Author(s): Spiegel BM, DeRosa VP, Gralnek IM, Wang V, Dulai GS
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Abstract BACKGROUND & AIMS: Some patients with diarrhea-predominant irritable bowel syndrome (IBS-D) may have undiagnosed celiac sprue (CS). Because the symptoms of CS respond to a gluten-free diet, testing for CS in IBS may prevent years of morbidity and attendant expense. We sought to determine whether this might be a cost-effective diagnostic strategy in IBS-D. METHODS: We used decision analysis to calculate the cost-effectiveness of 2 competing strategies in IBS-D: (1) start empirical IBS treatment and (2) perform serologic test for CS followed by endoscopic biopsy for positive tests. The base-case cohort had a CS prevalence of 3.4\%, which was varied between 0\% and 100\% in sensitivity analysis. The outcome measure was cost per symptomatic improvement. RESULTS: Under base-case conditions, testing for CS instead of starting empiric IBS therapy cost an incremental $11,000 to achieve one additional symptomatic improvement. Testing for CS became the dominant strategy when the prevalence of CS exceeded 8\%, the specificity of CS testing exceeded 98\%, or the cost of IBS therapy exceeded $130/month. The incremental cost-effectiveness of testing for CS exceeded $50,000 when the prevalence fell below 1\%. CONCLUSIONS: Testing for CS in patients with IBS-D has an acceptable cost when the prevalence of CS is above 1\% and is the dominant strategy when the prevalence exceeds 8\%. The decision to test should be based on a consideration of the population prevalence of underlying CS, the operating characteristics of the screening test employed, and the cost of proposed therapy for IBS.
This article was published in Gastroenterology
and referenced in Internal Medicine: Open Access