A cost-analysis of alternative treatment strategies for achalasia

April 1998 G0075 NEWLY DEVELOPED SMALL CALIBER COLONOSCOPY SYSTEM IS MORE USEFUL FOR BOTH PATIENTS AND DOCTORS. Y. Honsako, K. Nishida, F. Tamada, S. Hirohata*, M. Miyamoto*, Y. Konda*, N. Aoyama*. Department of Gastroenterology, Saiseikai Hyogo-ken Hospital Imperial Gift Foundation, Inc. and 2nd Dept. of Int. Med., Kobe Univ. School of Medicine*, Kobe, JAPAN Introduction: The number of patients suffering colonic cancer in Japan is increasing consistently. To detect cancer(s) in their early stage, vigorous examination utilizing colonoscope should be widely performed. We must develope new colonoscope system that can ease patient's pain and doctor's efforts. For these purpose, we newly developed small caliber thinner colonoscpe in cooperation with Olympus Opt. Co. Ltd. Tokyo, Japan. New colonoscope is longer in effective length (180 cm vs. 160 cm) and thinner in diameter (8 mm vs. 15 mm) than present model, however, it could offer the same performance as present model in endoscopic surgery. Because of its decreased resistance and friction against colonic wall, small caliber colonoscope was expected to be easy to manipulate, to give less pain to patients and to provide more time for doctors to make finer diagnosis. Small caliber colonoscope were also expected to be useful for the examination of colonic cancers with severe stenosis. Methods and Result: (1) In 22 cases with colonic adenomas, degree of pain patients felt during examination and time needed for the total procedure using small caliber colonoscope did not significantly differ from those of using present model. (2) For 10 patients who complained severe pain during former examination using present model of colonoscope, examination could reduce procedure time by 4.5 min on an average and patients felt less pain. (3) In 8 cases who could not pass through stenotic lesion because of severe diverticulitis or abdomnal adhesion due to previous surgical operation, 6 cases out of 8 could achieved totalcolonoscopy with small caliber colonoscopy system. (4) In 14 cases out of 16 advanced colonic cancer cases with severe stenosis through which present model of colonoscope could not pass, we got clear information of oral side of these obstructive lesions by small caliber colonoscopic system. Furthermore, we could detect 10 more tumoric lesions and 1 obstructive colitis in these 14 cases by using small caliber colonoscope. Conclusion: These results suggest that small caliber colonoscope is more useful than present model for the cases with severe stenosis, adhesion or diverticulitis. • G0076 A COST-ANALYSIS OF ALTERNATIVE TREATMENT STRATEGIES FOR ACHALASIA. TF Imveriale. JB O'Connor, MF Vaezi, JE Richter. Department of Medicine, Indiana University and Roudebush VA Medical Centers, Indiana University School of Medicine, Indianapolis, IN, and Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, OH. Background: The optimal treatment for otherwise healthy patients with achalasia is controversial. Obiective: To compare the costs per cure of alternative strategies for treatment of achalasia using decision analysis. Methods: A decision model compared the cost per cure for achalasia among otherwise healthy adults who would be candidates for any one of the following three treatment strategies: 1) laparoscopic Heller myotomy with fundoplication (LHM); 2) pneumatic dilation (PD) with surgery reserved for treatment failures and PD perforations; 3) botulinum toxin (BT) injection of the LES, with PD reserved for treatment failures (defined as lack of response to two consecutive BT sessions). LHM failures and PD perforations were managed with open HeUer myotomy with fundoplication, with an assumption of long-term cure. Probabilities of short- and long-term efficacy, treatment failure, symptomatic recurrence rates, and complications were derived from a weighted average of data from the published literature. Baseline probabilities included 5% for PD perforation; 80% and 70% immediate success rates for PD and BT, respectively; 2.5% for PPI-requiring GERD following BT and PD, and 5% for post-LHM GERD. Only direct costs were considered, and were derived from hospital accounting departments and Medicare-allowable payments. During the 5-year time horizon, BT responders were assumed to require a mean of 7 treatment sessions, and PD responders who developed a recurrence were assumed to require a mean of 2 additional PD sessions. Results: Under base-case conditions, the respective costs per cure of PD, BT and LHM were $3245, $3911, and $10,800, respectively. Despite rates of 96% and 94% for short-and long-term efficacy, respectively, LHM remained the most costly strategy. In one-way sensitivity analysis, LHM was less costly than BT only when LHM cost was < $3440, a highly unlikely scenario. PD remained less costly than BT, as long as rates of PD efficacy and perforation were > 70% and < 10%, respectively, and cost of BT (including endoscopy) was > $450. Long-term cure from the 1st and 2nd BT session would have to exceed 42% for BT to cost less than PD. The results were not sensitive to the probabilities of short-and long-term response to BT, recurrence following PD, LHM efficacy, and post-LHM GERD, nor to the costs of LHM and PD. Conclusion: For otherwise healthy patients with achalasia, PD is the least costly initial strategy, provided that the PD perforation rate remains less than 10%. BT becomes less costly only when its costs decrease by 25%. LHM is the most costly strategy under all clinically plausible scenarios. Subsequent

Clinical Practice A19 analysis should include a longer time horizon and an assessment of patient preference for each treatment strategy. G0077 ABDOMINAL ULTRASONOGRAPHY: DOES ITS ROUTINE USE AFFECT PROGNOSIS? Jechart G., Zenker-Wendlinger K., Fleischmann R., Wienbeck M., Dept. of Internal Medicine III, Zentralklinikum Augsburg, D86009 Augsburg, Germany Background: Abdominal ultrasonography may reveal unexpected pathology, e.g. unknown tumors, abdominal aneurysm or cholecystolithiasis. We, therefore, set out to test the prognostic value of unexpected ultrasonographic findings in a prospective study. Methods: 2287 consecutive abdominal ultrasonographic examinations in hospitalized patients were documented within six months (Real - time scanner, Picker CS 9200, 3.5 MHz and 7.5 MHz). All unexpected findings not related to the main diagnosis, were noted and evaluated with regard to their effect on prognosis of the patient. Results: 637 of 2287 ultrasonographic examinations revealed incidental pathology. Steatosis hepatis (41%), asymptomatic cholecystolithiasis (21%), and renal cysts (24%) were the most common diagnoses, but they did not influence the therapeutic strategy. Only 2.6% of all investigations appeared to have prognostic impact: malignant tumors (20), aneurysm of the aorta (19), premalignant lesions (8), and alike (13). In the follow up of these patients 18 therapeutic procedures (surgery of tumors and aneurysm, drainage) presumably improved survival of patients with unexpected ultrasonographic pathology (0.4%). In addition 18 patients (0.4%) were included in follow-up programs for aortic aneurysm, gallbladder polyps and myoma. Total No. of examinations Incidental pathology Pathology of prognostic impact Intervention to improve prognosis Inclusion in follow-up programs

2287 637 60 18 18

100% 28% 2.6% 0.4% 0.4%

Discussion: Only 0.4% of abdominal ultrasonographic examinations revealed unexpected pathology, that presumably influenced the prognosis of patients. The routine use ultrasonographic screening in hospitalized patients therefore is not a cost-effective investigation to improve survival. This result has no implications on the indications for ultrasonography in symptomatic patients and certain risk groups. G0078 THE PREVALENCE AND RISK FACTORS OF REFLUX ESOPHAGITIS IN KOREA. SG Jeon, PL Rhee, MH Shin*, J Kim, KC Koh, SW Paik, JC Rhee and KW Choi. Dept. of Medicine, Dept. of Preventive Medicine*, Sung Kyun Kwan University College of Medicine, Samsung Medical Center, Seoul, Korea Introduction: There were very few epidemiological data on reflux esophagitis in Korea. The aims of this study are to evaluate the prevalence and risk factors of reflux esophagitis in Korea. Methods: We enrolled 8314 subjects (male 4694, female 3410; age range 18 - 83 yr) visiting health promotion center for routine check-up including EGD. 1) We measured the prevalence of reflux esophagitis. 2) We undertook a case-control study to evaluate the effects of smoking, alcohol consumption, diet habits (large meals, high fat meals, coffee consumption), use of drugs (antihypertensives, sedatives), serum cholesterol, triglyseride, BMI(kg/m2) and full-term parity on the risk of reflux esophagitis. We recruited 200 cases with reflux esophagitis on EGD and 400 controls without reflux esophagitis on EGD. We matched 2 controls to each case on the basis of sex, age and residence. Results: I) One hundred eighty-two male subjects and twenty-eight female subjects were found to have reflux esophagitis. The prevalence of reflux esophagitis was 3.88% in male and 0.82% in female. The prevalence in male was significantly higher than that in female (p < 0.01). 2) On the monovariate analysis, smoking, alcohol consumption and BMI were significant risk factors of reflux esophagitis (p < 0.05). On the multivariate analysis, smoking was a significant risk factor of reflux esophagitis (p < 0.05). Condusions: The prevalence of reflux esophagitis in Korea was 3.88% in male and 0.82% in female. Smoking was a significant risk factor of reflux esophagitis.