Primary prophylaxis of variceal bleeding in cirrhosis: a cost-effectiveness analysis.
OBJECTIVE
Prophylaxis against the first variceal bleeding has been proposed to reduce morbidity and mortality in cirrhotic patients. No previous information is available regarding the cost-effectiveness of prophylaxis. The aim of this study was to compare the cost-effectiveness of variceal bleeding prophylaxis with propranolol, sclerotherapy, and shunt surgery in cirrhotic patients stratified by bleeding risk.


METHODS
A hypothetical cohort was stratified according to bleeding risk. The natural history of cirrhosis with esophageal varices was simulated using a Markov model. Transitional probabilities extracted from published studies and costs were obtained from our institution's billing department. Sensitivity analyses were performed for important variables.


RESULTS
Propranolol results in cost savings ranging between $450 and $14,600 over a 5-year period. The extent of cost savings depended on the individual patient's bleeding risk. In addition, propranolol increased the quality-adjusted life expectancy by 0.1-0.4 years. Sclerotherapy was significantly less cost-effective than propranolol and had no advantage on quality of life. Shunt surgery was effective therapy for prevention of bleeding but decreased life expectancy and quality of life in some risk groups and was not cost-effective.


CONCLUSIONS
Propranolol is the only cost-effective form of prophylactic therapy for preventing initial variceal bleeding in cirrhosis regardless of bleeding risk.
Teran
J C
JC
Department of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA.
Imperiale
T F
TF
Mullen
K D
KD
Tavill
A S
AS
McCullough
A J
AJ
D003362:Cost-Benefit Analysis; D004932:Esophageal and Gastric Varices / Q000209:etiology / Q000601:surgery / Q000628:therapy*; D017048:Health Care Costs; D006470:Hemorrhage / Q000209:etiology* / Q000517:prevention & control*; D006801:Humans; D008017:Life Expectancy; D008103:Liver Cirrhosis / Q000150:complications*; D011336:Probability; D011433:Propranolol / Q000627:therapeutic use; D012307:Risk Factors; D015911:Sclerotherapy; D012680:Sensitivity and Specificity
D011433:Propranolol