The Economic Impact of Esophageal Variceal Hemorrhage: Cost–Effectiveness Implications of Endoscopic Therapy

Abstract

Esophageal variceal hemorrhage (EVH) is a serious and expensive sequela of chronic liver disease, leading to increased utilization of resources. Today, endoscopic sclerotherapy (ES) and endoscopic ligation (EL) are the accepted, community standards of endoscopic treatment of patients with EVH. However, there are no published studies comparing the economic costs of treating EVH using these interventions. As part of a prospective, randomized trial comparing ES and EL for the treatment of EVH, we estimated the direct costs of health care utilization and cost-effectiveness for the prevention of variceal rebleeding and patient survival at 1-year follow-up. Esophageal variceal hemorrhage (EVH) is a common cause of upper gastrointestinal (UGI) hemorrhage, accounting for approximately one third of diagnoses in individuals presenting with UGI bleeding. 1,2 Individuals with EVH require hospital admission, usually to an intensive care unit (ICU), blood product transfusions, acute and follow-up endoscopic treatment sessions in an attempt to obliterate varices, and, overall, they place a prodigious demand on resources used for health care. 3 Accordingly, the estimated direct and indirect medical costs of care for EVH are enormous. 4 In 1985, direct costs of medical care for esophageal varices were estimated to be $78.2 million. 4,5 This figure includes hospital charges, physician fees, and outpatient care. During that same year, the diagnosis of EVH accounted for approximately 62,000 total hospital days in nonfederal, short-stay hospitals in the United States and was the most expensive of all digestive diseases in terms of average daily cost of hospitalization ($1,091 per day). 4,5 Moreover, the indirect costs of esophageal varices were estimated to be $47.5 million. 4,5 Endoscopic and nonendoscopic therapies for the acute treatment of EVH as well as for the prevention of variceal rebleeding are available. 6 Nonendoscopic modalities include mechanical tamponade; pharmacologic agents such as vasopressin, terlipressin, somatostatin, octreotide, and ␤-blockers; transjugular intrahepatic portosystemic shunt (TIPS); and surgery including portosystemic shunt, esophageal transection and devascularization, and liver transplantation. 6 Until recently, endoscopic sclerotherapy (ES) was the only endoscopic therapy available for the treatment of patients with EVH. However, during the last several years, a number of prospective, randomized trials comparing ES and endoscopic ligation (EL) have reported ligation to be as efficacious and safe as sclerotherapy. 7-14 Based on lower rates of variceal rebleeding, mortality, treatment-related complications (e.g., esophageal stricture formation), and fewer endoscopic treatment sessions to achieve variceal obliteration, two recent meta-analyses concluded that EL should be considered the endoscopic treatment of choice for patients with EVH. 15,16 However, there are limited economic data on the medical costs of care for patients treated with alternative endoscopic hemostatic therapies for EVH. [17][...

Cost of preventing variceal rebleeding with transjugular intrahepatic portal systemic shunt and distal splenorenal shunt

“…In one study the one year direct costs of managing patients who bled from varices with endoscopic therapy were $13,197 for sclerotherapy and $9,696 for variceal band ligation (25). In two reports using modeling the estimated annual direct costs for preventing rebleeding using variceal band ligation or TIPS were $16,600 to $23,459 and $26,275 to $30,900 respectively (13,15).…”

Liver Transplantation in a Randomized Controlled Trial of Emergency Treatment of Acutely Bleeding Esophageal Varices in Cirrhosis

“…More recently, elective therapy with endoscopic variceal ligation (EVL) has replaced EST in some centers as a result of several studies showing more rapid eradication of varices, lower rates of recurrent bleeding, and fewer complications [22]. However, replacement of EST by EVL increasingly has been questioned [22][23][24][25]. In a 2003 survey of 93 gastroenterologists who treated 725 patients in various centers, EST was used more frequently than EVL for control of variceal bleeding, and as frequently as EVL for initial control of acute bleeding [23].…”

Terlipressina: profilo farmacologico clinico, terapeutico e farmacoeconomico nel trattamento delle varici esofagee

“…Nel sottogruppo di pazienti con sanguinamento attivo durante la procedura endoscopica, invece, ES è risultato associato a un costo/sopravvissuto nettamente inferiore ($28.523 vs. $51.696), in virtù della nota superiorità clinica di questa tecnica in presenza di emorragia acuta. Gli autori ritengono pertanto che la scelta tra le due tecniche endoscopiche alternative debba essere guidata da considerazioni prettamente cliniche, visto il paragonabile assorbimento di risorse sanitarie, per quanto auspichino la conduzione di ulteriori studi di rilevamento degli esiti clinici ed economici delle terapie dell'emorragia da rottura di varice [44].…”