Decision analysis of prophylactic treatment for patients with high-risk esophageal varices.
BACKGROUND
Clinical decision analyses were conducted to quantify the uncertainty and to identify important factors in selection of prophylactic therapy for patients with esophageal varices.


METHODS
A Markov model compared variceal ligation, beta-blockers, and "watchful waiting" strategies in terms of bleeding-free life years. Transition probabilities were obtained from meta-analyses of published data. A hypothetical 50-year-old white man with high-risk esophageal varices and cirrhosis served as the prototypical baseline case. Traditional n-way sensitivity analyses were applied to clarify the influence of each factor, and Monte Carlo probabilistic sensitivity analyses were used to investigate clinical uncertainty.


RESULTS
Probabilistic sensitivity analyses demonstrated that 77.0% of hypothetical cases had more bleeding-free life years after variceal ligation, whereas 23% had more when treated with beta-blockers. On the basis of one-way sensitivity analyses, only 2 factors (variceal bleeding rates after ligation and treatment with beta-blockers) influenced the strategy choice.


CONCLUSIONS
Variceal ligation is an effective prophylactic therapy in many cases, but nearly one quarter of patients with high-risk esophageal varices and cirrhosis may benefit more from prophylactic treatment with beta-blockers. Additional clinical studies identifying key variceal bleeding risk factors may lead to more effective clinical decision making for these patients.
Aoki
N
N
Information Technology, Baylor College of Medicine, Houston, Texas 77030, USA. Kansai Denryoku Hospital, Osaka, and Departmen.
Kajiyama
T
T
Beck
J R
JR
Cone
R W
RW
Soma
K
K
Fukui
T
T
D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage*; D016001:Confidence Intervals; D003661:Decision Support Techniques; D004932:Esophageal and Gastric Varices / Q000517:prevention & control / Q000628:therapy*; D006471:Gastrointestinal Hemorrhage / Q000517:prevention & control*; D006801:Humans; D008026:Ligation / Q000379:methods; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D008962:Models, Theoretical; D009010:Monte Carlo Method; D011336:Probability; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D013997:Time Factors
D000319:Adrenergic beta-Antagonists