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. 2021 Aug;8(1):e000641.
doi: 10.1136/bmjgast-2021-000641.

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

Richard Mattock  1 , Dhiraj Tripathi  2 , Frank O'Neill  3 , Joyce Craig  4 , Jennifer Tanner  3 , David Patch  5 , Guruprasad Aithal  6
Affiliations

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

Richard Mattock et al. BMJ Open Gastroenterol. 2021 Aug.

Abstract

Objectives: Transjugular 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.

Methods: A 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.

Results: TIPSS 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.

Conclusions: TIPSS 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.

Keywords: ascites; bleeding; cost-effectiveness; economic evaluation; liver cirrhosis.

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Conflict of interest statement

Competing interests: RM is an employee of York Health Economics Consortium who were commissioned by W.L. Gore & Associates to provide consultancy, develop the economic model and write the manuscript.

Figures

Figure 1
Figure 1
Structure of the Markov model. QALY, quality-adjusted life year; RA, refractory ascites; SBP, spontaneous bacterial peritonitis; TIPSS, transjugular intrahepatic stent shunt.
Figure 2
Figure 2
PSA results. PSA, probabilistic sensitivity analysis; QALY, quality-adjusted life year; CE, cost-effectiveness.
See this image and copyright information in PMC

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