Cost-effectiveness of screening, surveillance, and primary prophylaxis strategies for esophageal varices

• Published in: The American journal of gastroenterology Vol. 97; no. 9; pp. 2441 - 2452
• Main Authors: ARGUEDAS, Miguel R, HEUDEBERT, Gustavo R, ELOUBEIDI, Mohamad A, ABRAMS, Gary A, FALLON, Michael B
• Format: Journal Article
• Language: English
• Published: Oxford Blackwell Publishing 01.09.2002; Wolters Kluwer Health Medical Research, Lippincott Williams & Wilkins
• Subjects: Biological and medical sciences; Cost-Benefit Analysis; Decision Support Techniques; Esophageal and Gastric Varices - diagnosis; Esophageal and Gastric Varices - economics; Esophageal and Gastric Varices - prevention & control; Esophagus; Gastroenterology; Gastroenterology. Liver. Pancreas. Abdomen; Humans; Liver Cirrhosis - economics; Markov Chains; Mass Screening - economics; Medical sciences; Middle Aged; Odds Ratio; Other diseases. Semiology; Population Surveillance; Sensitivity and Specificity; Human; Portal circulation disease; Esophageal disease; Cardiovascular disease; Medical screening; Venous disease; Esophagus; Vascular disease; Prevention; Surveillance; Health economy; Primary; Digestive diseases; Strategy; Public health; Cost efficiency analysis; Varix
• ISSN: 0002-9270; 1572-0241
• DOI: 10.1111/j.1572-0241.2002.06000.x

Screening for varices is recommended in patients with cirrhosis to institute primary prophylaxis to prevent variceal bleeding. Our aim was to compare the cost-effectiveness of four strategies, including no screening/no prophylaxis, universal screening and primary prophylaxis with beta-blockers, universal screening and primary prophylaxis with variceal ligation, and universal institution of primary prophylaxis with beta-blockers without screening. We constructed a Markov simulation model in two hypothetical cohorts of 50-yr-old patients with cirrhosis (one compensated and one decompensated), who were followed for 5 yr. Transition probabilities were derived from the medical literature, and costs reflected Medicare reimbursement rates at our institution. In patients with compensated cirrhosis, screening and primary prophylaxis with beta-blockers is associated with an incremental cost-effectiveness ratio of $3605 per year of life saved. The results were most sensitive to the prevalence of varices and risk of variceal bleeding. In patients with decompensated liver disease, primary prophylaxis without screening was associated with an incremental cost-effectiveness ratio of $1154 per year of life saved. The results were most sensitive to the cost of beta-blockers and endoscopy. Screening for varices is an affordable strategy in compensated liver disease, whereas universal primary prophylaxis with beta-blockers is cost-effective in decompensated patients.