The cost-effectiveness of hepatic venous pressure gradient monitoring in the prevention of recurrent variceal hemorrhage.
OBJECTIVE
Recurrent variceal hemorrhage is common following an initial bleed in patients with cirrhosis. The current standard of care for secondary prophylaxis is endoscopic band ligation (EBL). Combination of beta-blocker and nitrate therapy, guided by hepatic venous pressure gradient (HVPG) monitoring, is a novel alternative strategy. We sought to determine the cost-effectiveness of these competing strategies.


METHODS
Decision analysis with Markov modeling was used to calculate the cost-effectiveness of three competing strategies: (1) EBL; (2) beta-blocker and nitrate therapy without HVPG monitoring (HVPG-); and (3) beta-blocker and nitrate therapy with HVPG monitoring (HVPG+). Patients in the HVPG+ strategy who failed to achieve an HVPG decline from medical therapy were offered EBL. Cost estimates were from a third-party payer perspective. The main outcome measure was the cost per recurrent variceal hemorrhage prevented.


RESULTS
Under base-case conditions, the HVPG+ strategy was the most effective yet most expensive approach, followed by EBL and HVPG-. Compared to the EBL strategy, the HVPG+ strategy cost an incremental 5,974 dollars per recurrent bleed prevented. In a population with 100% compliance with all therapies, the incremental cost of HVPG-versus EBL fell to 5,270 dollars per recurrent bleed prevented. The model results were sensitive to the cost of EBL, the cost of HVPG monitoring, and the probability of medical therapy producing an adequate HVPG decline.


CONCLUSIONS
Compared to EBL for the secondary prophylaxis of variceal rebleeding, combination medical therapy guided by HVPG monitoring is more effective and only marginally more expensive.
Targownik
Laura E
LE
Section of Gastroenterology, University of Manitoba, Winnipeg, Manitoba, Canada.
Spiegel
Brennan M R
BM
Dulai
Gareth S
GS
Karsan
Hetal A
HA
Gralnek
Ian M
IM
D000319:Adrenergic beta-Antagonists / Q000191:economics / Q000627:therapeutic use; D001795:Blood Pressure Determination / Q000191:economics*; D003362:Cost-Benefit Analysis; D016145:Endoscopy, Digestive System / Q000191:economics; D004784:Environmental Monitoring / Q000191:economics; D004932:Esophageal and Gastric Varices / Q000150:complications*; D006471:Gastrointestinal Hemorrhage / Q000191:economics / Q000517:prevention & control* / Q000628:therapy; D006503:Hepatic Veins / Q000503:physiopathology*; D006801:Humans; D008026:Ligation / Q000191:economics; D008390:Markov Chains; D009566:Nitrates / Q000191:economics / Q000627:therapeutic use; D012008:Recurrence; D012680:Sensitivity and Specificity; D016896:Treatment Outcome
D000319:Adrenergic beta-Antagonists; D009566:Nitrates