Current management of patients with compensated cirrhosis recommends universal screening endoscopy, followed by prophylactic beta-blocker therapy. This aims to prevent initial hemorrhage in those found to have esophageal varices.
However, cost-effectiveness has not been established.
|The ‘do nothing’ strategy was the least expensive, but also the least effective.|
In this study, researchers from Los Angeles, California, determined whether screening endoscopy was cost-effective, compared with empiric medical management in patients with compensated cirrhosis.
The research team used decision analysis with Markov modeling to calculate the cost-effectiveness of 6 competing strategies:
- Universal screening endoscopy (EGD) followed by beta-blocker therapy (EGDBB) if varices are present.
- EGD followed by endoscopic band ligation (EBL) (EGDEBL) if varices are present.
- Selective screening endoscopy (sEGD) in high risk patients followed by beta-blocker therapy if varices are present (sEGDBB).
- Selective screening endoscopy followed by EBL (sEGDEBL) if varices are present.
- Empiric beta-blocker therapy in all patients.
- And no prophylactic therapy (‘do nothing’).
The team estimated costs were from a third-party payer perspective.
The main outcome measure was the cost per initial variceal hemorrhage prevented.
The research team found that the ‘do nothing’ strategy was the least expensive approach. However, it was also the least effective.
When compared with the ‘do nothing’ strategy, the empiric beta-blocker strategy cost an incremental $12,408 per additional variceal bleed prevented.
Furthermore, compared with the empiric beta-blocker strategy, both the EGDBB and the EGDEBL strategies cost over $175,000 more per additional bleed prevented.
The team determined that the sEGDBB and sEGDEBL strategies were more expensive, and less effective, than the empiric beta-blocker strategy.
Dr Brennan Spiegel’s team concluded, “Empiric beta-blocker therapy for the primary prophylaxis of variceal hemorrhage is a cost-effective measure, as the use of screening endoscopy to guide therapy adds significant cost with only marginal increase in effectiveness”.