Heidi J Miller, MD, MPH, Ruel Neupane, BS, Mojtaba Fayezizadeh, MD, Arnab Majumder, MD, Jeffrey M Marks, MD, FACS, FASGE. UH Case Medical Center
Peroral Endoscopic Myotomy (POEM) is a safe and effective treatment for achalasia with few contraindications and the added benefit of an endoscopic, minimally invasive approach. Alternative treatments include Laparoscopic Heller Myotomy (LHM) along with endoscopic treatments including Pneumatic Dilation (PD) and onabotulinumtoxina injections (BI). We evaluate the economics and cost-effectiveness of treating achalasia.
We performed an analysis of charges for POEM, LHM, PD and BI performed at our institution from 2011-2013. The Consumer Price Index inflation calculator was used to bring charges equivalent to 2015 USD. Cost-effectiveness was calculated based on institutional charges, number of interventions required for best results for dilations and injections, and efficacy reported in current literature. Incremental cost effectiveness ratio (ICER) was calculated by a cost-utility analysis using quality-adjusted life year (QALY) gained, defined as a symptom-free year in a patient with achalasia.
The average number of interventions required is 2.3 dilations or 2 injections for efficacies of 80% and 61% respectively, with charges of $12,427 for PD and $12,440 for BI. Charges were $38,552 for LHM and $40,585 for POEM with efficacies of 90%. Annual cost per cure over a period of three years for POEM, BI and PD are $15,032, $51,834 and $4,931 respectively. PD remains cost-effective over the course of 5 years when compared to POEM, however these calculations do not account for the cost of complications or secondary procedures required due to failure of pneumatic dilations. POEM becomes more cost-effective than BI at 2 years. ICER ($/QALY) for POEM vs BI is $24,264 at 2 years, $11,442 at 3 years and $7906 at 4 years. An accepted benchmark for the value of care is $50,000 per QALY, therefore at year two, POEM has reached incremental cost effectiveness based on quality adjusted life years over BI.
POEM clearly becomes more cost-effective than BI after 2 years post procedure due to high failure rates of the relatively economical BI intervention. There are additional costs after BI and PD as the majority of patients will require either LHM or POEM within 2 years of BI and PD. Therefore these should be reserved for patients who are unable to tolerate general anesthesia or have life expectancy less than 3 years. From an economic standpoint, POEM should be considered equivalent to LHM and superior to BI or PD as standard treatment for achalasia.