Underfunding of German university-based high-performance medicine exemplified by the treatment of varices in cirrhosis.

Facing increasing economization in the health care sector, clinicians have to adapt not only to the ever-growing economic challenges, but also to a patient-oriented health care. Treatment costs are the most important variable for optimizing success when facing scarce human resources, increasing material- and infrastructure costs in general, as well as low revenue flexibility due to flat rates per case in Germany, the so-called Diagnosis-Related Groups (DRG). University hospitals treat many patients with particularly serious illnesses. Therefore, their share of complex and expensive treatments, such as liver cirrhosis, is significantly higher. The resulting costs are not adequately reflected in the DRG flat rate per case, which is based on an average calculation across all hospitals, which increases this economic pressure. Thus, the aim of this manuscript is to review cost and revenue structures of the management of varices in patients with cirrhosis at a university center with a focus on hepatology. For this monocentric study, the data of 851 patients, treated at the Gastroenterology Department of a University Hospital between 2016 and 2020, were evaluated retrospectively and anonymously. Medical services (e.g., endoscopy, radiology, laboratory diagnostics) were analyzed within the framework of activity-based-costing. As part of the cost unit accounting, the individual steps of the treatment pathways of the 851 patients were monetarily evaluated with corresponding applicable service catalogs and compared with the revenue shares of the cost center and cost element matrix of the German (G-) DRG system. This study examines whether university-based high-performance medicine is efficient and cost-covering within the framework of the G-DRG system. We demonstrate a dramatic underfunding of the management of varicose veins in cirrhosis in our university center. It is therefore generally questionable whether and to what extent an adequate care for this patient collective is reflected in the G-DRG system.

Transparent cap-assisted endoscopic sclerotherapy in esophageal varices: a randomized-controlled trial.

BACKGROUND AND AIM: Endoscopic treatment is widely accepted as the first-line therapy selection for esophageal variceal bleeding. Nevertheless, endoscopic injection sclerotherapy requires experienced endoscopists and is associated with a high risk of bleeding. Our study evaluates the feasibility and efficacy of transparent cap-assisted endoscopic sclerotherapy in the management of esophageal varices. PATIENTS AND METHODS: A randomized-controlled trial was conducted in a tertiary referral center from April 2015 to May 2016. Patients who received endoscopic sclerotherapy were randomized in a blinded manner into two groups: the transparent cap-assisted group (n=59) and the control group (n=61). RESULTS: The average injection sites were reduced in the transparent cap-assisted group compared with the control group (1.2±0.4 vs. 1.4±0.05, P=0.000), whereas no difference was observed in the dosage of lauromacrogol (16.97±4.91 vs. 16.85±4.57, P=0.662) and the hemorrhage that occurred during injection made no difference (50.8 vs. 61.0%, P=0.276); yet, salvage hemostasis methods were used in only nine patients in the transparent cap-assisted group compared with 17 patients in the control group (25.0 vs. 38.7%, P=0.0936). The cost of each procedure in the cap-assisted group was ¥2578 (1878-4202), whereas it was ¥3691 for the control group (2506-5791) (P=0.023). Moreover, in both groups, no esophageal constriction was observed during the 6-month follow-up period, whereas the rebleeding rate between two groups showed no statistical significance in 6 months (89.8 vs. 93.4%, P=0.563). CONCLUSION: Transparent cap-assisted sclerotherapy provided a clear field of vision and helped to fix the targeted veins, thus significantly reducing the use of the salvage hemostasis method during sclerotherapy injection hemorrhage. It is also associated with reduced injection sites and endoscopic therapy cost.

Transjugular intrahepatic portosystemic shunt versus open splenectomy and esophagogastric devascularization for portal hypertension with recurrent variceal bleeding.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) and open splenectomy and esophagogastric devascularization (OSED) are widely used to treat patients with portal hypertension and recurrent variceal bleeding (PHRVB). This study aimed to compare the effectiveness between TIPS and OSED for the treatment of PHRVB. METHODS: The data were retrospectively retrieved from 479 cirrhotic patients (Child-Pugh A or B class) with PHRVB, who had undergone TIPS (TIPS group) or OSED (OSED group) between January 1, 2010 and October 31, 2014. RESULTS: A total of 196 patients received TIPS, whereas 283 underwent OSED. Within one month after TIPS and OSED, the rebleeding rates were 6.1% and 3.2%, respectively (P=0.122). Significantly lower incidence of pleural effusion, splenic vein thrombosis, and pulmonary infection, as well as higher hepatic encephalopathy rate, shorter postoperative length of hospital stay, and higher hospital costs were observed in the TIPS group than those in the OSED group. During the follow-up periods (29 months), significantly higher incidences of rebleeding (15.3% vs 4.6%, P=0.001) and hepatic encephalopathy (17.3% vs 3.9%, P=0.001) were observed in the TIPS group than in the OSED group. The incidence of in-stent stenosis was 18.9%. The survival rates were 91.3% in the TIPS group and 95.1% in the OSED group. The long-term liver function did not worsen after either TIPS or OSED. CONCLUSION: For the patients with liver function in the Child-Pugh A or B class, TIPS is not superior over OSED in terms of PHRVB treatment and rebleeding prevention.

Medical expenses in treating acute esophageal variceal bleeding: A 15-year nationwide population-based cohort study.

Acute variceal bleeding in patients with cirrhosis is related to high mortality and medical expenses. The purpose of present studies was to analyze the medical expenses in treating acute esophageal variceal bleeding among patients with cirrhosis and potential influencing clinical factors.A total of 151,863 patients with cirrhosis with International Classification of Diseases-9 codes 456.0 and 456.20 were analyzed from the Taiwan National Health Insurance Research Database from January 1, 1996 to December 31, 2010. Time intervals were divided into three phases for analysis as T1 (1996-2000), T2 (2001-2005), and T3 (2006-2010). The endpoints were prevalence, length of hospital stay, medical expenses, and mortality rate.Our results showed that more patients were <65 years (75.6%) and of male sex (78.5%). Patients were mostly from teaching hospitals (90.8%) with high hospital volume (50.9%) and high doctor service load (51.1%). The prevalence of acute esophageal variceal bleeding and mean length of hospital stay decreased over the years (P < 0.001), but the overall medical expenses increased (P < 0.001). Multiple regression analysis showed that older age, female sex, Charlson comorbidity index (CCI) score >1, patients from teaching hospitals, and medium to high or very high patient numbers were independent factors for longer hospital stay and higher medical expenses. Aged patients, female sex, increased CCI score, and low doctor service volume were independent factors for both in-hospital and 5-year mortality. Patients from teaching hospitals and medium to high or very high service volume hospitals were independent factors for in-hospital mortality, but not 5-year mortality.Medical expenses in treating acute esophageal variceal bleeding increased despite the decreased prevalence rate and length of hospital stay in Taiwan. Aged patients, female sex, patients with increased CCI score from teaching hospitals, and medium to high or very high patient numbers were the independent factors for increased medical expenses.

Comparison of 2 days versus 5 days of octreotide infusion along with endoscopic therapy in preventing early rebleed from esophageal varices: a randomized clinical study.

BACKGROUND: Variceal bleeding is a medical emergency with 20% mortality at 6 weeks. The role of vasoactive agents in achieving hemostasis and preventing rebleeding has been well documented. The optimal duration of these agents has not been well established. There are no previous studies yielding the exact duration of octreotide to be administered to prevent rebleed and mortality from esophageal varices. The aim of this study is to evaluate the effect of combination therapy (octreotide and endoscopy), the exact duration of octreotide infusion, its cost-effectiveness, and the outcome in terms of rebleed and mortality. PATIENTS AND METHODS: This was a randomized clinical trial including 124 patients with acute variceal bleeding who underwent endoscopic therapy; they were assigned randomly to 2 days (n=62) and 5 days (n=58) of continuous octreotide infusion (50 µg/kg). Early rebleeding (within 42 days of index bleed according to Baveno IV consensus guidelines), transfusion requirement, and mortality were assessed. RESULTS: The study had predominantly male patients, average age 47 years. Among the patients in the 2-day group, 3 (4.8%) showed early rebleed versus 5 (8.6%) in the 5-day group, but the difference was not statistically significant (P>0.05). Among the patients in the 2-day group, one patient died after 3 weeks and all the patients in the 5-day group survived till 6 weeks on follow-up, and the survival rates were comparable (P>0.05). The treatment in the 5-day group was 2.5 times costlier than that for the 2-day group as shown by a cost-wise analysis. CONCLUSION: Two days of octreotide infusion following endoscopic therapy is sufficient and as efficacious as 5 days of infusion in preventing early rebleed, with reasonably better cost-effectiveness.

The cost of screening esophageal varices: traditional endoscopy versus computed tomography.

OBJECTIVE: Under current guidelines, patients diagnosed with cirrhosis are to undergo initial and continued screening endoscopy for esophageal varices throughout the course of disease. Recent literature suggests that computed tomography (CT) of the abdomen is adequately sensitive for detecting grade 3 varices, those in need of immediate intervention. This study presents a cost comparison of traditional endoscopy versus CT of the abdomen. METHODS: Using TreeAge Pro software, a budget impact cost model was created for a hypothetical managed care organization covering 1 million lives over a 10-year period. Incidence figures for cirrhosis and the progression of esophageal varices were applied to the patient population. National Medicare reimbursement costs were used to compare screening with traditional endoscopy versus CT. Costs utilizing screening with combined endoscopy and CT were also examined. RESULTS: The results of comparing screening paradigms under a budget impact cost model results in an outcome measure termed "per-member, per-month" (PMPM) cost of implementing a new strategy. Computed tomography was the least expensive modality with an average 10-year cost per screened patient of $1097.30 and PMPM of $0.03. Endoscopy was the most expensive modality with an average 10-year cost per screened patient of $1464.89 and PMPM of $0.04. CONCLUSION: Computed tomography has been shown to be sensitive in detecting esophageal varices and now less costly to implement in screening. The cost of esophageal rupture in endoscopy and the less costly risk of contrast reaction as well as radiation exposure in CT of the abdomen should be considered when developing a screening paradigm.

Cost-effectiveness analysis of beta-blockers vs endoscopic surveillance in patients with cirrhosis and small varices.

AIM: 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. CONCLUSION: 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.

Economic modelling of early transjugular intrahepatic portosystemic shunt insertion for acute variceal haemorrhage.

INTRODUCTION: Early insertion of transjugular intrahepatic portosystemic shunt (TIPS) in high-risk patients with acute variceal haemorrhage reduces rebleeding and mortality. However, the economic benefit of utilizing this approach remains unclear. We evaluated the economic implications of introducing early TIPS into routine algorithms for the management of variceal bleeding. METHODS: Consecutive patients admitted in 2009 with variceal haemorrhage to two liver units and eligible for early TIPS insertion were identified retrospectively. The costs of a 12-month follow-up from index bleeding admission were calculated--the actual cost of follow-up and rebleeding in this cohort was compared with the theoretical 12-month follow-up costs of instead inserting an early TIPS at index admission. Our findings were subjected to a sensitivity analysis to assess the cost effectiveness of early TIPS insertion compared with standard care. RESULTS: In 2009, 78 patients were admitted to our units with variceal haemorrhage; 27 patients (35%) were eligible for early TIPS insertion. The actual cost of a 12-month follow-up was £138 473.50. Early TIPS insertion, assuming a 3.2% rebleeding rate, would save £534.70 per patient per year (P<0.0001). On sensitivity analysis, early TIPS dominated standard care up to an early TIPS rebleeding rate of 6% and remained cost-effective up to a rebleeding rate of 12%. CONCLUSION: Early TIPS insertion for high-risk patients with acute variceal bleeding is a cost-efficient intervention. This has important implications for the introduction of early TIPS as standard care and the organization of interventional radiology services.

Cost-effective analysis of transjugular intrahepatic portosystemic shunt versus surgical portacaval shunt for variceal bleeding in early cirrhosis.

Upper gastrointestinal hemorrhage carries significant morbidity and mortality in patients with portal hypertension and cirrhosis. The optimal prevention strategy for rebleeding in these patients remains controversial with respect to the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) versus a portocaval surgical shunt (PC). We sought to determine the long-term cost-effectiveness of these two treatments. A Markov state transition decision analysis was created and Monte Carlo sensitivity analysis performed to follow patients with early cirrhosis who have an upper gastrointestinal bleed despite medical therapy into either TIPS or PC. Patients were followed throughout the transition states until either death or survival. Probabilities of gastrointestinal rebleed, hepatic encephalopathy, surgical and TIPS-related complications as well as death were obtained from an extensive literature review. Costs were derived from average Medicare reimbursements. The main outcome was dollars per life-year saved. For patients with mild to moderate cirrhosis with upper gastrointestinal variceal bleed, the average cost per life year saved was $17,771 (SD = 471) and $21,438 (SD = 308) for TIPS and PC, respectively. The average life expectancy was 5.0 years and 7.0 years for TIPS and PC, respectively. This yielded an incremental cost-effectiveness rate for portocaval shunt of $3,299 per life year saved. Compared with TIPS, surgical PC shunt resulted in improved survival with minimal increase in cost. Therefore, given the low incremental cost of PC, it should be adopted as a cost-effective strategy in managing this patient population.

Emergency portacaval shunt versus rescue portacaval shunt in a randomized controlled trial of emergency treatment of acutely bleeding esophageal varices in cirrhosis--part 3.

BACKGROUND: Emergency treatment of bleeding esophageal varices in cirrhosis is of singular importance because of the high mortality rate. Emergency portacaval shunt is rarely used today because of the belief, unsubstantiated by long-term randomized trials, that it causes frequent portal-systemic encephalopathy and liver failure. Consequently, portacaval shunt has been relegated solely to salvage therapy when endoscopic and pharmacologic therapies have failed. QUESTION: Is the regimen of endoscopic sclerotherapy with rescue portacaval shunt for failure to control bleeding varices superior to emergency portacaval shunt? A unique opportunity to answer this question was provided by a randomized controlled trial of endoscopic sclerotherapy versus emergency portacaval shunt conducted from 1988 to 2005. METHODS: Unselected consecutive cirrhotic patients with acute bleeding esophageal varices were randomized to endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Diagnostic workup was completed and treatment was initiated within 8 h. Failure of endoscopic sclerotherapy was defined by strict criteria and treated by rescue portacaval shunt (n = 50) whenever possible. Ninety-six percent of patients had more than 10 years of follow-up or until death. RESULTS: Comparison of emergency portacaval shunt and endoscopic sclerotherapy followed by rescue portacaval shunt showed the following differences in measurements of outcomes: (1) survival after 5 years (72% versus 22%), 10 years (46% versus 16%), and 15 years (46% versus 0%); (2) median post-shunt survival (6.18 versus 1.99 years); (3) mean requirements of packed red blood cell units (17.85 versus 27.80); (4) incidence of recurrent portal-systemic encephalopathy (15% versus 43%); (5) 5-year change in Child's class showing improvement (59% versus 19%) or worsening (8% versus 44%); (6) mean quality of life points in which lower is better (13.89 versus 27.89); and (7) mean cost of care per year ($39,200 versus $216,700). These differences were highly significant in favor of emergency portacaval shunt (all p < 0.001). CONCLUSIONS: Emergency portacaval shunt was strikingly superior to endoscopic sclerotherapy as well as to the combination of endoscopic sclerotherapy and rescue portacaval shunt in regard to all outcome measures, specifically bleeding control, survival, incidence of portal-systemic encephalopathy, improvement in liver function, quality of life, and cost of care. These results strongly support the use of emergency portacaval shunt as the first line of emergency treatment of bleeding esophageal varices in cirrhosis.

An economic evaluation of vasoactive agents used to treat acute bleeding oesophageal varices in Belgium.

BACKGROUND AND STUDY AIMS: Increasingly, cost influences all areas of healthcare, including the management of life threatening events, such as bleeding oesophageal varices (BOV). In light of the need to control costs, an economic evaluation of vasoactive agents used to treat cirrhotic patients with BOV within the emergency setting in Belgium has been assessed. PATIENTS AND METHODS: A previously reported economic evaluation of vasoactive agents used to treat BOV was identified and adapted to the Belgium hospital setting. The economic evaluation was based on double-blind randomised controlled trials of vasoactive agents previously reported as Cochrane meta-analyses. Belgian cost data was obtained from local published sources and hospital databases. We assessed average disaggregated and aggregated treatment costs, average and incremental cost per quality adjusted life years (QALYs) and life-years gained (LYG). RESULTS: Total treatment costs at 1 year were: terlipressin Euro 2,734; somatostatine Euro 2,972; octreotide Euro 2,801; and placebo Euro 2,874. The average costs per QALY were: terlipressin Euro 4,672; somatostatine Euro 5,878; octreotide Euro 5,540; and placebo Euro 5,687. In the cost per LYG analysis terlipressin achieved the lowest cost per life-year. Results from the incremental cost per QALY and LYG analysis indicated that terlipressin was the most cost-effective agent. CONCLUSIONS: One year simulations indicate somatostatine is the most expensive treatment option and terlipressin the least costly. Amongst the vasoactive products, the incremental analysis indicated terlipressin was dominant when compared with octreotide and somatostatine because of improved survival and cost-saving potential that is likely attributed to avoiding additional and more costly interventions.

The budget impact of endoscopic screening for esophageal varices in cirrhosis.

BACKGROUND: The cost-effectiveness of screening for esophageal varices in cirrhosis remains uncertain. Previous analyses found that screening with upper endoscopy (EGD) may not be cost effective versus empiric beta-blocker (BB) therapy. However, these models were conducted before advances in variceal screening, including capsule endoscopy (CE), and they did not measure the budget impact (vs cost-effectiveness) of variceal screening. OBJECTIVE: To compare the managed care budget impact of variceal screening strategies. DESIGN: Budget impact model. SETTING: Hypothetical managed care organization with 1 million covered lives. PATIENTS: Patients with compensated cirrhosis. INTERVENTIONS: Compared 5 strategies: (1) empiric BB, (2) screening EGD followed by BB if varices present (EGD --> BB), (3) EGD followed by endoscopic band ligation if varices present (EGD --> EBL), (4) CE followed by BB if varices present (CE --> BB), and (5) CE followed by EBL if varices present (CE --> EBL). MAIN OUTCOME MEASUREMENT: Per-member per-month cost. RESULTS: BB was the least expensive, and CE --> EBL was the most expensive. Substituting CE --> BB in lieu of BB cost each member an additional $0.20 per month to subsidize. Compared with CE --> BB, both EGD-based strategies were more expensive. However, CE was not viable in managed care organizations capable of reducing the cost of endoscopy below $410, unless the cost of CE was reduced in lockstep. LIMITATIONS: Data on CE remain limited. CONCLUSIONS: Screening for varices may have an acceptable budget impact but is highly sensitive to local costs of EGD and CE. In managed care organizations willing to subsidize EBL for variceal prophylaxis, it is inefficient to screen with CE compared with EGD.

Cost of treatment of oesophageal variceal bleeding in patients with cirrhosis in France: results of a French survey.

OBJECTIVE: To estimate the costs to treat oesophageal variceal bleeding in patients with cirrhosis in France from a hospital perspective. METHODS: A model was developed to present the current treatment pathway of variceal bleeding in France covering 42 days from hospital admission. Input of the model was based on interviews with 10 hepatogastroenterologists geographically spread throughout France. A validated questionnaire was used to collect medical resource-use of the treated patients separated for patients suffering from Child-Pugh class A, B and C liver disease. RESULTS: Average hospital treatment cost of patients requiring only initial management to stop the bleeding was euro 9906. Costs of patients in whom initial treatment was not successful averaged euro 23,113 and euro 29,406 for patients requiring respectively one or two additional procedures to control the bleeding. On average, the hospital incurred euro 11,134, euro 12,698 and euro 14,168 for class A, B and C patients, respectively. CONCLUSIONS: Management of variceal bleeding is very costly compared with other digestive diseases. In particular, additional treatment needed because of failure to control bleeding or early rebleeding makes the management expensive. The severity of the underlying liver disease has a great impact on treatment outcome, leading to higher treatment costs for class C patients than less affected patients.

An economic evaluation of vasoactive agents used in the United Kingdom for acute bleeding oesophageal varices in patients with liver cirrhosis.

OBJECTIVE: To conduct an economic evaluation of terlipressin, octreotide and placebo in the treatment of bleeding oesophageal varices (BOV) where endotherapy could be used concomitantly. METHODS: A discrete event simulation model was created with transition states: bleeding, no bleeding, no bleeding post transjugular intrahepatic portosystemic shunt, post-salvage surgery, and death. Efficacy data on survival, re-bleeding and control of bleeding were obtained from high quality studies reported in Cochrane meta-analyses. Baseline outcomes related to the course of disease and health-state utilities were derived from published sources. Vasoactive treatment costs and all related BOV costs were obtained from published UK sources. RESULTS: The average aggregated treatment cost per person for all medical interventions at 1 year was lower for terlipressin-treated patients (2623 pounds sterling) compared with those treated using octreotide (2758 pounds sterling) or placebo (2890 pounds sterling). The incremental analysis comparing terlipressin with octreotide and placebo using a cost per quality adjusted life year (QALY) and cost per life year gained (LYG) approach indicated that terlipressin was the dominant BOV treatment option (i.e. it cost less and it was more effective). Based on a maximum willingness to pay of 20,000 pounds sterling/QALY terlipressin was more effective and cost-saving compared to octreotide and placebo for simulations ranging from 42 days to 2 years. In point estimation analyses octreotide was dominant compared to placebo; however, probabilistic sensitivity analysis indicated that octreotide was unlikely to be cost-effective compared to placebo. CONCLUSIONS: The findings indicated that vasoactive treatment in BOV was cost-saving compared to no vasoactive treatment. Furthermore, terlipressin was the more cost-effective vasoactive treatment for BOV in cirrhotic patients.

Treating bleeding oesophageal varices with vasoactive agents: good value for money?

This article provides an editorial commentary to accompany the publication of an article on the economic evaluation of vasoactive agents used in the United Kingdom for acute bleeding oesophageal varices in patients with cirrhosis by Wechowski et al. From a clinical standpoint, the successful management of bleeding oesophageal varices should be based on definitive treatments such as therapeutic endoscopy or transjugular intrahepatic portosystemic stent shunt (TIPSS). Vasoactive agents such as terlipressin can be useful and potentially cost-effective additional therapy, however, particularly in patients where endoscopic treatment is likely to be delayed or is contraindicated.

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.

Cost-effectiveness of treating esophageal varices.

The clinical effectiveness of the various prophylaxis methods used to treat esophageal varices remains unknown because of limited evidence. Even less is known about the extent of resource use and subsequent impact on health status associated with primary and secondary prophylaxis. Recently, several economic analyses have been developed to answer these questions and identify gasps in knowledge. This article provides an overview of results from these studies and explores areas in need of future investigation.

Detachable endoloop vs. elastic band ligation for bleeding esophageal varices.

BACKGROUND: Variceal bleeding is a serious complication with a mortality rate that ranges from 20% to 50%. Patients who have variceal hemorrhage usually are treated by endoscopic injection sclerotherapy or elastic band ligation to eradicate the varices. Endoloop ligation is a newly developed technique for achieving hemostasis and variceal eradication. This study compared endoloop ligation with elastic band ligation in patients with acute esophageal variceal bleeding. METHODS: Fifty patients with acute esophageal variceal bleeding were recruited: 25 were treated by elastic band ligation and 25 by endoloop ligation. RESULTS: Although the number of patients in whom bleeding recurred during a follow-up period of 6 months was smaller in the endoloop group (12%) vs. the band group (28%), this difference was not statistically significant. Furthermore, no statistically significant difference was found between the two groups with respect to the number of patients in whom variceal eradication was achieved, the number of treatment sessions required for variceal eradication, or the frequency of variceal recurrence. The total cost for variceal obliteration by endoloop ligation was 342 dollars per patient, whereas, the total cost of variceal eradication by elastic band ligation was 356 dollars per patient. The endoloop had certain technical advantages over band application: a better field of vision, tighter application, good results with junctional varices, and a lack of strain exerted by the device on the endoscope. CONCLUSIONS: Endoloop ligation is a promising new technique for management of patients with bleeding esophageal varices.

Randomised controlled trial of long term portographic follow up versus variceal band ligation following transjugular intrahepatic portosystemic stent shunt for preventing oesophageal variceal rebleeding.

BACKGROUND/AIMS: Transjugular intrahepatic portosystemic stent shunt (TIPSS) is effective in the prevention of variceal rebleeding but requires invasive portographic follow up. This randomised controlled trial aims to test the hypothesis that combining variceal band ligation (VBL) with TIPSS can obviate the need for long term TIPSS surveillance without compromising clinical efficacy, and can reduce the incidence of hepatic encephalopathy. PATIENTS/METHODS: Patients who required TIPSS for the prevention of oesophageal variceal rebleeding were randomised to either TIPSS alone (n = 39, group 1) or TIPSS plus VBL (n = 40, group 2). In group 1, patients underwent long term TIPSS angiographic surveillance. In group 2, patients entered a banding programme with TIPSS surveillance only continued for up to one year. RESULTS: There was a tendency to higher variceal rebleeding in group 2 although this did not reach statistical significance (8% v 15%; relative hazard 0.58; 95% confidence interval (CI) 0.15-2.33; p = 0.440). Mortality (47% v 40%; relative hazard 1.31; 95% CI 0.66-2.61; p = 0.434) was similar in the two groups. Hepatic encephalopathy was significantly less in group 2 (20% v 39%; relative hazard 2.63; 95% CI 1.11-6.25; p = 0.023). Hepatic encephalopathy was not statistically different after correcting for sex and portal pressure gradient (p = 0.136). CONCLUSIONS: TIPSS plus VBL without long term surveillance is effective in preventing oesophageal variceal rebleeding, and has the potential for low rates of encephalopathy. Therefore, VBL with short term TIPSS surveillance is a suitable alternative to long term TIPSS surveillance in the prevention of oesophageal variceal rebleeding.