The following is a summary of “Optimizing the Management Algorithm for Esophageal Dysphagia After Index Endoscopy: Cost-Effectiveness and Cost-Minimization Analysis,” published in the January 2024 issue of Gastroenterology by Shah, et al.

The prevailing guidelines recommend esophageal motility testing for individuals experiencing dysphagia once structural anomalies have been ruled out. However, concerns surrounding costs have hindered its widespread adoption. For a study, researchers sought the most cost-effective approach for incorporating esophageal motility testing into the diagnostic algorithm for esophageal dysphagia.

The approach involved constructing a decision analytic model that juxtaposed three distinct strategies: direct esophageal manometry,  a preliminary screening using impedance planimetry, with subsequent esophageal manometry if deemed necessary, and the nonalgorithmic standard care. They calibrated the diagnostic test accuracy based on the anticipated prevalence rates of esophageal motility disorders within general gastroenterology patient populations. The models compared routine testing for all patients manifesting nonstructural or mechanical dysphagia against selective testing, especially when strong suspicions of achalasia existed. They evaluated cost metrics based on datasets from national commercial entities and Medicare, segmented by age and gender. Meanwhile, health outcomes were extrapolated from populations diagnosed with achalasia. The analytical time frame spanned a year.

The findings indicated that opting for motility testing, specifically esophageal manometry, was economically favorable when juxtaposed with nonalgorithmic standard care, primarily due to cost-effectiveness rather than notable health improvements. For commercial insurance entities, the threshold for cost-saving was a reimbursed amount of $2,415 for routine esophageal manometry concerning nonstructural/mechanical dysphagia. In contrast, this threshold dropped to $1,130 for screening impedance planimetry. Interestingly, for individuals above 65 years, the cost-saving reimbursement threshold was lower, chiefly because of insurance dynamics. Gender did not emerge as a significant factor influencing cost-effectiveness. When the suspicion index for achalasia was below 6%, both patients and insurers favored the preliminary screening via impedance planimetry before resorting to manometry.

In concordance with existing practice guidelines, the analysis underscored that incorporating routine esophageal motility testing offers cost advantages to both patients and insurers when compared to the nonalgorithmic standard of care for assessing nonstructural/mechanical dysphagia. The selection of the testing modality should be judiciously guided by the level of suspicion for underlying conditions like achalasia.

Source: journals.lww.com/ajg/abstract/2024/01000/optimizing_the_management_algorithm_for_esophageal.17.aspx