Endoscopic ultrasound versus transjugular approaches for portal pressure measurement and liver biopsy: a cost-effectiveness analysis.

BACKGROUND AND AIMS: Although a transjugular (TJ) approach is the reference standard for hepatic venous pressure gradient (HVPG) measurement, EUS-guided portal pressure gradient (PPG) measurement has emerged as a viable alternative. A randomized trial demonstrated that EUS outperformed TJ in achieving reliable PPG and adequate liver biopsy (LB). We evaluated the cost-effectiveness of EUS PPG-LB versus TJ HVPG-LB for simultaneous PPG measurement and LB procurement.

METHODS

A decision tree model compared EUS PPG-LB with TJ HVPG-LB over a 1-year time horizon from the U.S. health care payer's perspective. Probabilities were derived from randomized trial data. Costs were sourced from Centers for Medicare & Medicaid Services reimbursement data. Outcomes were incremental cost-effectiveness ratios with a willingness-to-pay threshold of $100,000/quality-adjusted life-year (QALY). One-way, 2-way, and probabilistic sensitivity analyses were performed.

RESULTS

EUS PPG-LB dominated (ie, less costly and more effective) TJ HVPG-LB for acquisition of reliable PPG and adequate LB, totaling $4564 in cost savings and accumulating 0.02 more QALY. When a separate EGD was indicated for a TJ approach, the cost-effectiveness of EUS increased further. One-way sensitivity analyses confirmed that EUS would remain cost-effective if its cost was <$8614 and/or if it maintained reliable a PPG and adequate LB rates >29.5%. EUS was preferred in 100% of the 10,000 Monte Carlo simulations.

CONCLUSIONS

In patients requiring PPG and LB, EUS demonstrated lower costs and greater effectiveness than a TJ approach. The improved cost-effectiveness was driven by its higher clinical success rates and cost savings secondary to its one-stop-shop approach. With evidence now demonstrating the superior clinical and economic value of EUS, these findings support wider clinical adoption.