A cost-utility analysis of secondary prophylaxis for variceal hemorrhage.
BACKGROUND
Secondary prophylaxis for esophageal variceal hemorrhage (VH) is recommended, but there has never been a cost-utility analysis of its implementation.


OBJECTIVE
The objective was to compare the cost utility of various strategies for the secondary prophylaxis of VH including (a) observation alone, (b) medical therapy (MED), (c) endoscopic band ligation (EBL), (d) endoscopic band ligation plus medical therapy (EBL + M), and (e) transjugular intrahepatic portosystemic shunt (TIPS), and to examine the effect of adherence on these strategies.


METHODS
A Markov model was developed for all five strategies, and included surveillance, risk of hepatic encephalopathy, complications, and nonadherence.


METHODS
Published literature and the Health Care Financing Administration.


METHODS
People with cirrhosis and a history of controlled VH.


METHODS
Three years.


CONCLUSIONS
Third-party payer.


METHODS
Incremental cost-effectiveness ratios for quality-adjusted life-years (QALYs) gained.


RESULTS
Combination EBL + M was the optimal strategy, dominating all other strategies including observation, meaning that it was more effective and less expensive than the others. In addition, EBL alone dominated observation and TIPS in terms of QALYs, and MED alone dominated the strategy of observation in terms of QALYs.


RESULTS
Important variables affecting the optimal strategy were the odds ratio (OR) of VH with EBL compared to MED, the OR of VH with EBL + M compared to EBL, and patients' preferences regarding taking the medication as reflected in the associated toll exacted on the health state utility. Variations in these parameters within the range of clinical plausibility allowed EBL or MED to become the optimal strategy. TIPS was the optimal strategy only if adherence rates for all strategies were less than 12%. RESULTS OF MONTE CARLO ANALYSIS: Neither observation nor TIPS was ever the optimal strategy, and EBL + M was optimal in 62% of cases. If the variables identified in the sensitivity analysis were controlled, then EBL + M was optimal in 95% of cases.


CONCLUSIONS
TIPS should be reserved only for patients with very poor adherence. Otherwise, patients are best served by medications, EBL, or a combination of both, depending on the comparative rates of rebleeding with each and patients' preferences regarding medical therapy. The redundancy of combination band ligation plus medical therapy can improve outcomes, particularly in the setting of poor patient adherence.
Rubenstein
Joel H
JH
Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan 48109-0362, USA.
Eisen
Glenn M
GM
Inadomi
John M
JM
D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D003131:Combined Modality Therapy; D003362:Cost-Benefit Analysis; D016099:Endoscopy, Gastrointestinal / Q000191:economics; D004932:Esophageal and Gastric Varices / Q000150:complications*; D006471:Gastrointestinal Hemorrhage / Q000191:economics / Q000517:prevention & control*; D006801:Humans; D008390:Markov Chains; D008875:Middle Aged; D016017:Odds Ratio; D010342:Patient Acceptance of Health Care; D010349:Patient Compliance; D019168:Portasystemic Shunt, Transjugular Intrahepatic / Q000191:economics; D012680:Sensitivity and Specificity; D016896:Treatment Outcome