Cost minimising use of a new technology - wireless capsule endoscopy of the small bowel

Presenter: Jenny Bacon, Surrey and Sussex Healthcare NHS Trust

Abstract

Introduction: Many new, more effective but expensive diagnostic technologies are now available. It can be difficult to know when to use them rather than older, cheaper alternatives. Capsule endoscopy (CE) has been approved to investigate small bowel disease in the United Kingdom (UK) by National Institute for Health and Clinical Excellence since 2004 and is considered the most accurate test. The key indications for CE are to diagnose obscure gastrointestinal haemorrhage (OGIH) and small bowel Crohn’s disease (CD). The traditional alternative has been contrast fluoroscopy though angiography and nuclear medicine scans may also be used. CE delivers a high diagnostic yield (31-76% OGIH, 43-71% CD). It uses no radiation and causes few complications but is expensive. Robust comparable data for fluoroscopy is limited.

Objective: To determine the cost minimising approach for diagnosing OGIH and CD in the setting of a UK general hospital where both techniques are available.

Methodology: Patients receiving CE +/- fluoroscopy to investigate OGIB or CD at our institution from January 2007 to May 2008 were identified from databases. (Patients referred from elsewhere for CE were excluded.) The diagnostic indication and findings were determined from electronic records, positive diagnostic yields calculated and procedure costs examined. Cost minimisation and sensitivity analyses were performed and diagnostic pathways assessed.

Results: For investigation of CD, 136 patients had fluoroscopy, 21 CE and 3 both. For OGIH 47 had fluoroscopy, 59 CE and 8 had both. The positive diagnostic yield for CD was 23% with fluoroscopy, approximate half that of CE (57%) and for OGIH 2% with fluoroscopy and 56% with CE. Relative costs for CE in the UK ranges from USD1720-2189 and fluoroscopy USD234-462.

Conclusions: Our evidence suggests that fluoroscopy detects approximately half the CD cases that CE would at less than a quarter of the cost of CE. Across a broad range of assumptions cost minimisation analysis suggests that fluoroscopy should be used initially and only if negative and clinical suspicion of CD remains should CE then be done. Our observation of actual practice suggests that both positive and negative fluoroscopy results may conclude investigation of suspected CD in that few of the patients we studied had had both investigations. The very low diagnostic yield for fluoroscopy vs. CE for OGIH demands that CE should be the imaging modality of choice and fluoroscopy abandoned as a diagnostic option for OGIH.

We calculate that, for this patient cohort, to follow our proposals to use CE as the only investigation for OGIH and only after a negative fluoroscopy study in cases of suspected CD, our institution could have saved ~USD11,000. Other benefits may include faster diagnosis (of OGIH) and less radiation exposure.

New technologies may give higher diagnostic yields and be safer in use but nevertheless may need to sit alongside older, less effective but cheaper alternatives to minimise costs without denying patients their benefits. Simple analysis may define their place in practice, a place which our sensitivity analyses for CE suggest may change only if its relative cost fall substantially.