Defining a clinically significant adverse impact of diagnosing Barrett's esophagus

Background: Diagnosing a potentially life-threatening disease may adversely affect patient quality of life (QOL) independent of biologic effects. It is unknown whether the mere diagnosis of Barrett's esophagus (BE) adversely impacts patients' preferences (health-state utility) sufficiently to impair the cost-effectiveness of endoscopic screening for esophageal adenocarcinoma. Goal: To calculate the threshold impact on utility incurred by diagnosing BE that would allow screening to remain cost-effective. Study: A Markov model was developed to examine strategies of no screening, and screening with surveillance of BE. Patients were 50-year-old white men with symptoms of gastroesophageal reflux followed until 80 years of age or death. The primary outcomes were the threshold decrements in utility incurred by diagnosing BE based on willingness to pay (WTP) of $50,000 and $100,000 per quality adjusted life-year (QALY) gained. Results: For a WTP of $50,000/QALY, the decrement in utility could be as great as 9%, meaning that screening is cost-effective as long as diagnosing BE does not impair QOL by more than 9%. For a WTP of $100,000, the decrement could be as great as 10.5%. Conclusions: The decrement in utility caused by diagnosing BE may be substantial without compromising the cost-effectiveness of endoscopic screening.