Background and Aims
EUS-guided transmural drainage is effective in the management of pancreatic walled-off
necrosis (WON). A lumen-apposing metal stent (LAMS) has recently been developed specifically
for the drainage of pancreatic fluid collections that shows promising results. However,
no cost-effectiveness data have been published in comparison with endoscopic drainage
with traditional plastic stents (PSs). Our aim here was to compare the cost-effectiveness
of LAMSs to PSs in the management of WON.
Methods
A decision tree was developed to assess both LAMSs and PSs over a 6-month time horizon.
For each strategy, after the insertion of the respective stents, patients were followed
for subsequent need for direct endoscopic necrosectomy, adverse events requiring unplanned
endoscopy, percutaneous drainage (PCD), or surgery using probabilities obtained from
the literature. The unit of effectiveness was defined as successful endoscopic drainage
without the need for PCD or surgery. Costs in 2016 U.S.$ were based on inpatient institutional
costs. Sensitivity analyses were performed. An a priori willingness-to-pay threshold
of U.S.$50,000 was established.
Results
LAMSs were found to be more efficacious than PSs, with 92% and 84%, respectively,
of the patients achieving successful endoscopic drainage of WON. LAMSs, however, were
more costly: the average cost per patient of U.S.$20,029 compared with U.S.$15,941
for PSs. The incremental cost-effectiveness ratio favored LAMSs at U.S.$49,214 per
additional patient successfully treated. Sensitivity analyses confirmed the robustness
of the results.
Conclusion
LAMSs are more effective but also more costly than PSs in managing WON. Data from
high-quality, adequately controlled, prospective, randomized trials are needed to
confirm our findings.
Graphical abstract
Graphical Abstract
Abbreviations:
ICER (incremental cost-effectiveness ratio), LAMS (lumen-apposing metal stent), LOS (length of stay), PS (plastic stent), PCD (percutaneous drainage), WON (walled-off necrosis), WTP (willingness to pay)To read this article in full you will need to make a payment
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References
- Practice guidelines in acute pancreatitis.Am J Gastroenterol. 2006; 101: 2379-2400
- Asian consensus statements on endoscopic management of walled-off necrosis Part 1. Epidemiology, diagnosis, and treatment.J Gastroenterol Hepatol. 2016; 31: 1546-1554
- American College of Gastroenterology guideline: management of acute pancreatitis.Am J Gastroenterol. 2013; 108 (16): 1400-1415
- Management of pancreatic fluid collections: a comprehensive review of the literature.World J Gastroenterol. 2016; 22: 2256-2270
- A step-up approach or open necrosectomy for necrotizing pancreatitis.N Engl J Med. 2010; 362: 1491-1502
- IAP/APA evidence-based guidelines for the management of acute pancreatitis.Pancreatology. 2013; 13: e1-e15
- A novel lumen-apposing stent for transluminal drainage of nonadherent extraintestinal fluid collections.Endoscopy. 2011; 43: 337-342
- Management of pancreatic collections with a novel endoscopically placed fully covered self-expandable metal stent: a national experience (with videos).Gastrointest Endosc. 2015; 81: 127-135
- EUS-guided drainage of pancreatic fluid collections using a novel lumen-apposing metal stent on an electrocautery-enhanced delivery system: a large retrospective study (with video).Gastrointest Endosc. 2015; 82: 1039-1046
- Safety and efficacy of endoscopic ultrasound-guided drainage of pancreatic fluid collections with lumen-apposing covered self-expanding metal stents.Clin Gastroenterol Hepatol. 2015; 13: 747-752
- EUS-guided drainage of peripancreatic fluid collections and necrosis by using a novel lumen-apposing stent: a large retrospective, multicenter U.S. experience (with videos).Gastrointest Endosc. 2016; 83: 699-707
- A novel lumen-apposing metal stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a prospective cohort study.Endoscopy. 2015; 47: 63-67
- A comparison of direct endoscopic necrosectomy with transmural endoscopic drainage for the treatment of walled-off pancreatic necrosis.Gastrointest Endosc. 2009; 69: 1085-1094
- Stent selection for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a multicenter study in china.Gastroenterol Res Pract. 2014; 2014: 193562
- Endoscopic ultrasound-guided drainage of pancreatic pseudocysts: medium-term assessment of outcomes and complications.Endosc Ultrasound. 2013; 2: 199-203
- Non-fluoroscopic endoscopic ultrasound-guided transmural drainage of symptomatic non-bulging walled-off pancreatic necrosis.Dig Endosc. 2013; 25: 47-52
- Endoscopic therapy with lumen-apposing metal stents is safe and effective for patients with pancreatic walled-off necrosis.Clin Gastroenterol Hepatol. 2016; 14: 1797-1803
- Fully covered self-expanding metal stents versus lumen-apposing fully covered self-expanding metal stent versus plastic stents for endoscopic drainage of pancreatic walled-off necrosis: clinical outcomes and success.Gastrointest Endosc. 2017; 85: 758-765
- Endoscopic transmural drainage of peripancreatic fluid collections: outcomes and predictors of treatment success in 211 consecutive patients.J Gastrointest Surg. 2011; 15: 2080-2088
- Frequency of complications during EUS-guided drainage of pancreatic fluid collections in 148 consecutive patients.J Gastroenterol Hepatol. 2011; 26: 1504-1508
- Using hemospray improves the cost-effectiveness ratio in the management of upper gastrointestinal nonvariceal bleeding.J Clin Gastroenterol. 2018; 52: 36-44
- Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus.Gut. 2013; 62: 102-111
Chen Y-I, Khashab M. Johns Hopkins Hospital. Available at: http://intranet.insidehopkinsmedicine.org/finance/departments/revenue-reimbursement/informatics.html. Accessed October 2017.
Bai G. Centers for Medicare & Medicaid Services. Available at: https://www.cms.gov/. Accessed October 2017.
Chen Y-I, Bai G, Khashab M. Hospital form 2552-10. Baltimore, MD: Centers for Medicare & Medicaid Services, 2015. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Downloadable-Public-Use-Files/Cost-Reports/Hospital-2010-form.html. Accessed October 2017.
- Equal efficacy of endoscopic and surgical cystogastrostomy for pancreatic pseudocyst drainage in a randomized trial.Gastroenterology. 2013; 145: 583-590
Adam V. American Medical Association. Available at: http://www.ama-assn.org/. Accessed November 2017.
Adam V. U.S. Bureau of Labor Statistics. Available at: http://www.bls.gov/. Accessed November 2017.
- Decision modelling for health economic evaluation.Oxford University Press, Oxford, UK2006
- Partially covered self-expandable metal stents versus polyethylene stents for malignant biliary obstruction: a cost-effectiveness analysis.Can J Gastroenterol Hepatol. 2015; 29: 377-383
- Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement.Value Health. 2013; 16: e1-e5
- Handling uncertainty in cost-effectiveness models.Pharmacoeconomics. 2000; 17: 479-500
- Probabilistic analysis of cost-effectiveness models: choosing between treatment strategies for gastroesophageal reflux disease.Med Decis Making. 2002; 22: 290-308
- Lumen-apposing metal stents (LAMS) for pancreatic fluid collection (PFC) drainage: may not be business as usual.Gut. 2017; 66: 2054-2056
- Economic foundations of cost-effectiveness analysis.J Health Econ. 1997; 16: 1-31
- Assessing cost-effectiveness in healthcare.Expert Rev Pharmacoecon Outcomes Res. 2008; 8: 165-178
- What is the price of life and why doesn't it increase at the rate of inflation?.Arch Intern Med. 2003; 163: 1637-1641
- The limits of cost-effectiveness analysis.Circ Cardiovasc Qual Outcomes. 2009; 2: 55-58
- Real-life treatment paradigms show adalimumab is cost-effective for the management of ulcerative colitis.Can J Gastroenterol Hepatol. 2016; 2016: 5315798
- Factors determining recurrence of fluid collections following migration of intended long term transmural stents in patients with walled off pancreatic necrosis and disconnected pancreatic duct syndrome.Endosc Ultrasound. 2015; 4: 208-212
- Are QALYs an appropriate measure for valuing morbidity in acute diseases?.Health Econ. 2000; 9: 177-180
- Quality-adjusted life years was a poor predictor of women's willingness to pay in acute and chronic conditions: results of a survey.J Clin Epidemiol. 2005; 58: 291-303
- Analytic tools for public health decision making.Med Decis Making. 2002; 22: S3-S10
- Use of cost-effectiveness analysis in health-care resource allocation decision-making: how are cost-effectiveness thresholds expected to emerge?.Value Health. 2004; 7: 518-528
- Cost-effectiveness in health and medicine.2nd ed. Oxford University Press, Oxford, UK2017
Article info
Publication history
Published online: March 31, 2018
Accepted:
March 25,
2018
Received:
October 27,
2017
Footnotes
DISCLOSURE: The following authors disclosed financial relationships relevant to this publication: Y.-I. Chen, V. Kumbhari, A. Repici: Consultant for Boston Scientific. A. N. Barkun: Consultant for and research support recipient from Cook Inc, Pendopharm Inc, and Olympus; advisory committee member for Olympus. V. K. Singh: Consultant for Abbvie, Akcea Therapeutics, and Ariel Precision Medicine. M. A. Khashab: Consultant for Boston Scientific and Medtronic; medical advisory board member for Boston Scientific. All other authors disclosed no financial relationships relevant to this publication.
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© 2018 by the American Society for Gastrointestinal Endoscopy
