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COST EFFECTIVENESS ANALYSIS OF PRIMARY PROPHYLAXIS FOR VARICEAL BLEEDING IN PATIENTS WITH CIRRHOSIS: A CHALLENGE TO CURRENT GUIDELINES
F Tse, P Moayyedi, D Armstrong, J Marshall, R Goeree
BACKGROUND: Current guidelines recommend that all patients with cirrhosis undergo screening endoscopy (EGD), and primary prophylaxis with a non-selective beta-blocker (BB) for patients with large varices. Endoscopic banding ligation (EBL) is also effective in preventing variceal bleeding. The cost-effectiveness of these different approaches remains unclear.
AIM: To compare, over a 5-year period, the expected costs and outcomes of 4 primary prophylaxis strategies for variceal bleeding in patients with cirrhosis.
METHODS: A Markov model was developed to evaluate the cost effectiveness of 4 primary prophylaxis strategies for variceal bleeding in patients with compensated and decompensated cirrhosis: (1) Screening EGD and BB, (2) Do nothing, (3) Universal BB, and (4) Screening EGD and EBL. The hypothetical cohort consisted of patients with newly diagnosed cirrhosis and no history of variceal bleeding. The perspective was that of a third-party payer. Clinical probability estimates were derived from published literature. Cost estimates were obtained from Ontario provincial databases, and expressed in Canadian dollars at 2007. The primary outcome was incremental cost per life-year saved. Probabilistic sensitivity analyses were carried out for all model parameters.
RESULTS: Universal BB was the most cost effective strategy in both compensated and decompensated patients. The strategy of screening EGD and EBL for large varices cost an additional $46,450 and $17,170 to gain 1 additional life-year in compensated and decompensated patients, respectively. The results were most sensitive to the probability of bleeding from small varices.
CONCLUSION: Current guidelines recommending screening EGD followed by BB therapy for large varices may not be cost effective. Universal BB therapy and universal screening EGD followed by EBL for large varices are the 2 most cost effective strategies. Choosing between these 2 strategies depends on the societal willingness-to-pay thresholds for health gain.