Optimizing the management algorithm for esophageal dysphagia after index endoscopy: Cost-effectiveness and cost-minimization analysis

Abstract

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 three strategies: (1) esophageal manometry, (2) screening impedance planimetry followed by esophageal manometry if needed, or (3) non-algorithmic 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 non-structural/mechanical dysphagia compared to 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 achalasia populations. The time horizon was one year.

RESULTS:

Motility testing was preferred over non-algorithmic usual care due to cost-savings rather than health gains. To commercial insurers, routine esophageal manometry for non-structural/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 >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 appears cost-saving to patients and insurers compared to non-algorithmic usual care to evaluate non-structural/mechanical dysphagia. Choice of testing should be guided by index of suspicion.

INTRODUCTION

Dysphagia is a common reason for patients to seek gastroenterology care.(1) When no structural or mechanical cause is identified on upper endoscopy to explain esophageal dysphagia, practice guidelines then advise esophageal motility testing to evaluate for achalasia.(2,3) Esophageal manometry is a brief, tolerable, catheter-based test that defines the gold standard to identify achalasia and does not require sedation.(4) Esophageal manometry requires a second appointment in an office setting or motility laboratory after the endoscopy. Impedance planimetry is a newer modality involving transoral catheter-balloon placement during sedated endoscopy.(5) Guidelines position impedance planimetry as an adjunctive test for expert centers, while some authors suggest its potential as a screening test during the index sedated endoscopy.(2,6) While there is not clinical evidence to support this approach directly, we can apply accurate diagnostic accuracy performance characteristics of motility tests to expected prevalence rates in general gastroenterology populations.(6) Ultimately, identifying achalasia is important, because this disorder of both esophagogastric junction outflow and abnormal esophageal peristalsis can be managed with pneumatic dilation or myotomy in surgically fit patients to effectively improve dysphagia symptoms.(3)

Despite guidelines, many patients are not offered timely esophageal motility testing in usual care, because the costs and broad clinical relevance of esophageal motility testing remain controversial in general gastroenterology.(7) Compared to the sheer number of patients with non-structural/mechanical esophageal dysphagia, few patients in general gastroenterology will be diagnosed with achalasia.(8) Instead, patients with non-structural/mechanical dysphagia routinely receive repeated diagnostic upper endoscopy(9), barium studies that can be helpful but are poorly standardized(10), and repeated course of proton pump inhibitor therapy despite their having symptoms suggestive of obstructive rather than reflux-related causes.(9) Clarifying the impact of routine esophageal motility testing on costs and clinical outcomes is relevant, because dysphagia is such a common symptom in general gastroenterology.

We aimed to determine the cost-effective positioning of esophageal motility testing with available modalities in the dysphagia algorithm when non-structural/mechanical esophageal causes are suspected in general gastroenterology. We evaluated two possible scenarios applicable to general gastroenterology: (1) routine esophageal motility testing performed for all patients with a suspected non-structural/mechanical cause of esophageal dysphagia and without eosinophilic esophagitis, and (2) selective testing among patients with a strong suspicion for achalasia based on endoscopy or barium esophagram.

METHODS

We developed a Markov decision analytic model to follow costs and health outcomes among patients undergoing various diagnostic strategies for esophageal motility testing. Our base-case patient was an individual complaining of dysphagia with a normal upper endoscopy with biopsies demonstrating no evidence of structural/mechanical causes of dysphagia or eosinophilic esophagitis, and for whom oropharyngeal dysphagia is either not suspected or ruled out. The age and sex of our base-case patient were based on average ages in commercial and Medicare populations.(9) Our study adhered to the CHEERS checklist and methodologic guidance from the Second Panel on Cost-Effectiveness in Health and Medicine.(11)

Modeled strategies to evaluate dysphagia after index upper endoscopy

We modeled three diagnostic strategies: (1) “Esophageal manometry”: performed as a next step after normal index upper endoscopy, (2) “Screening impedance planimetry”: performed during index upper endoscopy followed by esophageal manometry if abnormal, and (3) “Non-algorithmic usual care” that included a barium study, trial of empiric esophageal dilation, and over-the-counter proton pump inhibitor. We chose to model impedance planimetry as a possible screening test for esophageal motility disorders (with esophageal manometry for an abnormal impedance planimetry), due to our focus on initial dysphagia evaluation rather than its use as an adjunctive test for patients with equivocal findings on manometry and barium esophagram. Despite longstanding guidelines, expectations on what consists of usual care for dysphagia are inherently based on literature that are >20 years old and single-center in nature.(12) In line with usual cost-effectiveness methodology, we therefore varied this assumption extensively in sensitivity analysis.

Model design

We modeled the impact of esophageal manometry to identify achalasia (amenable to surgery) and absent contractility (conservative management for most patients). This approach mitigates controversy in managing esophagogastric junction outflow obstruction or hypercontractility as test findings rather than a diagnoses, and overlap between ineffective esophageal motility patterns in healthy patients or those with reflux-related disease.(13–15) For the non-algorithmic usual care strategy, we followed healthcare utilization and outcomes with prevalent cases of achalasia (Figure 1).(9) In this strategy, we necessarily assumed that patients with absent contractility would have similar outcomes as patients with achalasia under usual care when it is not positively identified without manometry, due to clinical experience and given the relative lack of published evidence on outcomes for this rare disorder.(16) For the esophageal manometry strategy, we modeled outcomes with achalasia on incident cases of positively identified achalasia and assumed that patients would experience health gains with prompt evaluation and management compared to usual care. For the purposes of modeling, we assumed that patients with absent contractility would receive appropriate dietary counseling and no further investigation, but would not experience health gains as typically there remains no treatment of curative intent.(16) For the impedance planimetry strategy, we assigned patients to true positive, true negative, false positive, and false negative identification of achalasia and absent contractility in which true positive cases were treated as outlined, while false negative cases followed outcomes associated with prevalent cases of achalasia.(17) True and false positive incurred costs of esophageal manometry. Conservatively, we assumed that esophageal motility testing had no impact on outcomes for patients without achalasia or absent contractility.

Figure 1:

Model diagram.

Diagnostic test accuracy of esophageal manometry and impedance planimetry

Sensitivity and specificity to detect achalasia reflects diagnostic test accuracy, which is stable regardless of patient population. Studies enrolling patient populations at expert centers that have higher prevalence of rare diagnoses such as achalasia are generally more accurate to estimate sensitivity and specificity, because individual cases will have less impact on the resultant accuracy of sensitivity and specificity estimates. In contrast, the pre- and post-test likelihood of achalasia are determined by sensitivity and specificity of testing and the likelihood of achalasia in a given population. We assumed that esophageal manometry reflects a gold standard and in practice would be used to diagnose motility disorders in accordance with STARD guidelines.(18) We identified a 99.6% sensitivity and 59.8% specificity with impedance planimetry compared to esophageal manometry as reference standard.(17) The model was then calibrated on expected rates of achalasia in general gastroenterology populations approximating ~1% of patients undergoing routine evaluation for non-structural/mechanical dysphagia.(12) As a result, in general gastroenterology, our model suggested that impedance planimetry would be normal 51.5% of the time. We also calibrated the likelihood of achalasia for selective use of motility testing in general gastroenterology when achalasia was strongly suspected, to approximate the 15% of patients that undergo esophageal motility testing and have achalasia in expert centers.

Outcomes and costs

Model inputs are detailed in Table 1. Costs associated with achalasia management were informed by national claims analysis including commercial and Medicare populations stratified on age and sex. Procedural costs were extracted from Centers for Medicare and Medicaid Services data for Medicare-eligible populations at least 65 years of age. For commercially insured populations, these costs were inflated using a multiplier that was varied in sensitivity analysis. All costs were inflated to 2022 US dollars. Health states were modeled on health-utilities reported in populations with achalasia to determine quality-adjusted life years (QALY).

Table 1:

Model inputs.

Description	Base-case value	Min	Max	Distribution	References
Outcomes
Sensitivity of impedance planimetry to detect achalasia	99.6%			Beta: alpha=223, beta=1	Carlson, et al. (2021)(17)
Specificity of impedance planimetry to detect achalasia	59.8%			Beta: alpha=155, beta=104	Carlson, et al. (2021)(17)
Likelihood of achalasia	15.6% (selective testing) 1.0% (routine testing)			Beta: alpha=33, beta=178 Adjusted to calibrate a likelihood of achalasia to 1.0%	Carlson, et al. (2021)(17) Esfandyari, et al. (2002)(12)
Sensitivity of impedance planimetry to detect absent contractility	71.4%			Beta: alpha=5, beta=2	Carlson, et al. (2021)(17)
Specificity of impedance planimetry to detect absent contractility	87.0%			Beta: alpha=154, beta=23	Carlson, et al. (2021)(17)
Likelihood of absent contractility	4.1% (selective testing) 0.3% (routine testing)			Beta: alpha=33, beta=178 Adjusted on the same scale calibrated on the likelihood of achalasia	Carlson, et al. (2021)(17) Esfandyari, et al. (2002)(12)
Quality-adjusted life years
Health-utility associated with achalasia	0.80	0.80	1.00		Torquati, et al. (2006)(22)
Costs
Cost of over-the-counter proton pump inhibitor	$0.34	$0	$3		Amazon.com(23)
Estimated one-year healthcare costs to manage an incident case of achalasia (commercial insurance for individuals under 65 years of age)*	$5,705	$0	$10,000		Gaber, et al. (2022)(9)
Estimated one-year healthcare costs to manage a prevalent case of achalasia (commercial insurance for individuals at under 65 years of age)*	$4,055	$0	$10,000		Gaber, et al. (2022)(9)
Estimated one-year healthcare costs to manage an incident case of achalasia (Medicare insurance for individuals at least 65 years of age)*	$1,500	$0	$10,000		Gaber, et al. (2022)(9)
Estimated one-year healthcare costs to manage a prevalent case of achalasia (Medicare insurance for individuals at least 65 years of age)*	$1,775	$0	$10,000		Gaber, et al. (2022)(9)
Cost of barium esophagram (CPT 74220)	$101				Physician Fee Schedule(24)
Cost of upper endoscopy with dilation (CPT 43245, APC 5301, and CPT 99152)	$1,014				Physician Fee Schedule(24)
Cost of esophageal manometry (CPT 91010 and CPT 91037)	$769				Physician Fee Schedule(24)
Cost of impedance planimetry (CPT 91040)	$568				Physician Fee Schedule(24)
Work-productivity impairment due to achalasia including less productive work and/or missed work	5.6%	0%	10%		Nenshi, et al. (2010)(8)
Mean annual wage	$46,800	$0	$100,000		US Bureau of Labor Statistics(25)
Half-day cost of childcare to attend clinic (accounting for 25% of households having children)	$14.50	$0	$14.50		US Census Bureau(26) Cost of Care Survey(27)
Transportation to/from medical visits	$20	$0	$20		Muennig (2008)(28)

^*Costs are inflated to 2022 US dollars on the U.S. Healthcare Consumer Price Index and then adjusted for commercial insurance at a multiplier of 1.99 for inputs that reflect Medicare costs.(29)

^**Endoscopy costs were modeled on moderate sedation to provide a more conservative on the value of esophageal motility testing, noting that monitored anesthesia costs increase the value of esophageal motility testing and are accounted for in sensitivity analysis.

Analysis

Our base-case analysis followed outcomes and costs accumulated over a one-year time horizon to evaluate cost-effectiveness from the patient perspective and cost-savings from the insurer perspective. This time horizon aligns with usual budgetary timeframes. We compared strategies by calculating incremental cost-effectiveness ratios (ICER) in which incremental costs are divided by incremental health gains, for which a willingness-to-pay (WTP) threshold of $100,000 per QALY-gained is typically considered cost-effective. Probabilistic sensitivity analysis was performed on 100,000 simulated patients to identify robustness of model estimates. Sensitivity analyses were conducted across ranges for all model inputs. A 3% annual discount rate was used. Analysis was performed with TreeAge Pro 2023 R1.2 (TreeAge Software Inc, Williamstown, MA).

RESULTS

Costs of non-algorithmic usual care

Relevant to routine motility testing, commercially insured general gastroenterology populations under 65 years of age incurred $2,271 in costs to insurers and $535 to patients over a one-year period. Medicare-eligible general gastroenterology populations at least 65 years of age incurred $1,138 to Medicare and $505 to patients.

Relevant to selective motility testing among patients with a high index of suspicion for achalasia, commercially insured general gastroenterology populations under 65 years of age incurred $3,063 in costs to insurers and $1,933 to patients over a one-year period. Medicare-eligible general gastroenterology populations at least 65 years of age incurred $1,469 to Medicare and $1,323 to patients.

Costs and outcomes with routine motility testing

In commercially insured populations below 65 years of age, routine esophageal manometry maximized cost-savings to insurers ($684 saved) compared to screening impedance planimetry ($355 saved), while screening impedance planimetry maximized cost-savings to patients ($281 saved) compared to esophageal manometry ($53 saved) (Figure 2A).

Figure 2: Cost-effectiveness of routine esophageal motility testing to evaluate dysphagia after index endoscopy.

Routine testing was cost-saving to insurers (panel A) and patients (panel B). Figures reflect commercially insured patients under 65 years of age. Relationships among strategies for Medicare patients at least 65 years of age were similar (not shown).

For Medicare patients at least 65 years of age, routine esophageal manometry saved $354 to insurers and $62 to patients. Using impedance planimetry would save $176 to insurers and $294 to patients in the Medicare population.

There were no significant differences in modeled health gains or losses among strategies in general gastroenterology populations, because achalasia and absent contractility were rare diagnoses (difference of 0.002 QALY/year). Therefore, cost-effectiveness comparisons on ICER values were not sufficiently accurate for reporting purposes.

At current reimbursement, routine esophageal manometry was the preferred management option from an insurer perspective (Figure 3A). Routine screening impedance planimetry would be cost-saving to patients by avoiding a second visit for esophageal manometry for many patients, but esophageal manometry without screening impedance planimetry would be preferred at higher willingness-to-pay thresholds due to greater accuracy on a single test (Figure 3B).

Figure 3:

Probabilistic sensitivity analyses demonstrate that routine esophageal motility is preferred across contemporary willingness-to-pay ranges from insurer (panel A) and patient perspectives (panel B).

Costs and outcomes with selective motility testing for high index of suspicion for achalasia

To commercial insurers, selective esophageal manometry maximized cost-savings among strategies, with $604 saved to insurers and $202 saved to patients (Figure 2B). Using impedance planimetry as a screening tool for patients with a high index of suspicion for achalasia would cost an additional $36 to insurers and $156 to patients in the commercially insured population due to the higher likelihood of a second visit for manometry. For Medicare patients at least 65 years of age, selective esophageal manometry saved $465 to insurers and $405 to patients. Cost-savings with impedance planimetry as a screening tool in a Medicare population were lower but achievable, saving $287 to insurers and $241 to patients.

When achalasia is strongly suspected, using impedance planimetry to screen for achalasia adds 0.02 QALYs/year and esophageal manometry without impedance planimetry adds 0.03 QALYs/year compared to non-algorithmic usual care. These health gains are averaged across all patients that undergo testing, including the ~85% of patients that do not have achalasia in this setting.

Threshold reimbursement of routine esophageal manometry and screening impedance planimetry

Maximum theoretical reimbursement for routine esophageal manometry was $2,214 to commercial insurers and $1,123 to Medicare based on expected reductions in unnecessary testing/treatment and identification of achalasia including patients for whom the index of suspicion was not high. The maximum theoretical reimbursement for screening impedance planimetry was $1,127 to commercial insurers and $574 to Medicare. These costs included physician and facility fees, which incorporate device costs in a capitated payment model. These estimates varied mostly on assumptions of usual care.

Sensitivity analyses

Patients preferred screening impedance planimetry among referral populations that had a prevalence of achalasia below ~6.0% and prevalence of absent contractility below 1.2% (Supplement Figures 1-2). Otherwise, patients preferred routine esophageal testing over non-algorithmic care across the range of model inputs (Supplement Figures 3-5). Insurer preference depended on the relative costs of diagnostic testing compared to non-algorithmic usual care (Supplement Figures 6-8).

DISCUSSION

To our knowledge, this is the first cost-effectiveness study evaluating utility of foregut motility testing advocated in dysphagia management guidelines.(2,3) Aligned with practice guidelines, we report a cost-effectiveness and cost-minimization analysis demonstrating that routine esophageal motility testing is cost-saving as a next best step in evaluating non-structural/mechanical dysphagia compared to selective testing only for patients with a high index of suspicion for esophageal motility disorders. Impedance planimetry appears cost-saving from a patient perspective to rule out esophageal motility disorders when the index of suspicion for achalasia is low.

In an increasingly value-based environment, the mantra is to minimize unnecessary testing.(19) Our study suggests that avoiding motility testing quietly adds to overall testing burden and costs, due to delay in diagnosis. In other words, the hidden effects of faulty reassurance add to financial and health burden. That these effects are hidden may explain limited adoption of routine esophageal motility testing compared to guidelines. We also demonstrate that motility testing is financially sustainable to insurers if appropriately reimbursed, adding to the argument that such testing is ready for and belongs in general gastroenterology to address common symptoms as advocated in guidelines—much like endoscopy is today.

As a screening tool, impedance planimetry can be performed during index endoscopy, does not require physical space, and can follow a standardized, simplified protocol. Screening tools offer the opportunity to reduce the need for esophageal manometry, recognizing that many practices and hospitals do not presently offer this test. In routine use, the value of impedance planimetry appears to lie in its negative predictive value (high sensitivity with low disease prevalence). As such, this study does not advocate skipping esophageal manometry altogether given that some patients with abnormal impedance planimetry do not have an esophageal motility disorder. Carlson, et al. identified 59.8% and 87.0% specificity of impedance planimetry to detect achalasia and absent contractility, respectively.(17) This suggests that a portion of patients with normal esophageal peristalsis on manometry would undergo unnecessary procedures if impedance planimetry were used as the sole diagnostic tool to diagnose surgically-amenable motility disorders.

The major limitation of our study is that several key model inputs are under-reported in the literature despite them being common across gastroenterology. For example, while non-algorithmic usual care is the status quo in most practices, we did not identify contemporary literature describing such care. Therefore, we modeled observations from our own geographically diverse general gastroenterology practice patterns supported by available evidence.(7,12) Our extensive sensitivity analysis accept that every gastroenterologist will have a strong opinion on their own usual care algorithm. Indeed, our modeling can support that avoiding any further routine testing in patients with a normal endoscopy would be almost as cost-saving as routine esophageal motility testing. Yet such a conclusion would require two additional assumptions: gastroenterologists would have to stand by the decision to defer evaluation for achalasia altogether(20) and would have to decline every opportunity to offer “just one more test”, because these added tests represent the value described in our study.(21) Second, outcomes with absent contractility are not known.(16) Therefore, we assumed that a missed diagnosis would incur costs similar to achalasia in practice, and that positively identifying absent contractility would typically result in conservative management for most patients except in special circumstances at expert centers.(16)

Case-by-case technical limitations with catheter placement should also be considered for individual patients, beyond the scope of our modeling study. For example, manometry catheters may not traverse the esophagogastric junction in achalasia or scleroderma with dilated esophagus. In such cases, the decision to choose manometry catheter placement with endoscopic guidance or impedance planimetry should depend on clinical context rather than economic analysis.(6) Other patients with suspected achalasia may have borderline integrated relaxation pressure values that can be challenging to differentiate from absent contractility. Ultimately, our study focuses on considering motility disorders at all in general gastroenterology, rather than informing practice patterns when a motility disorder is already suspected.(16)

We did not model certain motility disorders such as ineffective esophageal motility that frequently overlaps with normal esophageal function or gastroesophageal reflux, or hypercontractile esophagus that frequently has a benign course.(13,14) Esophagogastric junction outflow obstruction (EGJOO) is a test finding with a broad differential diagnosis rather than a unified disease, and is frequently artifactual, and is less commonly diagnosed with the advent of Chicago Classification version 4.0 that requires supportive findings such as hypercontractility and distal compartmental pressurization, persistent EGJOO in supine and upright positions and on provocative maneuvers.(14) Finally, testing is only as effective as the gastroenterologist that performs and interprets the test, and so we assumed that gastroenterologists should be appropriately trained or have access to competent gastroenterologists to assist with motility testing as a key component to any practice, no different than expectations on performance of endoscopy. As with the intent of guidelines, our study aims to inform where gastroenterology practice could or should be, rather than where the majority of practice stands today.

In summary, our findings provide robust support to longstanding practice guidelines advocating routine esophageal motility testing.(2,3) Our study supports the perceived impression of general gastroenterologists on a day-to-day basis appears correct—routine esophageal motility testing does not appear to change clinical outcome when averaged across all patients, because it intends to find rare diagnoses.(7) And yet, routine esophageal motility testing appears to substantially reduce hidden costs by identifying patients that do not present in a typical fashion, and therefore such testing appears clinically appropriate in routine care.

Figure 4: Sensitivity analysis demonstrates that insurer preferences depend on the cost of motility tests.

Screening impedance planimetry is increasingly preferred among patients with low symptom burden on quality-of-life.

Table 2:

Cost-effectiveness of algorithmic strategies to evaluate non-structural/mechanical dysphagia from commercial insurer (patients below 65 years of age) and Medicare (patients >65 years of age) perspectives.

Strategy	Total cost ($/year)	Total effectiveness (QALY gained/year)	Incremental cost ($)	Incremental effectiveness (quality adjusted life year or QALY)	Incremental cost-effectiveness ratio or ICER ($/QALY-gained)
Routine testing (insurer perspective)
Non-algorithmic usual care	$2,271 (commercial) $1,138 (Medicare)	1.00	Reference	Reference	Reference
Routine screening impedance planimetry, followed by manometry for abnormal impedance planimetry	$1,943 (commercial) $960 (Medicare)	1.00	$328 saved to commercial $178 saved to Medicare	No change	Dominates non-algorithmic usual care
Routine esophageal manometry	$1,588 (commercial) $784 (Medicare)	1.00	$683 saved to commercial $354 saved to Medicare	No change	Dominates other strategies
Routine testing (patient perspective)
Non-algorithmic usual care	$535 (commercial) $505 (Medicare)	1.00	Reference	Reference	Reference
Routine esophageal manometry	$253 (commercial) $211 (Medicare)	1.00	$282 saved to commercial $294 saved to Medicare	No change	Dominates non-algorithmic usual care
Routine screening impedance planimetry, followed by manometry for abnormal impedance planimetry	$200 (commercial) $149 (Medicare)	1.00	$335 saved to commercial $356 saved to Medicare	No change	Dominates other strategies
Selective testing for patients with a high index of suspicion for achalasia (insurer perspective)
Non-algorithmic usual care	$3,027 (commercial) $1,469 (Medicare)	0.96	Reference	Reference	Reference
Screening impedance planimetry, followed by manometry for abnormal impedance planimetry	$3,063 (commercial) $1,291 (Medicare)	0.98	$36 added expense (commercial) $178 saved (Medicare)	+0.02	$2,269/QALY-gained compared to non-algorithmic usual care to commercial insurance Dominates non-algorithmic usual care to Medicare
Esophageal manometry	$2,423 (commercial) $1,004 (Medicare)	0.99	$604 saved (commercial) $465 saved (Medicare)	+0.03	Dominates other strategies
Selective testing for patients with a high index of suspicion for achalasia (patient perspective)
Non-algorithmic usual care	$1,777 (commercial) $1,323 (Medicare)	0.96	Reference	Reference	Reference
Routine screening impedance planimetry, followed by manometry for abnormal impedance planimetry	$1,933 (commercial) $1,159 (Medicare)	0.98	$156 added expense (commercial) $164 saved (Medicare)	+0.02	$9,804/QALY-gained compared to non-algorithmic usual care to commercial insurance Dominates non-algorithmic usual care to Medicare
Routine esophageal manometry	$1,575 (commercial) $917 (Medicare)	0.99	$202 saved (commercial) $406 saved (Medicare)	+0.03	Dominates other strategies

Study highlights.

WHAT IS KNOWN

• Dysphagia is a common symptom in general gastroenterology.

• The appropriate positioning of motility testing in the routine algorithm is controversial due to perceived cost.

WHAT IS NEW HERE

• Esophageal manometry appears more cost-effective than avoiding motility testing to evaluate non-structural/non-mechanical dysphagia following a normal index endoscopy.

• Screening impedance planimetry appears cost-effective to rule out motility disorders when achalasia is unlikely.

• Abnormal screening impedance planimetry requires esophageal manometry to positively diagnose esophageal motility disorders.

• Our findings provide robust evidence on cost-effectiveness to support adoption of recent practice guidelines in general gastroenterology.