An Economic Analysis of Transjugular Intrahepatic Portosystemic Covered Stent Shunt for Variceal Bleeding and Refractory Ascites in a Spanish Setting

IntroductionThe primary aim is to estimate the cost-effectiveness of transjugular intrahepatic portosystemic stent shunt (TIPSS) in two indications from a Spanish perspective. Firstly, as pre-emptive treatment for patients with acute variceal bleeding (indication 1) compared with endoscopic band ligation plus drug therapy. Secondly, to treat refractory ascites (indication 2) compared with large volume paracentesis.MethodsA two-state (alive and dead) Markov model was developed to capture the costs and health impact for the two indications over a 2-year time horizon with monthly cycles. In the alive state, patients could experience adverse event(s), associated with costs and disutility, such as recurrent variceal bleeding, ascites, and hepatic encephalopathy. Discount rates of 3% for utilities and costs and a cost-effectiveness threshold of euro25,000 per QALY were applied.ResultsIn the base case analysis, TIPSS was estimated to be cost-effective as a pre-emptive treatment for indication 1 (incremental cost and QALYs of - euro230 and 0.211, respectively). TIPSS also remained cost-effective (euro16,819/QALY) in a conservative scenario analysis, conducted with an alternate source for clinical parameters. The key drivers of the outcomes were survival for the comparator arm, mean band ligation outpatient procedures, and TIPSS treatment costs. TIPSS was estimated to dominate the comparator for indication 2 (incremental cost and QALYs of - euro25,687 and 0.531, respectively). The key drivers of the outcomes were monthly paracentesis sessions and cost per inpatient stay for those undergoing paracentesis.ConclusionsTIPSS is likely to be a cost-effective and a cost-saving treatment in patients with cirrhosis in indications 1 and 2, compared with standard treatments. The analyses estimate clinical benefits along with reduced healthcare costs from avoided downstream resource consumption.