Cost‐effectiveness of hepatic venous pressure gradient measurements for prophylaxis of variceal re‐bleeding

Abstract

Summary Background : Measurement of the hepatic venous pressure gradient may identify a sub‐optimal response to drug prophylaxis in patients with a history of variceal bleeding. However, the cost‐effectiveness of routine hepatic venous pressure gradient measurements to guide secondary prophylaxis has not been examined. Methods : A Markov model was constructed using specialized software (DATA 3.5, Williamstown, MA, USA). Three strategies involved secondary prophylaxis without haemodynamic monitoring using beta‐blockers alone, beta‐blockers plus isosorbide mononitrate or endoscopic variceal ligation alone. Four strategies involved secondary prophylaxis with beta‐blockers plus isosorbide mononitrate or beta‐blockers alone, accompanied by one or two hepatic venous pressure gradient measurements to identify haemodynamic non‐responders, who underwent endoscopic variceal ligation as an alternative. The total expected costs, variceal bleeding episodes and total deaths were calculated for each strategy over 3 years. Results : The two most effective strategies were combination therapy alone and combination therapy with two hepatic venous pressure gradient measurements. The incremental cost‐effectiveness ratio of the latter strategy was $136 700 per year of life saved compared with combination therapy alone. The ratio improved as the time horizon was extended or the rates of variceal re‐bleeding were increased. Conclusions : The cost‐effectiveness of haemodynamic monitoring to guide secondary prophylaxis of recurrent variceal bleeding is highly dependent on local hepatic venous pressure gradient measurement costs, life expectancy and re‐bleeding rates.

Use of portal pressure studies in the management of variceal haemorrhage

“…The number of patients required to carry out a randomized control trial comparing beta blocker therapy and HVPG monitoring with unselected beta blocker treatment are large (n = 600) and have financial and resource implications for a study group to take on [73] . Raines et al [74] proposed a model to evaluate the cost and efficacy of routine HVPG measurement to guide secondary prophylaxis of recurrent variceal bleedingwhilst combination therapy (beta blockers and band ligation) with two HVPG measurements was expensive, it became cost-effective at 1 year compared with standard prophylaxis with combination pharmacotherapy. The cost-effectiveness of haemodynamic monitoring to guide secondary prohylaxis of recurrent variceal bleeding is highly dependent on local hepatic venous pressure gradient measurement costs, life expectancy and rebleeding rates.…”

Wedged hepatic vein pressure (WHVP): Ready for prime time

“…A third concern is cost and cost-effectiveness. 15,16 In the study by Blasco et al 10 measurement of pressure was the same cost as a liver biopsy. The medicare reimbursement for a liver biopsy and HVPG measurement (technical plus professional fees) at my institution is $508 and $636 respectively.…”

Hepatic Venous Pressure Gradient Predicts Further Decompensation in Cirrhosis Patients with Acute Esophageal Variceal Bleeding

“…The same results, however, cannot be extrapolated to all patients who have decompensated liver disease. The Baveno consensus sets a restrictive guideline for decompensated patients in whom TIPSS is recommended, as there is a paucity of data as to which potential interventions would improve survival with better risk-and cost-benefit ratios [31].…”