Prophylaxis of Esophageal Variceal Bleeding: A Cost-Utility Analysis Comparing Five Strategies
Keywords:prevention, esophageal varices, hemorrhage, economics, cost-utility analysis
Objectives: To compare the cost-utility of five strategies for preventing esophageal variceal bleeding: (1) universal primary beta-blocker prophylaxis; (2) selective primary beta-blocker prophylaxis; (3) primary endoscopic rubber band ligation (EBL) prophylaxis; (4) secondary beta -blocker prophylaxis; and (5) secondary EBL prophylaxis. The economic viewpoint was that of third-party payers.
Methods: A decision analysis was performed based on a six-state Markov model. Data on the transition probabilities between states for each prophylactic strategy were derived from a systematic search of the literature. Data on the cost of each strategy were from hospital charges to patients with bleeding esophagogastric varices admitted to the authors' hospital during the years 2002 to 2004. Effectiveness was measured using Quality Adjusted Life-Years (QALY). The outcome of the analysis was the incremental cost-utility ratio between the two most effective strategies. The cost-utility ratios were compared with the willingness-to-pay of Baht 10,000 (250 US dollars) or Baht 100,000 (2500 US dollars). Both one-way and multiway sensitivity analyses were performed.
Results: Primary EBL prophylaxis was the most cost-effective long-term (greater than five years) strategy for the prevention of bleeding esophageal varices, while universal primary be ta-blocker prophylaxis was most cost-effective in the short term. Sensitivity analyses did not substantially affect this result.
Conclusion: Primary EBL prophylaxis is the recommended strategy for the prevention of esophageal varices bleeding in the long-term.
2. Rubenstein JH, Eisen GM, Inadomi JM. A cost-utility analysis of secondary prophylaxis for variceal hemorrhage. Am J Gastroenterol 2004;99:1274-88.
3. Arguedas MR, Heudebert GR, Eloubeidi MA, et al. Cost-effectiveness of screening, surveillance, and primary prophylaxis strategies for esophageal varices. Am J Gastroenterol 2002;97:2441-52.
4. Hicken BL, Sharara Al, Abrams GA, et al, Arguedas MR. Hepatic venous pressure gradient measurements to asses response to primary prophylaxis in patients with cirrhosis: a decision analytical study. Aliment Pharmacol Ther 2003: 17:145-53.
5. Carbonell N, Pauwels A, Serfaty L, et al. Improved survival after variceal bleeding in patients with cirrhosis over past two decades. Hepatology 2004; 40: 652-9.
6. Talwalkar JA, Kamath Ps. An evidence-based medicine approach to beta-blocker therapy in patients with cirrhosis, Am J Med 2004; 116: 759-66.
7. Lui HF, Stanley AJ, Forrest EH, et al. Primary prophylaxis of variceal hemorrhage: a randomized controlled trial comparing band ligation, propanolol and isosorbide mononitrate, Gastroenterology 2002; 123: 735-44.
8. Narahara Y, Kanazawa H, Kawamata H, et al. A randomized clinical trial comparing transjugular intrahepatic portosystemic shunt with endoscopic sclerotherapy in the long-term management of patients with cirrhosis after recent variceal hemorrhage. Hepatology Res 2001; 21: 189-98.
9. Henderson JM, Barnes DS, Geisinger MA. Portal hypertension, Curr Probl Surg 1998; 35: 379-452.
10. Henderson JM, Nagle A, Curtas S, et al. Surgical shunts and TIPS for variceal decompression in the 1990s. Surgery 2000;128:540-47.
11. Bosch J, Garcia-Pagan JC. Prevention of variceal rebleeding. Lancet. 2003; 361: 952-54.
12. Imperiale TF, Chalasani N. A meta-analysis of endoscopic variceal ligation for primary prophylaxis of esophageal variceal bleeding. Hepatology 2001; 33: 802-7.
13. Sarin SK, Lamba GS, Kumar M, et al. Comparison of endoscopic ligation and propanolol for the primary prevention of variceal bleeding. N Engl J Med 1999;340:988-93.
14. Schepke M, Kleber G, Nurnberg D, et al. Ligation versus propanolol for the primary prophylaxis of variceal bleeding in cirrhosis. Hepatology 2004; 40:65-72.
15. Lo GH, Chen WC, Chen MH, et al. Endoscopic ligation versus nadolol in the prevention of first variceal bleeding in patients with cirrhosis. Gastrointest Endosc 2004;59: 333-8.
16. Garcia-Pagan JC, Morillas R, Banares R, et al. propanolol plus placebo versus propanolol plus isosorbide-5-mono-nitrate in the prevention of a first variceal bleed: a double blind RCT. Hepatology 2003: 37: 1260-6.
17. Lo GH, Chen WC, Chen MH, et al. Banding ligation versus nadolol and isosorbide mononitrate for the prevention of esophageal varices bleeding. Gastroenterology 2002; 123:728-34.
18. Drummond MF, O'Brien B, Stoddart GL, Torrance GW. Methods for the economic evaluation of health care programs. 2nd ed. Oxford: Oxford University Press, 1997.
19. Doubilet P, McNeil BJ. Clinical decision making. Med Care 1985;23:648-62.
20. Coast J. Is economic evaluation in touch with society's health values? BMJ, 2004; 329:1233-6.
21. Aoki N, Kajjyama T, Beck JR, et al. Decision analysis of prophylactic treatment for patients with high-risk esophageal varices. Gastrointest Endosc 2000;52: 707-14.
22. Targownik LE, Spiegel BMR, Dulai GS, et al. The cost-effectiveness of hepatic venous pressure gradient monitoring in the prevention of recurrent variceal bleeding. Am J Gastroenterol 2004; 99: 1306-15.
23. Raines DL, Dupont AW, Arguedas MR. Cost-effectiveness of hepatic venous pressure gradient measurements for prophylaxis of variceal re-bleeding. Aliment Pharmacol Ther 2004; 19:571-81.
24. Spiegel BM, Targownik L, Dulai GS, et al. Endoscopic screening for esophageal varices in cirrhosis: is it ever cost-effective? Hepatology 2003; 37: 366-77.
25. Sonnenberg FA, Beck JR. Markov models in medical decision making: a practical guide. Med Decis Making 1993;13:322-38.
26. Jalan R, Hayes PC, UK guidelines on the management of variceal hemorrhage in cirrhotic patients. Gut 2000; 46 (Suppl III): iii1-iii15.
27. Younossi ZM, Boparai N, McCormick M, et al. Assessment of utilities and health-related quality of life in patients with chronic liver disease. Am J Gastroenterol 2001; 96: 579-83.
28. Chong AKY, Gulamhussein A, Heathcote J, et al. Health-state utilities and quality of life in hepatitis C patients. Am J Gastroenterol 2003:98: 630-8.
29. Bennett WG, Inoue Y, Beck JR, et al. Estimates of the cost-effectiveness of a single course of interferon-allpha2b in patients with histologically mild chronic hepatitis C. Ann Intern Med 1997; 127: 855-65.
30. Tomikawa M, Shimabukuro R, Okita K, et al. Propanolol alone may not be acceptable to prevent first esophageal bleeding in Japanese cirrhotic patients: randomized controlled trial, J Gastroenterol Hepatol 2004; 19: 576-81.
31. Lopes CV, Pereira-Lima LF, Hornos AP, et al. The efficacy of endoscopic ligation for the prevention of variceal rebleeding in cirrhotic patients according to the hepatocellular function. Hepatogastroenterology 2004;51:195-200.
32. Beck JR, Pauker SG, Gottlieb JE, et al. A convenient approximation of life expectancy (the "DEALE") II. Use in medical decision making. Am J Med 1982; 73: 889-897.
33. Japanese International Cooperation Agency (JICA)-Thailand. Directions for development and aid priority sectors in Thailand (cited 2004 Dec 29), Available from: URL: http://www.jica.go.jp/english/index.html
34. Shah V, Long KH. Modeling our way toward the optimal management of variceal hemorrhage. Am J Gastroenterol 2004;99:1289-90.
35. Zoli M, Merkel C, Magalotti D, et al. Natural history of cirrhotic patients with small esophageal varices; a prospective study. Am J Gastroenterol. 2000;95:503-8.
36. Merli M, Nicolini G, Angeloni S, et al, Incidence and natural history of small esophageal varices in cirrhotic patients. J Hepatology 2003; 38: 266-72.
37. van Buuren HR, Rasch MC, Batenburg PL, et al. Endoscopic sclerotherapy compared with no specific treatment for the primary prevention of bleeding from esophageal varices. A randomized controlled multicentre trial (ISRCTNO3215899). BMC Gastroenterol 2003: 3: 22-31.
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