Cost-effectiveness analysis of variceal ligation vs. beta-blockers for primary prevention of variceal bleeding

Endoscopic variceal ligation is cost-effective relative to beta-blockers for the prevention of variceal bleeding in cirrhotic patients if quality of life-years are considered.

If only life-years are considered, then endoscopic variceal ligation is not cost-effective. These findings are published in the April issue of Hepatology, the official journal of the American Association for the Study of Liver Diseases (AASLD). Published by John Wiley & Sons, Inc., Hepatology is available online via Wiley InterScience.

Thirty to forty percent of patients with cirrhosis have esophageal varices. Bleeding from varices occurs in almost one in three of these patients and can be fatal. Non-selective beta-adrenergic blockade has been the most widely investigated therapy to reduce the risk of variceal bleeding. Another effective alternative is endoscopic variceal ligation. The effects of both treatment options on mortality are uncertain.

Since both approaches reduce the risk of variceal bleeding, researchers led by Thomas Imperiale, MD, of Indiana University School of Medicine, sought to compare their cost-effectiveness and quality of life outcomes.

They developed a Markov decision model for patients with cirrhosis, portal hypertension, and medium-to-large esophageal varices who would be candidates for primary prophylaxis with either beta-blockade or ligation. Using a 5-year time horizon, they examined direct costs, life-years, and quality-adjusted life years.

The researchers found that when only life-years are considered, ligation is not cost-effective when compared with beta-blocker therapy. However, when both life-years and quality are considered, "the gain in effectiveness with initial ligation is "worth" the increase in cost," they report. They found that over five years, for every 1000 patients with high-risk varices, initial ligation prevents variceal bleeding in 77 persons, 65 bleeding episodes, 5 TIPS procedures, and 7 deaths, as compared with initial beta-blocker therapy.

The study did not consider severe complications from TIPS, ligation or beta-blocker therapy. It also did not examine non-adherence. If TIPS or compliance (or both) had been included in the model, ligation would have been even more cost-effective. Finally, the study did not look at the costs and effects of liver transplantation or development and management of hepatocellular carcinoma. But in spite of these limitations, it clearly showed that ligation was cost-effective based on quality-adjusted life years.

"At a $50,000 willingness to pay, ligation is not cost-effective compared to beta-blocker therapy if only the life years are considered; however, at $25,548 / QALY, ligation is cost-effective if quality-adjusted life years are considered," they conclude. "Further study is needed to determine the extent to which these findings may be affected by the use of beta-blocker co-therapy after a first bleed, an extended time horizon, and by patient-derived utilities."