Cost-effectiveness of endoscopy in HIV-positive patients with chronic diarrhea

Background: Endoscopy is commonly performed in HIV-positive patients with chronic diarrhea when stool studies fail to identify a pathogen. However, the cost-effectiveness of this practice has not been established. Our purpose was to determine the diagnostic yield and cost per diagnosis of endoscopic evaluation in a large group of HIV-positive patients with chronic diarrhea and negative stool studies. Methods: All HIV-positive patients with chronic diarrhea who were referred for diagnostic endoscopy in our hospital from October 1, 1993 to October 31, 1996 were identified. Data was collected by reviewing patient charts, pathology reports, and our endoscopic database. The cost of endoscopy was calculated by adding the physician fee under Medicaid reimbursement, the facility charge, and the cost of processing the biopsy specimens. We used Medicaid reimbursement in the cost analysis because it was most applicable to our patient population. Results: A total of 479 endoscopic procedures were performed in 307 patients. All patients had a negative stool work-up prior to endoscopy. The mean age was 38 ± 7.6 years (range, 19-63) and the mean CD4 count was 98 ± 120.9 cells/mm³ (range, 0-500). The average cost of an endoscopic work-up was $1, 830.53 per patient. Endoscopic Procedure (n) Diagnostic Yield (n%) Cost per Diagnosis All Patients Cost per Diagnosis CD4<100 Cost per Diagnosis CD4≥100 EGD(203) 60(29.6%) $4,868 $3,717 $17,520 Flex Sig(85) 19(22.4%) $3,353 $2,682 N/A Colonoscopy(191) 74(38.7%) $2,787 $2,159 $25,372 All Patients(307) 147(47.9%) $3,823 $2,935 $21,584 Conclusions: Endoscopy in HIV-positive patients with chronic diarrhea and a negative stool work-up frequently yields a pathogen. The average cost of making a diagnosis by endoscopy in our patient population was $3,823. In patients with a CD4 count of < 100/mm³, endoscopy had a greater diagnostic yield and was considerably more cost-effective than in those with higher CD4 counts.