Cost-effectiveness analysis of variceal ligation vs. beta-blockers for primary prevention of variceal bleeding.
Although both beta-blockade (BB) and endoscopic variceal ligation (EVL) are used for primary prevention of variceal bleeding (VB) in patients with cirrhosis with moderate to large esophageal varices (EVs), the more cost-effective option is uncertain. We created a Markov decision model to compare BB and EVL in such patients, examining both cost-effectiveness (cost per life year [LY]) and cost-utility (cost per quality-adjusted life year [QALY]). Outcomes included cost per LY, cost per QALY, proportions of persons with VB, TIPS, and all-cause mortality. EVL and BB were compared using the incremental cost-effectiveness ratio (ICER) and incremental cost-utility ratio (ICUR). When considering only LYs, initial EVL exceeds the benchmark of 50,000 dollars/LY, with an ICER of 98,407 dollars. However, when quality of life (QoL) is considered, EVL is cost-effective compared to BB (ICUR of 25,548 dollars/QALY). In sensitivity analysis, EVL is cost-effective if the yearly risk of EV bleeding is > or = 0.26 (base case 0.15), the relative risk of bleeding on BB is > or = 0.69 (base case 0.58), or if the relative risk of bleeding with EVL is < 0.27 (base case 0.35). The ICUR favored EVL unless the relative risk of bleeding on BB is < 0.46, the relative risk of bleeding with EVL is > 0.46, or the time horizon is < or = 24 months. Whether EVL is "cost-effective" relative to BB therapy for primary prevention of EV bleeding depends on whether LYs or QALYs are considered. If only LYs are considered, then EVL is not cost-effective compared to BB therapy; however, if QoL is considered, then EVL is cost-effective.
Imperiale
Thomas F
TF
Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
Klein
Robert W
RW
Chalasani
Naga
N
D000319:Adrenergic beta-Antagonists / Q000191:economics* / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D004932:Esophageal and Gastric Varices / Q000188:drug therapy* / Q000191:economics / Q000601:surgery*; D006471:Gastrointestinal Hemorrhage / Q000517:prevention & control*; D006801:Humans; D008026:Ligation / Q000191:economics; D018803:Models, Economic; D011788:Quality of Life; D014656:Vascular Surgical Procedures / Q000191:economics*
D000319:Adrenergic beta-Antagonists