Peroral endoscopic myotomy (POEM) is more cost-effective than laparoscopic Heller myotomy in the short term for achalasia: economic evaluation from a randomized controlled trial
Background and study aims We aimed to perform an economic evaluation of peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) for the treatment of achalasia.
Materials and methods An economic cost-utility analysis was carried out over a time horizon of 1 year. Patients with achalasia who were admitted to the gastroenterology outpatient clinic of a public tertiary referral hospital were assigned to undergo POEM or LHM. The monetary amounts were extracted from the intranet of the institution using microcosting. All costs associated with the procedure, hospitalization, clinical follow-up and resolution of therapeutic complications were included. The utility data were measured in quality-adjusted life years (QALYs), which were estimated from the scores of a quality-of-life questionnaire.
Results Forty patients (20 POEM patients and 20 LHM patients) were included. The final cost associated with POEM and LHM was US$ 2,619.19 ± 399.53 and US$ 1,696.44 ± 412.21, respectively (P < 0.001). However, the QALYs in the POEM group (0.434 ± 0.215 vs 0.332 ± 0.222, P = 0.397) were slightly higher than those in the LHM group. The incremental cost-utility ratio (ICUR) suggested that an additional US$ 9,046.41/QALY gained was required when using POEM.
Conclusion For the treatment of achalasia in the public health system, POEM appears to be more cost-effective than LHM in the short term.
Received: 10 June 2020
Accepted: 18 August 2020
22 October 2020 (online)
© 2020. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany
- 1 Lake JM, Wong RKH. Review article: the management of achalasia – a comparison of different treatment modalities1. Aliment Pharmacol Ther 2006; 24: 909-918
- 2 Vaezi MF, Pandolfino JE, Vela MF. ACG Clinical Guideline: Diagnosis and Management of Achalasia. Am J Gastroenterol 2013; 108: 1238-1249
- 3 Gunasingam N, Perczuk A, Talbot M. et al. Update on therapeutic interventions for the management of achalasia. J Gastroenterol Hepatol 2016; 31: 1422-1428
- 4 Richter JE. Achalasia - An Update. J Neurogastroenterol Motil 2010; 16: 232-242
- 5 Winter H, Shukla R, Elshaer M. et al. Current management of achalasia – A review. Br J Med Pract 2015; 8: a810 https://www.bjmp.org/content/current-management-achalasia-review
- 6 Pandolfino JE, Gawron AJ. Achalasia. JAMA 2015; 313: 1841
- 7 Anefalos A, Herbella FAM, Patti MG. Upper esophageal sphincter motility and thoracic pressure are determinants of pressurized waves in achalasia subtypes according to the Chicago Classification. World J Surg 2020; 44: 1932-1938
- 8 Jung H-K, Hong SJ, Lee OY. et al. 2019 Seoul Consensus on Esophageal Achalasia Guidelines. J Neurogastroenterol Motil 2020; 26: 180-203
- 9 Tsuboi K, Hoshino M, Srinivasan A. et al. Insights gained from symptom evaluation of esophageal motility disorders: a review of 4,215 patients. Digestion 2012; 85: 236-242
- 10 Sinan H, Tatum RP, Soares RV. et al. Prevalence of respiratory symptoms in patients with achalasia. Dis Esophagus 2011; 24: 224-228
- 11 Coronel MA, Bernardo WM, de Moura DTH. et al. The efficacy of the different endoscopic treatments versus sham, pharmacologic or surgical methods for chronic gastroesophageal reflux disease: a systematic review and meta-analysis. Arq Gastroenterol 2019; 55: 296-305
- 12 Gupta M, Ghoshal UC, Jindal S. et al. Respiratory dysfunction is common in patients with achalasia and improves after pneumatic dilation. Dig Dis Sci 2014; 59: 744-752
- 13 Bianchi ET, Sallum RAA, Szachnowicz S. et al. Heller-Pinotti, a modified partial fundoplication associated with myotomy to treat achalasia: technical and final results from 445 patients. Mini-invasive Surg 2017; 1: 153-159 DOI: 10.20517/2574-1225.2017.41.
- 14 Inaba CS, Wright AS. Laparoscopic Heller myotomy and Toupet fundoplication for achalasia. J Laparoendosc Adv Surg Tech 2020; 30 DOI: 10.1089/lap.2020.0158.
- 15 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
- 16 Montalvo-Javé EE, Crisanto-Campos BA, Tapia-Jurado J. et al. Perspectiva actual de la cirugía endoscópica transluminal por orificios naturales (CETON) [A current perspective of natural orifices transluminal endoscopic surgery (NOTES)]. Rev Gastroenterol Peru 2016; 36: 242-248
- 17 Nesargikar PN, Jaunoo SS. Natural orifice translumenal endoscopic surgery (N.O.T.E.S). Int J Surg 2009; 7: 232-236
- 18 Pasricha P, Hawari R, Ahmed I. et al. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy 2007; 39: 761-764
- 19 Miller HJ, Neupane R, Fayezizadeh M. et al. POEM is a cost-effective procedure: cost-utility analysis of endoscopic and surgical treatment options in the management of achalasia. Surg Endosc 2017; 31: 1636-1642
- 20 Greenleaf EK, Winder JS, Hollenbeak CS. et al. Cost-effectiveness of per oral endoscopic myotomy relative to laparoscopic Heller myotomy for the treatment of achalasia. Surg Endosc 2018; 32: 39-45
- 21 Delgado AAA, de Moura DTH, Ribeiro IB. et al. Propofol vs traditional sedatives for sedation in endoscopy: A systematic review and meta-analysis. World J Gastrointest Endosc 2019; 11: 573-588
- 22 Hathorn KE, Chan WW, Aihara H. et al. Determining the safety and effectiveness of electrocautery enhanced scissors for peroral endoscopic myotomy (with video). Clin Endosc 2020; 53: 443-451 DOI: 10.5946/ce.2019.214.
- 23 Martins RK, Ribeiro IB, de Moura DTH. et al. Peroral (POME) or surgical myotomy for the treatment of achalasia: a systematic review and meta-analyis. Arq Gastroenterol 2020; 57: 79-86
- 24 Weusten BLAM, Barret M, Bredenoord AJ. et al. Endoscopic management of gastrointestinal motility disorders – part 1: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2020; 52: 498-515
- 25 Runge TM, Ichkhanian Y, Khashab MA. POEM for achalasia: endoscopic myotomy enters its golden age, and we are taking NOTES. Gastrointest Endosc 2020; 91: 1045-1049.e1
- 26 Werner YB, Hakanson B, Martinek J. et al. Endoscopic or Surgical myotomy in patients with idiopathic achalasia. N Engl J Med 2019; 381: 2219-2229
- 27 Noguchi K, Gel Y, Brunner E. et al. nparLD: An R Software Package for the Nonparametric Analysis of Longitudinal Data in Factorial Experiments. J Stat Software 2012; 50: 1-23
- 28 Noguchi K, Latif M, Thangalevu K. et al. Nonparametric Analysis of Longitudinal Data in Factorial Experiments. New York: John Wiley & Sons;
- 29 Swanström LL. Achalasia: treatment, current status and future advances. Korean J Intern Med 2019; 34: 1173-1180
- 30 Martins RK, Bernardo WM, Moura ET. et al. Peroral endoscopic myotomy versus surgical myotomy for the treatment of achalasia: Systematic review and meta-analysis. Gastrointest Endosc 2018; 87: AB538-AB539
- 31 Mohan BP, Ofosu A, Chandan S. et al. Anterior versus posterior approach in peroral endoscopic myotomy (POEM): a systematic review and meta-analysis. Endoscopy 2020; 52: 251-258
- 32 Hashimoto R, Inoue H, Shimamura Y. et al. POEM as salvage therapy in patients with achalasia refractory to endoscopic or surgical therapy is technically feasible and safe: A systematic review and meta‐analysis. Dig Endosc 2020; DOI: 10.1111/den.13643. [Epub ahead of print. PMID: 32012360]
- 33 Farias GFA, de Moura DTH, de Moura ETH. et al. Peroral endoscopic myotomy (POEM): a comparative study between Chagasic and idiopathic achalasia. Endosc Int Open 2020; 08: E506-E512
- 34 Antonini Ribeiro R, Lavanholi Neyeloff J, Itria A. et al. Diretriz metodológica para estudos de avaliação econômica de tecnologias em saúde no Brasil. J Bras Econ da Saúde 2016; 8: 174-184
- 35 Ministério da Saúde. Diretrizes metodológicas: diretriz de avaliação econômica. 2 ed. Brasília: 2014 https://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_metodologicas_diretriz_avaliacao_economica.pdf
- 36 Kahaleh M, Xu M-M, Zamarripa F. et al. POEM in Latin America. J Clin Gastroenterol 2019; 53: e352-e355
- 37 Schwarzer R, Rochau U, Saverno KJ. et al. Systematic overview of cost– effectiveness thresholds in ten countries across four continents. J Comp Eff Res 2015; 4: 485-504