strategy, as long as the cost of SBBs stayed less than $67. In addition, the ICER of strategy A was preferable, providing the cost of biopsy stays under $77. Monte Carlo simulation demonstrated that strategy A yielded the same QALY but with lower costs than strategy B.

CONCLUSION

Our model suggests that EGD with routine SBBs is a cost-effective approach with improved QALYs in patients with IDA when the prevalence of CD is 5% or greater. SBBs should be a routine screening tool for CD among patients with IDA, regardless of their celiac antibody status.

Keywords: Celiac disease; Iron deficiency anemia; Cost-effectiveness; Esophagogastroduodenoscopy; Markov model

Core tip: Common practice, and currents recommendations are to perform celiac serology tests and endoscopies to iron defeciency patients. Obtaining duodenal biopsies is usually reserved to patients with positive celiac serology. We aimed to investigate the cost effectiveness of routine duodenal biopsies in each and every patient with iron deficiency anemia, regardless serology status. We found this strategy to have a higher quality adjusted life years, a lower cost and a higher incremental cost effectiveness ratio over the common strategy of selected duodenal biopsies strategy.