Value of magnetic resonance cholangiopancreatography in the diagnosis of biliary abnormalities in postcholecystectomy patients: A probabilistic cost-effectiveness analysis of diagnostic strategies

Abstract

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is considered the gold standard for imaging of the biliary tract but is associated with complications. Less invasive imaging techniques, such as magnetic resonance cholangiopancreatography (MRCP), have a much lower complication rate. The accuracy of MRCP is comparable to that of ERCP, and MRCP may be more effective and cost-effective, particularly in cases for which the suspected prevalence of disease is low and further intervention can be avoided. A model was constructed to compare the effectiveness and cost-effectiveness of MRCP and ERCP in patients with a previous history of cholecystectomy, presenting with abdominal pain and/or abnormal liver function tests. Methods: Diagnostic accuracy estimates came from a systematic review of MRCP. A decision analytic model was constructed to represent the diagnostic and treatment pathway of this patient group. The model compared the following two diagnostic strategies: (i) MRCP followed with ERCP if positive, and then management based on ERCP; and (ii) ERCP only. Deterministic and probabilistic analyses were used to assess the likelihood of MRCP being cost-effective. Sensitivity analyses examined the impact of prior probabilities of common bile duct stones (CBDS) and test performance characteristics.

Cost-Effectiveness Analysis of Endoscopic Ultrasound versus Magnetic Resonance Cholangiopancreatography in Patients with Suspected Common Bile Duct Stones

“…Consistent with previous studies this study finds that initial MRCP or EUS to select patients for ERCP are cost-effective compared with direct ERCP. [ 23 – 26 ] Unlike other studies results in this study are not sensitive to varying the probability that CBD stones were present. [ 23 , 26 ]…”

“…[ 23 – 26 ] Unlike other studies results in this study are not sensitive to varying the probability that CBD stones were present. [ 23 , 26 ]…”

“…[ 33 ] After reviewing the reference lists of identified studies and removing duplicates, four studies containing relevant utility data were identified. [ 23 , 25 , 34 – 35 ] Utility scores for the health states required by the model were taken from one study,[ 23 ] selected because utility scores for all the health states in the model were included in this study enabling better comparability between values, and because the study reported parameter values that could be used in sensitivity analyses ( S1 Table ). No published studies were found that reported on the duration of each event in the decision tree so all assumptions were based on clinical opinion and varied in sensitivity analysis ( S1 Table ).…”

“…[ 22 ] Howard et al found MRCP was less costly and more effective than ERCP in patients with abdominal pain and/or abnormal liver function tests at a prior probability of CBD stones of <60%. [ 23 ] Kaltenthaler et al found that MRCP was less costly and more effective than ERCP in patients with biliary tree obstruction. [ 24 – 25 ] Arguedas et al found that in patients with acute biliary pancreatitis at probabilities of CBD stones of ≤45% EUS was most cost-effective, and at probabilities >45% direct ERCP was most cost-effective.…”

Cost-effectiveness of emergencyversusdelayed laparoscopic cholecystectomy for acute gallbladder pathology

“…The primary outcome measure was the QALY, which is a composite measure of the length and quality of life; 1 QALY is defined as 1 year lived in perfect health. Following the approach used by Morris and co‐workers to identify the most appropriate utility values, a review of the Cost‐effectiveness Analysis Registry was conducted and 20 studies identified. The utility scores in this analysis were taken from a single study ( Table S3 , supporting information).…”