Minimizing procedural cost in diagnosing small bowel bleeding: comparison of a strategy based on initial capsule endoscopy versus initial double-balloon enteroscopy

Introduction Capsule endoscopy (CE) and double-balloon enteroscopy (DBE) detect small bowel bleeding with equal diagnostic yield. We aimed to detect factors that influence procedural cost of CE and DBE in diagnosing and treating small bowel bleeding, and to compare them with reimbursement. Methods A cost model analysed procedural cost for diagnostic CE versus diagnostic, unidirectional DBE (scenario 1) and CE plus directed therapeutic DBE (positive findings in CE) versus unidirectional diagnostic plus therapeutic DBE (scenario 2). The frequency of investigations per annum (p.a.) at which cost per procedure is equalized (break-even point) was determined for CE versus DBE. A retrospectively collected cohort of patients was used to validate the cost model and to compare procedural costs with reimbursement (German diagnosis-related groups, G-DRG). Results The break-even point at which cost per procedure is equalized for CE versus DBE was reached at 100 procedures p. a. in scenario 1 and 79 in scenario 2 for a rate of therapeutic enteroscopy of 14%, and 27 for a therapeutic enteroscopy rate of 30%. Personnel cost, procedure time, procedures p. a. and the rate of therapeutic enteroscopy had a major influence on procedural cost. In this patient cohort, the 'CE-first' and the 'DBE-first' strategies produced procedural costs of (sic)830 and (sic)1076 per patient to attain a diagnosis, and (sic)1042 versus (sic)1181 to achieve therapeutic enteroscopy, respectively. For this cohort, potential reimbursement was (sic)2320 and (sic)3047 for the 'CE-first' and the 'DBE-first' strategies, respectively (G-DRG). Conclusion Workflow management of CE versus DBE should consider frequency of investigations p. a. and probability for therapeutic enteroscopy to minimize procedural costs. The cost of DBE increases with less frequent or time-consuming investigations; CE is more robust with regard to these factors. From a third-party payer perspective, a strategy incorporating CE seems to minimize costs in G-DRG. Eur J Gastroenterol Hepatol 22:679-688 (C) 2010 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins.