York Health Economics Consortium, University of York, York, UK
Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
BMJ Open Gastroenterol. 2021 Aug;8(1). doi: 10.1136/bmjgast-2021-000641.
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.
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.
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.
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.
经颈静脉肝内门体分流术（TIPSS）在治疗静脉曲张出血和难治性腹水方面具有显著的临床疗效；然而，TIPSS 在英国的成本效益尚未得到评估。本研究旨在评估（i）预防性 TIPSS 与内镜套扎（EBL）治疗静脉曲张出血患者，以及（ii）TIPSS 与大量腹腔穿刺放液术（LVP）治疗难治性腹水患者的成本效益。
本研究采用成本效用分析，从医疗保健成本和质量调整生命年（QALY）的角度进行分析。构建了一个具有 2 年时间范围的 Markov 模型，包括死亡和生存状态以及静脉曲张出血、腹水和肝性脑病发展的概率。对难治性腹水指征进行生存分析，以推断 12 个月至 24 个月的死亡率。在确定性和概率敏感性分析中进行了不确定性分析。
对于两种指征，TIPSS 均具有成本效益（占优），并且节省成本。对于静脉曲张出血，预防性 TIPSS 可使患者获得额外的 0.209 个 QALY，并比 EBL 节省 600 英镑。TIPSS 在 95%的情况下具有很高的成本效益概率，但在受静脉曲张再出血率驱动的情景分析中，并不具有成本效益。对于难治性腹水，TIPSS 可使患者获得额外的 0.526 个 QALY，并比 LVP 节省 17983 英镑，同时具有 100%的成本效益和成本节约概率。
TIPSS 是治疗静脉曲张出血和难治性腹水的一种具有成本效益的干预措施。对于难治性腹水，TIPSS 具有很高的成本节约效果。需要进行严格的随机临床试验，以确认预防性 TIPSS 是否具有成本效益，从而节约静脉曲张出血患者的成本。
