INTRODUCTION Guidelines advise esophageal motility testing for dysphagia when structural disorders are ruled out, but cost concerns impede adoption. We evaluated cost-effective positioning of esophageal motility testing in the algorithm to evaluate esophageal dysphagia. METHODS We developed a decision analytic model comparing 3 strategies: (i) esophageal manometry, (ii) screening impedance planimetry followed by esophageal manometry if needed, or (iii) nonalgorithmic usual care. Diagnostic test accuracy was adapted to expected rates of esophageal motility disorders in general gastroenterology populations. We modeled routine testing for all patients with nonstructural/mechanical dysphagia compared with selective testing with strong suspicion for achalasia. Cost outcomes were defined on national commercial and Medicare datasets stratified on age and sex. Health outcomes were modeled on populations with achalasia. The time horizon was 1 year. RESULTS Motility testing was preferred over nonalgorithmic usual care due to cost savings rather than health gains. To commercial insurers, routine esophageal manometry for nonstructural/mechanical dysphagia would be cost-saving below a reimbursed cost of $2,415. Screening impedance planimetry would be cost saving below a reimbursed cost of $1,130. The limit for reimbursed costs would be lower for patients older than 65 years to achieve cost savings mainly due to insurance. Sex did not significantly influence cost-effectiveness. Patients and insurers preferred routine screening impedance planimetry before manometry when the index of suspicion for achalasia was below 6%. DISCUSSION Aligning with practice guidelines, routine esophageal motility testing seems cost saving to patients and insurers compared with nonalgorithmic usual care to evaluate nonstructural/mechanical dysphagia. Choice of testing should be guided by index of suspicion.

中文翻译：

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优化索引内窥镜检查后食管吞咽困难的管理算法：成本效益和成本最小化分析。

引言 指南建议在排除结构性疾病的情况下对吞咽困难进行食管动力测试，但成本问题阻碍了采用。我们评估了评估食管吞咽困难的算法中食管运动测试定位的成本效益。方法 我们开发了一个决策分析模型，比较 3 种策略：(i) 食管测压，(ii) 筛查阻抗平面测量，然后根据需要进行食管测压，或 (iii) 非算法常规护理。诊断测试的准确性适应了一般胃肠病学人群食管运动障碍的预期发生率。我们对所有非结构性/机械性吞咽困难患者的常规测试进行了建模，与强烈怀疑患有贲门失弛缓症的选择性测试进行比较。成本结果是根据按年龄和性别分层的国家商业和医疗保险数据集定义的。健康结果以贲门失弛缓症人群为模型。时间范围为一年。结果 由于节省成本而非健康益处，运动测试优于非算法常规护理。对于商业保险公司来说，针对非结构性/机械性吞咽困难进行常规食管测压可以节省成本，报销费用低于 2,415 美元。筛查阻抗平面测量法可节省成本，报销成本低于 1,130 美元。65岁以上患者的报销限额将较低，主要通过保险来节省费用。性别对成本效益没有显着影响。当贲门失弛缓症的怀疑指数低于 6% 时，患者和保险公司更倾向于在测压之前进行常规筛查阻抗平面测量。讨论 与实践指南一致，与评估非结构性/机械性吞咽困难的非算法常规护理相比，常规食管运动测试似乎可以节省患者和保险公司的成本。测试的选择应以怀疑指数为指导。