Cost-effectiveness analysis of transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic therapy for the prevention of recurrent esophageal variceal bleeding

Abstract

For the prevention of recurrent esophageal variceal bleeding, studies show that patients treated with transjugular intrahepatic portosystemic shunt (TIPS) have lower rebleeding rates compared with endoscopic therapy. However, TIPS is associated with higher rates of portosystemic encephalopathy and possibly higher costs. The aim of this study was to conduct a cost-effectiveness analysis comparing TIPS with endoscopic sclerotherapy and endoscopic ligation for the prevention of recurrent esophageal variceal bleeding. Data for rates of rebleeding, death, complications, and crossover from endoscopy to TIPS were obtained from the literature. Variceal bleeding is a major cause of morbidity and mortality in patients with cirrhosis. Variceal bleeding occurs in 33% of patients with cirrhosis and carries a mortality of 30% to 50%. [1][2][3] Up to 70% of patients have recurrent bleeding within the first year of the first bleeding episode. 1,3 Strategies have been developed for the prevention of recurrent esophageal bleeding in the high-risk group of patients who have had a first bleed.Treatment for acute variceal bleeding includes endoscopic therapy and the transjugular intrahepatic portosystemic shunt (TIPS). Endoscopic sclerotherapy can stop bleeding in 75% to 85% of cases, but recurrent bleeding occurs in 30% to 50% of patients within the first year. 4-9 Studies comparing endoscopic sclerotherapy to endoscopic ligation (banding) show higher rates for controlling bleeding with ligation and lower, but still substantial, recurrent bleeding rates of 26% to 36%. 5,8,9 Twelve percent to 28% of patients undergoing follow-up endoscopy have recurrent variceal bleeding and receive TIPS. [10][11][12][13][14][15][16] TIPS reduces the portosystemic gradient by placing a stent joining the hepatic and portal veins. By reducing portal hypertension, TIPS decompresses varices and prevents recurrent bleeding. Randomized controlled trials comparing TIPS with endoscopic sclerotherapy for recurrent variceal bleeding show that recurrent bleeding rates are 15% to 20% at 1 year, which is 28% to 38% lower than sclerotherapy. 11,13-16 Although TIPS leads to lower recurrent bleeding rates, it may lead to hepatic encephalopathy. [10][11][12][13][14][15]

Cost of preventing variceal rebleeding with transjugular intrahepatic portal systemic shunt and distal splenorenal shunt

“…In one study the one year direct costs of managing patients who bled from varices with endoscopic therapy were $13,197 for sclerotherapy and $9,696 for variceal band ligation (25). In two reports using modeling the estimated annual direct costs for preventing rebleeding using variceal band ligation or TIPS were $16,600 to $23,459 and $26,275 to $30,900 respectively (13,15). In the current study the median annual direct costs for survivors at 5 years were for TIPS = $16,363 and for DSRS = $13,492.…”

“…More recently variceal decompression can also be performed less invasively by placing a stent within the liver that connects the portal vein to the hepatic vein (transjugular intrahepatic portosystemic shunt-TIPS) leading to decompression of the entire portal system and prevention of rebleeding (6,(11)(12)(13)(14). Although TIPS may be the preferred approach in compensated and decompensated patients due to availability and efficacy (6,11), it is unknown whether TIPS is as cost effective as shunts.…”

“…TIPS in the prevention of rebleeding have been investigated using a modeling approach. Total annual costs with TIPS were slightly greater than with endoscopic therapy but the incremental cost effectiveness ratio (ICER) per variceal bleed prevented favored the TIPS treatment strategy in one report whereas in another report band ligation plus a beta-blocker dominated all other forms of therapy (13,15). The difficulty with both of these modeling studies is that the outcome of the analysis was dependent upon the assumptions chosen about the bleeding risk with each form of therapy.…”

Terlipressina: profilo farmacologico clinico, terapeutico e farmacoeconomico nel trattamento delle varici esofagee

“…A partire da questi esiti, sono stati calcolati i rapporti costo-efficacia incrementali della tecnica più efficace e più costosa, la TIPSS, rispetto alle alternative: $8.803 e $ 12.660 per emorragia evitata rispetto a EL ed ES, rispettivamente (tabella II). In questo modello, inoltre, EL è risul- ICER TIPSS = Rapporto di costo-efficacia incrementale della TIPSS rispetto alle metodiche endoscopiche, ossia costo aggiuntivo per evento evitato, EE = evento evitato tata dominare ES, essendo associata contemporaneamente a una minor frequenza di emorragia e a costi minori [46]. La superiorità profilattica di EL rispetto a ES, dimostrata anche dalla meta-analisi di Laine e Cook del 1995 [47], è uno dei presupposti del recente studio di costo/utilità delle strategie di prevenzione secondaria dell'emorragia da varice condotto da Rubenstein e coll.…”

Financial impact of adult living donation

“…The cost of transjugular intrahepatic portosystemic shunting for treatment of complications of portal hypertension may be on the order of $15,000. 8 As patients become more debilitated with progressive liver failure, complications from portal hypertension may increase in frequency, leading to increased hospitalizations. Additionally, patients with cirrhosis awaiting liver transplantation may incur substantial financial losses with high indirect costs.…”