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OBJECTIVE:Screening for varices is recommended in patients with cirrhosis to institute primary prophylaxis to prevent variceal bleeding. Our aim was to compare the cost-effectiveness of four strategies, including no screening/no prophylaxis, universal screening and primary prophylaxis with β-blockers, universal screening and primary prophylaxis with variceal ligation, and universal institution of primary prophylaxis with β-blockers without screening.METHODS:We constructed a Markov simulation model in two hypothetical cohorts of 50-yr-old patients with cirrhosis (one compensated and one decompensated), who were followed for 5 yr. Transition probabilities were derived from the medical literature, and costs reflected Medicare reimbursement rates at our institution.RESULTS:In patients with compensated cirrhosis, screening and primary prophylaxis with β-blockers is associated with an incremental cost-effectiveness ratio of $3605 per year of life saved. The results were most sensitive to the prevalence of varices and risk of variceal bleeding. In patients with decompensated liver disease, primary prophylaxis without screening was associated with an incremental cost-effectiveness ratio of $1154 per year of life saved. The results were most sensitive to the cost of β-blockers and endoscopy.CONCLUSIONS:Screening for varices is an affordable strategy in compensated liver disease, whereas universal primary prophylaxis with β-blockers is cost-effective in decompensated patients. [Copyright &y& Elsevier]

OBJECTIVES: The role of ERCP in acute biliary pancreatitis (ABP) is controversial. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) are modalities for bile duct visualization that could lower costs and prevent ERCP-related complications. We analyzed costs and examined the cost effectiveness of these modalities to define their role in ABP. METHODS: A decision analysis model of ABP was constructed. The strategies evaluated were I) ERCP. 2) MRCP followed by RRCP if positive for common bile duct stones (CBDS) or if biliary sepsis ensued, 3) BUS followed by ERCP if positive or if biliary sepsis ensued, and 4) observation with intraoperative cholangiography at the time of cholecystectomy with ERCP only if biliary sepsis ensued. We compared costs and performed cost effectiveness analysis between strategies at probabilities of CBDS ranging from 0% to 100%. The outcome measures were total costs and costs per ABP death prevented. RESULTS: At probabilities of CBDS < 15% observation with intraoperative cholangiography is the least expensive strategy, whereas EUS and ERCP are the least expensive strategies at probabilities of 15-58% and >58%, respectively. In terms of cost-effectiveness, at probabilities of CBDS of 7-45%, EUS is the most cost-effective alternative, and at a probability of >45% ERCP is the most cost-effective option. CONCLUSIONS: Total costs and cost-effectiveness ratios of these strategies in patients with ABP are highly dependent on the probability of CBDS. [ABSTRACT FROM AUTHOR]