Cost-effectiveness analysis of variceal ligation vs. beta-blockers for primary prevention of variceal bleeding

Authors

  • Thomas F. Imperiale,

    Corresponding author
    1. Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, IN
    2. The Regenstrief Institute Inc., Indianapolis, IN
    • The Regenstrief Institute Inc., 1050 Wishard Boulevard, Indianapolis, IN 46202
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    • Fax: 317-630-6611

  • Robert W. Klein,

    1. Medical Decision Modeling Inc., Indianapolis, IN
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  • Naga Chalasani

    1. Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, IN
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  • Potential conflict of interest: Nothing to report.

Abstract

Although both β-blockade (BB) and endoscopic variceal ligation (EVL) are used for primary prevention of variceal bleeding (VB) in patients with cirrhosis with moderate to large esophageal varices (EVs), the more cost-effective option is uncertain. We created a Markov decision model to compare BB and EVL in such patients, examining both cost-effectiveness (cost per life year [LY]) and cost-utility (cost per quality-adjusted life year [QALY]). Outcomes included cost per LY, cost per QALY, proportions of persons with VB, TIPS, and all-cause mortality. EVL and BB were compared using the incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR). When considering only LYs, initial EVL exceeds the benchmark of $50,000/LY, with an ICER of $98,407. However, when quality of life (QoL) is considered, EVL is cost-effective compared to BB (ICUR of $25,548/QALY). In sensitivity analysis, EVL is cost-effective if the yearly risk of EV bleeding is ≥ 0.26 (base case 0.15), the relative risk of bleeding on BB is ≥ 0.69 (base case 0.58), or if the relative risk of bleeding with EVL is < 0.27 (base case 0.35). The ICUR favored EVL unless the relative risk of bleeding on BB is < 0.46, the relative risk of bleeding with EVL is > 0.46, or the time horizon is ≤ 24 months. Whether EVL is “cost-effective” relative to BB therapy for primary prevention of EV bleeding depends on whether LYs or QALYs are considered. If only LYs are considered, then EVL is not cost-effective compared to BB therapy; however, if QoL is considered, then EVL is cost-effective. (HEPATOLOGY 2007;45:870–878.)

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