Examining Cost-Utility Data for Interventions to Prevent Infection Transmission by Duodenoscopes

Examining Cost-Utility Data for Interventions to Prevent Infection Transmission by Duodenoscopes

Bret T. Petersen, MD, MASGE, reviewing Barakat MT, et al. Gastrointest Endosc 2022 Jan 10.

Transmission of multidrug-resistant organisms between patients undergoing ERCP prompted the U.S. Food and Drug Administration to issue guidance for endoscopy departments to adopt intensified reprocessing practices and/or newer endoscope designs that are partially or entirely disposable. These authors used a Monte Carlo analysis to evaluate the cost-utility of each of the currently advised approaches for reducing transmission, including single and double high-level disinfection (HLD), ethylene oxide (ETO) sterilization, culture and quarantine, use of instruments with removable/disposable endcaps, and single-use fully disposable instruments (SU). Cost of care for transmitted infections and postprocedure quality-adjusted life years (QALY) were included. 

When transmission rates were below 1%, the disposable-tip endoscopes yielded the most favorable cost-utility compared with both SU endoscopes and enhanced reprocessing of fixed-tip instruments. The cost-utility of SU instruments exceeded both single and double HLD reprocessing of fixed-tip endoscopes. SU endoscopes were also more cost-effective than culture-quarantine for infection rates >0.56% and ETO sterilization for rates >0.32%. Cost-utility profiles varied depending on variations in assigned QALY values, postexposure lifespan, hospital volume, and environmental costs.

Bret T. Petersen, MD, FASGE


Duodenoscopes with removable single-use endcaps for enhanced cleaning provided the greatest cost-utility in this analysis. As with any Monte Carlo simulation, the findings are highly dependent on the cost, frequency, and duration assumptions included in the analysis, many of which are unique to a given institution or environment. In this case, exposure rates, transmission efficacy, and resulting infection are speculative and remain incompletely defined, particularly for the instruments with disposable endcaps. The fixed-endcap instruments evaluated in most of the recent HLD literature are rapidly being withdrawn from the marketplace. Despite these reservations, incorporating cost-utility data into the conversation about duodenoscope transmission of infections will better our understanding of the tradeoffs among the available options.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.


Barakat MT, Ghosh S, Banerjee S. Cost utility analysis of strategies for minimizing risk of duodenoscope related infections. Gastrointest Endosc 2022 Jan 10. (Epub ahead of print) (https://doi.org/10.1016/j.gie.2022.01.002)

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