HOME
Return to Table of Contents
88 COST-EFFECTIVENESS COMPARING ELECTIVE OR ON DEMAND POLYETHYLENE STENT CHANGES TO COVERED OR UNCOVERED SELF-EXPANDABLE METAL STENTS IN PATIENTS WITH DISTAL MALIGNANT BILIARY OBSTRUCTION EB da Silveira, K Waschke, A Barkun, L Joseph, V Adam, O Oxlade
INTRODUCTION: Endoscopic placement of polyethylene (PE) and metal stents is the preferred palliative treatment in nonoperative candidates. The choice of the most cost-effective (CE) treatment is not clear due to variations in procedure and stent-related costs, patency of stents and uncertainty about patient survival.
AIM: To assess the cost-effectiveness of two strategies with PE, or uncovered or covered self-expandable metal stents (U-SEMS or C-SEMS) in patients with distal malignant biliary obstruction.
METHODS: A Markov model studied four initial approaches: 1) PE with replacement on demand (PE-D); 2) PE changed every three months (PE-Q3); 3) U-SEMS or 4) C- SEMS. Probabilities of stent insertion, occlusion and patient survival were abstracted from randomized trials and imputed to a 12-month time horizon. Effectiveness was calculated as number of occlusion-free months. Procedural and complication-related costs were derived from the Canadian Institutes for Health, adopting a third-party payer perspective.
RESULTS: PE-D had the lowest CE ratio followed by C-SEMS at an incremental cost-effectiveness ratio (ICER) of $1,919.42/month of stent patency. C-SEMS had the lowest CE ratio if: the probability of survival at 12 months was over 90%, or the ERCP costs were greater than $2,521.80, or costs for stent occlusion-associated cholangitis were over $8,185.50, or the probability of stent-occlusion associated cholangitis for PE exceeded 68%, or if the costs of C-SEMS were under $1,279.60. Although dominated for the base-case scenario, PE-Q3 was the preferred strategy if ERCP costs were below $233.30, or for a lower probability of stent occlusion or shorter life expectancy. Rates and costs of SEMS-associated pancreatitis and cholecystitis had little impact on CE ratios.
CONCLUSION: Initial insertion of PE stent and its on-demand replacement yields the lowest CE ratio. C-SEMS is a cost-effective alternative if cheaper or when costs for ERCP and complications or its rates are high. Periodic replacement of PE is unlikely to be CE.
Strategy
Cost (CDN$)
Effectiveness (months)
Average C/E (CDN$/months)
ICER (CDN$/months)
PE-D
2,363.3
5.07
465.54
C-SEMS
2,883.7
5.34
539.25
1,919.42
U-SEMS
2,890.8
5.34
540.58
Dominated
PE-Q3
3,222.9
5.07
634.86
Dominated