Original articleIllustrating Economic Evaluation of Diagnostic Technologies: Comparing Helicobacter pylori Screening Strategies in Prevention of Gastric Cancer in Canada
Introduction
A health technology is any method or intervention used to prevent, diagnose, and treat disease or to improve rehabilitation and long-term care. Health technology assessment (HTA) is a systematic evaluation of the technical performance, safety, clinical efficacy, cost-effectiveness, and social and ethical considerations of the application of a health technology [1]. An economic evaluation is thus an integrated component of any HTA and provides evidence on the cost-effectiveness of new technologies to inform decision making.
Although they share the same underlying principles and methodologies, economic evaluations of diagnostic technologies have unique characteristics compared with evaluations of other types of health technologies (eg, drugs). For example, the performance parameters of diagnostic technologies (ie, sensitivity and specificity) are key factors that are incorporated into evaluations. These parameters determine who will be treated and which treatment options will be selected and consequently model structure, costs, and outcomes of patients. In this paper, we present an example of an economic evaluation illustrating the use of Helicobacter pylori screening strategies for the prevention of gastric cancer in Canada. The methodologies used in this paper can be applied to other diagnostic technologies.
Gastric cancer is the second leading cause of cancer death worldwide [2]. It leads to a substantial increase in health care resource utilization and reduction in the quality of life [3, 4]. Helicobacter pylori was classified as a class I carcinogen by the International Agency for Research on Cancer in 1994 [5], and an H. pylori infection is thus an important risk factor for gastric cancer (distal) [6, 7, 8]. Nearly 50% of the world's population has been estimated to be infected by H. pylori [9]. Although the prevalence of the infection has dropped in developed countries [10], a substantial proportion of the Canadian population is still infected [11]. The early detection and eradication of H. pylori infection may represent a significant opportunity for gastric cancer prevention [12]. Helicobacter pylori can be diagnosed by noninvasive techniques, including the serology test by the enzyme-linked immunosorbent assay (ELISA), the stool antigen test (SAT), and the 13C-urea breath test (UBT) [13]. However, the choice among these alternatives varies across countries. European guidelines recommend both the UBT and the SAT for H. pylori diagnosis, while the serology test is to be used only under certain conditions [14, 15]. The Canadian Helicobacter Study Group recommended the UBT as the diagnostic method of first choice, although the serology test is still widely used in Canada [16]. The SAT has not been accepted as an alternative to the UBT in Canada [16]. Currently, there is no economic evidence available to compare these tests for the prevention of gastric cancer in Canada.
The objective of this study was to illustrate economic evaluation of diagnostic technologies by estimating the cost-effectiveness of different H. pylori screening strategies for the prevention of gastric cancer in Canada. It may not reflect the repeat-screening strategy adopted in current clinical practice and the potential for reinfection and reeradication of H. pylori over time.
Section snippets
Study Design
This model-based economic evaluation was conducted to compare one-time H. pylori screening and eradication strategies with no screening and no eradication from the perspective of a third-party payer over a lifetime horizon. Because the prevalence of H. pylori infection is significantly higher in men than in women [11], the target population was a hypothetical cohort of 10,000 Canadian men aged 35 years without symptoms of infection.
Markov Model
A Markov model was constructed to simulate the
Results
The results of the base-case analysis are shown in Table 2. The no-screening strategy detected and treated 61 gastric cancer cases and cost a total of $157,300 (for the treatment of gastric cancer). The corresponding values were 56 cases and $627,200 for the ELISA, 55 cases and $625,700 for the SAT, and 55 cases and $982,000 for the UBT. Compared with the no-screening strategy, the ICER was $33,000 per QALY for the ELISA, $29,800 per QALY for the SAT, and $50,400 per QALY for the UBT. The
Discussion
In this study, we compared the lifetime cost-effectiveness of different H. pylori screening strategies for the prevention of gastric cancer in male Canadians aged 35 years. The no-screening strategy was the most cost-effective strategy if the WTP was <$20,000 per QALY, while the SAT became the strategy with the highest probability of being cost effective if the WTP was >$30,000 per QALY. Both the ELISA and the UBT were not cost-effective strategies over a wide range of WTP values.
This economic
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2013, Best Practice and Research: Clinical GastroenterologyCitation Excerpt :The Gastric Cancer Consensus Conference recommended screening using a serological test [16], and this is what has been considered in most of the available studies. Only two studies have, so far, compared different screening tests and these provided little clarity on the issue of which is most cost-effective across settings: in the high-prevalence population serology dominated C-UBT, whereas in the lower-prevalence population, SAT dominated the other two options [34,38]. However, cost-effectiveness is not the only issue worth considering as regards choice of screening test.