Intrasphincteric botulinum toxin versus pneumatic dilatation for achalasia: a cost minimization analysis.

BACKGROUND Pneumatic dilatation or intrasphincteric botulinum toxin injection provide effective symptom relief for patients with achalasia. Although intrasphincteric botulinum toxin injection is simple and safe, its efficacy may be short-lived. Pneumatic dilatation lasts longer, but esophageal perforation is a risk. We compared treatment costs for pneumatic dilatation and intrasphincteric botulinum toxin injection using a decision analysis model to determine whether the practical advantages of intrasphincteric botulinum toxin injection outweigh the economic impact of the need for frequent re-treatment. METHODS Probability estimates for intrasphincteric botulinum toxin injection were derived from published reports. Probability estimates for the pneumatic dilatation strategy were obtained by retrospective review of our 10-year experience using the Rigiflex dilator. Direct, "third-party payer" costs were determined in Canadian dollars. RESULTS Intrasphincteric botulinum toxin injection was significantly more costly at $5033 compared with $3608 for the pneumatic dilatation strategy, yielding an incremental cost of $1425 over the 10-year period considered. Sensitivity analysis showed that pneumatic dilatation is less expensive across all probable ranges of costs and probability estimates. The intrasphincteric botulinum toxin injection strategy is less costly if life-expectancy is less than 2 years. CONCLUSIONS Intrasphincteric botulinum toxin injection is more costly than pneumatic dilatation for the treatment of achalasia. The added expense of frequent re-treatment with intrasphincteric botulinum toxin injection outweighs the potential economic benefits of the safety of the procedure, unless life-expectancy is 2 years or less.