Liver Failure/ Cirrhosis /Portal Hypertension
Article first published online: 27 MAR 2012
Copyright © 2011 American Association for the Study of Liver Diseases
Volume 55, Issue 4, pages 1164–1171, April 2012
How to Cite
Bajaj, J. S., Pinkerton, S. D., Sanyal, A. J. and Heuman, D. M. (2012), Diagnosis and treatment of minimal hepatic encephalopathy to prevent motor vehicle accidents: A cost-effectiveness analysis. Hepatology, 55: 1164–1171. doi: 10.1002/hep.25507
Potential conflict of interest: Nothing to report.
Supported, in part, by grant P30MH52776 from the National Institute of Mental Health, by grant U01AT004428 from the National Center for Complementary and Alternative Medicine, by grant R01DK087913, from the National Institute of Diabetes and Digestive and Kidney Diseases, and by an American College of Gastroenterology Junior Faculty Development Award grant.
Portions of this article were presented as an oral presentation at the American College of Gastroenterology Annual Meeting in Orlando and the abstract was awarded the ACG Board of Governors' Award for Excellence in Clinical Research.
See Editorial on Page 985
- Issue published online: 27 MAR 2012
- Article first published online: 27 MAR 2012
- Accepted manuscript online: 2 DEC 2011 01:19AM EST
- Manuscript Accepted: 18 NOV 2011
- Manuscript Received: 31 AUG 2011
Minimal hepatic encephalopathy (MHE) in cirrhosis is associated with impaired driving skills and increased risk of motor vehicle accidents (MVAs). Detection and treatment of MHE has the potential to reduce costs and morbidity associated with MVAs. We conducted a cost-effectiveness analysis to assess the benefits of different strategies of MHE diagnosis and treatment for reducing MVA-related societal costs. The analyses compared five MHE management strategies: (1) presumptive treatment of all cirrhosis patients; (2) diagnosis by neuropsychological exam (NPE) with treatment; (3) diagnosis by standard psychometric tests (SPTs) with treatment; (4) diagnosis by rapid screening using inhibitory control test (ICT) with treatment; and (5) no MHE diagnosis or treatment (status quo). Treatments considered were lactulose or rifaximin, which were assumed to reduce the MVA rate to the level of similarly aged noncirrhosis patients with benefit adjusted for treatment compliance. A Markov model followed a simulated cohort of 1,000 cirrhosis patients without overt hepatic encephalopathy (OHE), from entry into treatment, through MHE development, and later OHE, when they exited the modeled cohort. Follow-up was for 5 years and included biannual MHE testing. The societal cost of a single MVA was estimated at $42,100. All four strategies with lactulose were cost-saving compared with the status quo. Diagnosis with ICT and lactulose was the most cost-effective approach (cost/MVA prevented: $24,454 ICT; $25,470 SPT; $30,469 presumptive treatment and $33,742 NPE). Net program savings over 5 years ranged from $1.7 to 3.6 million depending on the strategy. Rifaximin therapy was not cost-saving at current prices but would become so at a monthly cost of <$353. Conclusion: Detection of MHE, especially using the ICT, and subsequent treatment with lactulose could substantially reduce societal costs by preventing MVAs. (HEPATOLOGY 2012)