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

Abstract

BackgroundPatients with suspected common bile duct (CBD) stones are often diagnosed using endoscopic retrograde cholangiopancreatography (ERCP), an invasive procedure with risk of significant complications. Using endoscopic ultrasound (EUS) or Magnetic Resonance CholangioPancreatography (MRCP) first to detect CBD stones can reduce the risk of unnecessary procedures, cut complications and may save costs.AimThis study sought to compare the cost-effectiveness of initial EUS or MRCP in patients with suspected CBD stones.MethodsThis study is a model based cost-utility analysis estimating mean costs and quality-adjusted life years (QALYs) per patient from the perspective of the UK National Health Service (NHS) over a 1 year time horizon. A decision tree model was constructed and populated with probabilities, outcomes and cost data from published sources, including one-way and probabilistic sensitivity analyses.ResultsUsing MRCP to select patients for ERCP was less costly than using EUS to select patients or proceeding directly to ERCP ($1299 versus $1753 and $1781, respectively), with similar QALYs accruing to each option (0.998, 0.998 and 0.997 for EUS, MRCP and direct ERCP, respectively). Initial MRCP was the most cost-effective option with the highest monetary net benefit, and this result was not sensitive to model parameters. MRCP had a 61% probability of being cost-effective at $29,000, the maximum willingness to pay for a QALY commonly used in the UK.ConclusionFrom the perspective of the UK NHS, MRCP was the most cost-effective test in the diagnosis of CBD stones.

Updated guideline on the management of common bile duct stones (CBDS)

“…Factors that favour MRCP over EUS include its wide availability, minimally invasive nature, ability to image the intrahepatic ducts, cost effectiveness67 and suitability for patients with altered gastric or duodenal anatomy. In addition, all images can be captured allowing for review by other clinicians at a later date.…”

Prevalence and characteristics of clinically significant retained common bile duct stones after laparoscopic cholecystectomy for symptomatic cholelithiasis

“…The original surgeon is likely to feel culpable for declaring complete recovery and may suffer a loss of rapport with the patient. Other issues include the medical expenditure associated with the diagnosis and treatment of retained CBD stones, the risk of complications associated with endoscopic retrograde cholangiopancreatography (ERCP), and increased patient distress [12]. …”

Choledocholithiasis: Should EUS replace MRCP in patients at intermediate risk?

“…According to a cost-effectiveness analysis performed in the United Kingdom, MRCP may be more cost-effective than EUS-first or ERCP-first approaches. 9 Overall, the cost of starting with MRCP was estimated to be $1299, EUS $1753, and $1781 for ERCP, with no significant differences in quality-adjusted life year over a 1-year time horizon. Although these findings cannot necessarily be generalized to other health care systems, the results appear to be robust and did not vary with sensitivity analyses.…”