Prevention of rebleeding from esophageal varices: Cost-effectiveness of alternate strategies

Following an episode of esophageal variceal hemorrhage (VH), 40-100% of patients experience one or more bleeding episodes in a year, and with each episode 30-50% die. Strategies to prevent variceal rebleeding include beta-blockers (BB), endoscopic sclerotherapy (ES) and more recently endoscopic variceal ligation (EVL). Our AIM was to compare the cost-effectiveness of beta-blocker therapy, ES and EVL in the management of patients with VH using decision analysis. METHODS: A Markov model was developed to compare three hypothetical cohorts presenting with the first VH; one cohort was treated with ES (+ ∼ 4.7 ES sessions for variceal obliteration), the second cohort with EVL (+ ∼3.7 sessions) and the third with beta-blocker therapy and EVL for acute episodes of VH. Annual rebleeding rates (ARR), mortality rate (MR) and complication rates (CR) related to acute VH and mortality due to liver disease for the three strategies were obtained from published literature. Costs were calculated from institutional charge data. Propronalol cost $316/year, one session of ES $1,540 and EVL $1,450, and an episode of acute VH $14,000. Cost of complications were not included; instead, using complications from EVL as baseline (one), the complications for other strategies were expressed as a factor above or below this baseline. Cost-effectiveness was expressed as cost per year of life saved ($/YOLS). RESULTS: Cost per year of life saved for three scenarios based on varying Table. Management Strategies, Assumptions and Results Strategy Assumptions $/YOLS ARR MR CR Best Intermediate Worst ES 47% 46% 20% $13,000 $15,000 $18,000 EVL 40% 35% 6% $12,000 $14,000 $16,000 BB + (EVL) 40% 32% 6% $9,000 $11,000 $12,000 ARR and MR are shown in the table. Complications from ES would cost an additional 2.4*(cost of complications from EVL). Sensitivity analysis for annual rebleeding rate and mortality rate related to bleeding did not have a significant effect on cost per year of life saved. CONCLUSION: All patients should be treated with beta-blocker therapy, unless contraindicated, and acute episodes of VH should be managed by EVL. Efforts to decrease rebleeding rates and mortality related to bleeding have a lesser impact on life expectancy compared to interventions targeted at preventing the first variceal hemorrhage.