Endoscopic screening for esophageal varices in cirrhosis: Is it ever cost effective?

Abstract

Current guidelines for the management of patients with compensated cirrhosis recommend universal screening endoscopy followed by prophylactic ␤-blocker therapy to prevent initial hemorrhage in those found to have esophageal varices. However, the cost-effectiveness of this recommendation has not been established. Our objective was to determine whether screening endoscopy is cost-effective compared with empiric medical management in patients with compensated cirrhosis. Decision analysis with Markov modeling was used to calculate the costeffectiveness of 6 competing strategies: (1) universal screening endoscopy (EGD) followed by ␤-blocker (BB) therapy (EGD3 BB) if varices are present, (2) EGD followed by endoscopic band ligation (EBL) (EGD3 EBL) if varices are present, (3) selective screening endoscopy (sEGD) in high risk patients followed by BB therapy if varices are present (sEGD3 BB), (4) selective screening endoscopy followed by EBL (sEGD3 EBL) if varices are present, (5) empiric ␤-blocker therapy in all patients, and (6) no prophylactic therapy ("Do Nothing"). Cost estimates were from a third-party payer perspective. The main outcome measure was the cost per initial variceal hemorrhage prevented. The "Do Nothing" strategy was the least expensive yet least effective approach. Compared with the "Do Nothing" strategy, the empiric ␤-blocker strategy cost an incremental $12,408 per additional variceal bleed prevented. Compared with the empiric ␤-blocker strategy, in turn, both the EGD3 BB and the EGD3 EBL strategies cost over $175,000 more per additional bleed prevented. The sEGD3 BB and sEGD3 EBL strategies were more expensive and less effective than the empiric ␤-blocker strategy. In conclusion, empiric ␤-blocker therapy for the primary prophylaxis of variceal hemorrhage is a cost-effective measure, as the use of screening endoscopy to guide therapy adds significant cost with only marginal increase in effectiveness. (HEPATOLOGY 2003;37:366-377.)

Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis

“…43,44 However, the predictive accuracy of such noninvasive markers is still unsatisfactory, and until large prospective studies of noninvasive markers are performed, endoscopic screening is still the main means of assessing for the presence of esophageal varices. 43 Cost-effective analyses using Markov models have suggested either empiric ␤-blocker therapy for all patients with cirrhosis 45 or screening endoscopy for patients with compensated cirrhosis, and universal ␤-blocker therapy without screening EGD for patients with decompensated cirrhosis. 46 Neither of these strategies considers a recent trial showing that ␤-blockers do not prevent the development of varices and are associated with significant side effects, 16 nor do they consider endoscopic variceal ligation as an alternative prophylactic therapy.…”

“…These results do not support the suggested universal use of ␤-blockers in cirrhosis. 45 Given the natural history of varices, expert consensus panels have determined that surveillance endoscopies should be performed every 2-3 years in these patients, and annually in the setting of decompensation. 6 …”

Prevention and Management of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis

“…Serious symptomatic adverse events occurred in 20 patients (18%) in the timolol group and in 6 patients (6%) in the placebo group. These results do not support the suggested universal use of β-blockers in cirrhosis (45). Given the natural history of varices, expert consensus panels have determined that surveillance endoscopies should be performed every 2-3 years in these patients, and annually in the setting of decompensation (6,42).…”

Non-Invasive Parameters of Oesophageal Varices Diagnosis: Which Sensitive and Applicable; A Pilot Study

“…However, this approach has some limitations as endoscopy is an invasive procedure, the cost-effectiveness is questionable, also, only 9%-36% of patients with cirrhosis found to have varices on screening endoscopy [7]. So, the possibility of non-invasive means for identifying cirrhotic patients with OV or collateral presence is appealing, in that it could decrease the necessity of endoscopic screening with reduced healthcare costs [1].…”