Cost-Effectiveness of Endoscopic Submucosal Dissection Versus Endoscopic Mucosal Resection for Barrett’s Esophagus–Associated Neoplasia

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Aims Endoscopic submucosal dissection (ESD) is increasingly used for Barrett’s esophagus–associated neoplasia due to superior en bloc and R0 resection rates compared with endoscopic mucosal resection (EMR). However, its cost-effectiveness in the United States remains uncertain due to a lack of standardized reimbursement codes for ESD. We evaluated the cost-effectiveness of ESD versus EMR using pooled clinical outcomes and contemporary U.S. Medicare payment data. Methods A decision-analytic model was developed from a U.S. Medicare perspective over a two-year horizon. Clinical probabilities were extracted from two meta-analyses ( Fujiyoshi 2024 , Radadiya 2024 ). Key pooled inputs included R0 resection (ESD 78% vs EMR 67%), recurrence (ESD 2% vs EMR 6%), perforation (1% vs 0.1%), delayed bleeding (10% vs 8%), and esophagectomy rates (ESD 8% vs EMR 5%). Costs were derived from 2024 Medicare national average payments and standardized inpatient cost benchmarks. QALYs incorporated decrements for recurrence, complications, strictures, and esophagectomy. Outcomes included total cost, QALYs, ICER, and net monetary benefit (NMB) at a $100,000/QALY threshold. One-way sensitivity analysis was performed. Results ESD costs $9,761.92 per patient versus $5,826.76 for EMR. QALYs were slightly lower with ESD (1.87180 vs 1.87638). ESD remained dominant, more costly, and less effective with an incremental cost of $3,935 and incremental QALY of –0.00458. Incremental NMB favored EMR by $4,393. Sensitivity analysis identified the ESD index procedure cost and ESD esophagectomy probability as the most influential parameters; however, ESD did not become cost-effective under any plausible range. Conclusions Despite superior en bloc and R0 resection, ESD is not cost-effective compared with EMR for Barrett’s-associated neoplasia under current U.S. Medicare reimbursement. Our limitations include a shorter follow-up period of 2 years and the absence of comprehensive prospective studies reporting the use of adjunctive therapies post-EMR, like cryoablation, radiofrequency ablation, or repeat EMR, which could increase the costs associated with the procedure and reduce its cost-effectiveness. Furthermore, higher esophagectomy rates post-ESD might be associated with advanced lesions to start with compared to EMR. ESD may become cost-effective with standardized reimbursement codes and lower esophagectomy in future large prospective studies. Publication History Article published online: 05 June 2026 © 2026. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

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