title: Cost-effectiveness analysis of beta-blockers vs endoscopic surveillance in patients with cirrhosis and small varices.
abstract: OBJECTIVE
  To evaluate the most cost-effectiveness strategy for preventing variceal growth and bleeding in patients with cirrhosis and small esophageal varices.
  
  
  METHODS
  A stochastic analysis based on decision trees was performed to compare the cost-effectiveness of beta-blockers therapy starting from a diagnosis of small varices (Strategy 1) with that of endoscopic surveillance followed by beta-blockers treatment when large varices are demonstrated (Strategy 2), for preventing variceal growth, bleeding and death in patients with cirrhosis and small esophageal varices. The basic nodes of the tree were gastrointestinal endoscopy, inpatient admission and treatment for bleeding, as required. All estimates were performed using a Monte Carlo microsimulation technique, consisting in simulating observations from known probability distributions depicted in the model. Eight-hundred-thousand simulations were performed to obtain the final estimates. All estimates were then subjected to Monte Carlo Probabilistic sensitivity analysis, to assess the impact of the variability of such estimates on the outcome distributions.
  
  
  RESULTS
  The event rate (considered as progression of varices or bleeding or death) in Strategy 1 [24.09% (95%CI: 14.89%-33.29%)] was significantly lower than in Strategy 2 [60.00% (95%CI: 48.91%-71.08%)]. The mean cost (up to the first event) associated with Strategy 1 [823 £ (95%CI: 106 £-2036 £)] was not significantly different from that of Strategy 2 [799 £ (95%CI: 0 £-3498 £)]. The cost-effectiveness ratio with respect to this endpoint was equal to 50.26 £ (95%CI: -504.37 £-604.89 £) per event avoided over the four-year follow-up. When bleeding episodes/deaths in subjects whose varices had grown were included, the mean cost associated with Strategy 1 was 1028 £ (95%CI: 122 £-2581 £), while 1699 £ (95%CI: 171 £-4674 £) in Strategy 2.
  
  
  CONCLUSIONS
  Beta-blocker therapy turn out to be more effective and less expensive than endoscopic surveillance for primary prophylaxis of bleeding in patients with cirrhosis and small varices.
authors.affiliation: Lorenza Di Pascoli, Massimo Bolognesi, Sara Montagnese, Angelo Gatta, Carlo Merkel, Hepatic Hemodynamic Laboratory and Clinica Medica 5, Department of Medicine, University of Padua, 35128 Padova, Italy.
authors.forename: Lorenza
authors.initials: L
authors.lastname: Di Pascoli
authors.affiliation: Lorenza Di Pascoli, Massimo Bolognesi, Sara Montagnese, Angelo Gatta, Carlo Merkel, Hepatic Hemodynamic Laboratory and Clinica Medica 5, Department of Medicine, University of Padua, 35128 Padova, Italy.
authors.forename: Alessandra
authors.initials: A
authors.lastname: Buja
authors.affiliation: Lorenza Di Pascoli, Massimo Bolognesi, Sara Montagnese, Angelo Gatta, Carlo Merkel, Hepatic Hemodynamic Laboratory and Clinica Medica 5, Department of Medicine, University of Padua, 35128 Padova, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Bolognesi
authors.affiliation: Lorenza Di Pascoli, Massimo Bolognesi, Sara Montagnese, Angelo Gatta, Carlo Merkel, Hepatic Hemodynamic Laboratory and Clinica Medica 5, Department of Medicine, University of Padua, 35128 Padova, Italy.
authors.forename: Sara
authors.initials: S
authors.lastname: Montagnese
authors.affiliation: Lorenza Di Pascoli, Massimo Bolognesi, Sara Montagnese, Angelo Gatta, Carlo Merkel, Hepatic Hemodynamic Laboratory and Clinica Medica 5, Department of Medicine, University of Padua, 35128 Padova, Italy.
authors.forename: Angelo
authors.initials: A
authors.lastname: Gatta
authors.affiliation: Lorenza Di Pascoli, Massimo Bolognesi, Sara Montagnese, Angelo Gatta, Carlo Merkel, Hepatic Hemodynamic Laboratory and Clinica Medica 5, Department of Medicine, University of Padua, 35128 Padova, Italy.
authors.forename: Dario
authors.initials: D
authors.lastname: Gregori
authors.affiliation: Lorenza Di Pascoli, Massimo Bolognesi, Sara Montagnese, Angelo Gatta, Carlo Merkel, Hepatic Hemodynamic Laboratory and Clinica Medica 5, Department of Medicine, University of Padua, 35128 Padova, Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: Merkel
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000191:economics* / Q000627:therapeutic use*; D000328:Adult; D000368:Aged; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D003663:Decision Trees; D016527:Drug Costs; D016099:Endoscopy, Gastrointestinal / Q000191:economics*; D004932:Esophageal and Gastric Varices / Q000188:drug therapy / Q000191:economics / Q000209:etiology / Q000473:pathology; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000191:economics / Q000209:etiology / Q000517:prevention & control; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications / Q000175:diagnosis / Q000191:economics; D008297:Male; D008875:Middle Aged; D018803:Models, Economic; D009010:Monte Carlo Method; D011237:Predictive Value of Tests; D013269:Stochastic Processes; D013997:Time Factors; D057832:Watchful Waiting / Q000191:economics*
chemical_list: D000319:Adrenergic beta-Antagonists
keywords: Cirrhosis; Esophageal varices; Pharmaco-economical analysis; Primary prophylaxis; Variceal bleeding