Costs and clinical outcomes of primary prophylaxis of variceal bleeding in patients with hepatic cirrhosis: a decision analytic model.
OBJECTIVE
Current guidelines recommend upper endoscopic screening for patients with hepatic cirrhosis and primary prophylaxis with a nonselective beta-blocker for those with large varices.


METHODS
However, only 25% of cirrhotics develop large varices. Thus, the aim of this study is to evaluate the most cost-effective approach for primary prophylaxis of variceal hemorrhage.


RESULTS
Using a Markov model, we compared the costs and clinical outcomes of three strategies for primary prophylaxis of variceal bleeding. In the first strategy, patients were given a beta-blocker without undergoing upper endoscopy. In the second strategy, patients underwent upper endoscopic screening; those found to have large varices were treated with a beta-blocker. In the third strategy, no prophylaxis was used. Selected sensitivity analyses were performed to validate outcomes. Our results show screening prophylaxis was associated with a cost of $37,300 and 5.72 quality-adjusted life yr (QALYs). Universal prophylaxis was associated with a cost of $34,100 and 6.65 QALYs. The no prophylaxis strategy was associated with a cost of $36,600 and 4.84 QALYs. The incremental cost-effectiveness ratio was $800/QALY for the endoscopic strategy relative to the no prophylaxis strategy. Screening endoscopy was cost saving when the compliance, bleed risk without beta-blocker, and variceal bleed costs were increased, and when the discount rate, bleed risk on beta-blockers, and cost of upper endoscopy were decreased. In contrast, the universal prophylaxis strategy was persistently cost saving relative to the no prophylaxis strategy. In comparing the strategies, sensitivity analysis on the death rates from variceal hemorrhage did not alter outcomes.


CONCLUSIONS
Our results provide economic and clinical support for primary prophylaxis of esophageal variceal bleeding in patients with hepatic cirrhosis. Universal prophylaxis with beta-blocker is preferred because it is consistently associated with the lowest costs and highest QALYs.
Division of Digestive Diseases, Department of Medicine, Dumont-UCLA Liver Transplant Center, Los Angeles, CA 90095, USA.
Sammy
S
Saab
Vincent
V
DeRosa
Jose
J
Nieto
Francisco
F
Durazo
Steven
S
Han
Bennett
B
Roth
D000319:Adrenergic beta-Antagonists / Q000191:economics* / Q000627:therapeutic use*; D000328:Adult; D003661:Decision Support Techniques; D016099:Endoscopy, Gastrointestinal / Q000191:economics* / Q000706:statistics & numerical data*; D004932:Esophageal and Gastric Varices / Q000191:economics* / Q000209:etiology / Q000517:prevention & control*; D005500:Follow-Up Studies; D006471:Gastrointestinal Hemorrhage / Q000191:economics* / Q000209:etiology / Q000517:prevention & control*; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications / Q000191:economics* / Q000628:therapy*; D008390:Markov Chains; D017063:Outcome Assessment, Health Care / Q000191:economics* / Q000706:statistics & numerical data*; D011788:Quality of Life; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index
D000319:Adrenergic beta-Antagonists