Economic evaluation of covered stents for transjugular intrahepatic portosystemic stent shunt in patients with variceal bleeding and refractory ascites secondary to cirrhosis

Abstract

ObjectivesTransjugular intrahepatic portosystemic stent shunt (TIPSS) is clinically effective in variceal bleeding and refractory ascites; however, the cost-effectiveness of TIPSS has yet to be evaluated in the UK. This study aimed to establish the cost-effectiveness of (i) pre-emptive TIPSS versus endoscopic band ligation (EBL) in populations with variceal bleeding and (ii) TIPSS versus large volume paracentesis (LVP) in refractory ascites.MethodsA cost-utility analysis was conducted with the perspective including healthcare costs and quality-adjusted life years (QALYs). A Markov model was constructed with a 2-year time horizon, health states for mortality and survival and probabilities for the development of variceal bleeding, ascites and hepatic encephalopathy. A survival analysis was conducted to extrapolate 12-month to 24-month mortality for the refractory ascites indication. Uncertainty was analysed in deterministic and probabilistic sensitivity analyses.ResultsTIPSS was cost-effective (dominant) and cost saving for both indications. For variceal bleeding, pre-emptive TIPSS resulted in 0.209 additional QALYs, and saved £600 per patient compared with EBL. TIPSS had a very high probability of being cost-effective (95%) but was not cost saving in scenario analyses driven by rates of variceal rebleeding. For refractory ascites, TIPSS resulted in 0.526 additional QALYs and saved £17 983 per patient and had a 100% probability of being cost-effective and cost saving when compared with LVP.ConclusionsTIPSS is a cost-effective intervention for variceal bleeding and refractory ascites. TIPSS is highly cost-saving for refractory ascites. Robust randomised trial data are required to confirm whether pre-emptive TIPSS is cost saving for variceal bleeding.

Guideline review: transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension—a BSG guideline

“…United Network for Organ Sharing data from 2002 to 13 indicated that patients with TIPSS had increased chances of surviving to receive liver transplant, reinforcing its role as a bridge in this setting 13. In addition, TIPSS has shown to be cost-effective in comparison to LVP, with an increase in 0.526 QALY and a saving of £17 983 per patient 14. Poor synthetic function (bilirubin >50 mmol/L and/or platelets <75×10 9 /L) is associated with poor outcomes and are relative contraindications 15…”

TIPS and splenorenal shunt for complications of portal hypertension in chronic hepatosplenic schistosomiasis–A case series and review of the literature

“…For the consideration of a possible introduction of the TIPS procedure in endemic regions, cost efficiency is one of the decisive criteria. Recent studies from Europe or North America have assessed the cost of TIPS procedure in patients with liver cirrhosis, which ranged from £4,646 (currently €5,509) [37] to $50,865.94 (currently €43,692) [38]. Since these calculations do not itemize personnel costs, consumables, profit margins, or basic technical equipment, a transfer to the economic situation in endemic regions is hardly possible.…”

LVP vs TIPS for Refractory Ascites: Where Do We Stand?

“…According to Mattock et al, TIPS resulted in 0.526 additional QALYs, saving £17,983 per patient and had a 100% probability of being cost-effective and cost-saving when compared with LVP. 67 The major savings were from avoided LVP sessions, fewer variceal bleeds, reduced SBP, fewer catheter failures, and fewer hospital bed days. With TIPS there is more cost incurred with mild HE, but a 100% probability of being cost-effective and cost saving when compared with LVP.…”