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Value of magnetic resonance cholangiopancreatography in the diagnosis of biliary abnormalities in postcholecystectomy patients: A probabilistic cost-effectiveness analysis of diagnostic strategies

Published online by Cambridge University Press:  27 February 2006

Kirsten Howard ,
Sarah J. Lord ,
Anthony Speer ,
Robert N. Gibson ,
Robert Padbury  and
Brendon Kearney
Kirsten Howard
Affiliation:
University of Sydney
Sarah J. Lord
Affiliation:
University of Sydney
Anthony Speer
Affiliation:
Royal Melbourne Hospital
Robert N. Gibson
Affiliation:
University of Melbourne and Royal Melbourne Hospital
Robert Padbury
Affiliation:
Flinders University and Flinders Medical Center
Brendon Kearney
Affiliation:
Adelaide University and Institute of Medical and Veterinary Science
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Abstract

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is considered the gold standard for imaging of the biliary tract but is associated with complications. Less invasive imaging techniques, such as magnetic resonance cholangiopancreatography (MRCP), have a much lower complication rate. The accuracy of MRCP is comparable to that of ERCP, and MRCP may be more effective and cost-effective, particularly in cases for which the suspected prevalence of disease is low and further intervention can be avoided. A model was constructed to compare the effectiveness and cost-effectiveness of MRCP and ERCP in patients with a previous history of cholecystectomy, presenting with abdominal pain and/or abnormal liver function tests.

Methods: Diagnostic accuracy estimates came from a systematic review of MRCP. A decision analytic model was constructed to represent the diagnostic and treatment pathway of this patient group. The model compared the following two diagnostic strategies: (i) MRCP followed with ERCP if positive, and then management based on ERCP; and (ii) ERCP only. Deterministic and probabilistic analyses were used to assess the likelihood of MRCP being cost-effective. Sensitivity analyses examined the impact of prior probabilities of common bile duct stones (CBDS) and test performance characteristics. The outcomes considered were costs, quality-adjusted life years (QALYs), and cost per additional QALY.

Results: The deterministic analysis indicated that MRCP was dominant over ERCP. At prior probabilities of CBDS, less than 60 percent MRCP was the less costly initial diagnostic test; above this threshold, ERCP was less costly. Similarly, at probabilities of CBDS less than 68 percent, MRCP was also the more effective strategy (generated more QALYs). Above this threshold, ERCP became the more effective strategy. Probabilistic sensitivity analyses indicated that, in this patient group for which there is a low to moderate probability of CBDS, there was a 59 percent likelihood that MRCP was cost-saving, an 83 percent chance that MRCP was more effective with a higher quality adjusted survival, and an 83 percent chance that MRCP had a cost-effectiveness ratio more favorable than $50,000 per QALY gained.

Conclusions: Costs and cost-effectiveness are dependent upon the prior probability of CBDS. However, probabilistic analysis indicated that, with a high degree of certainty, MRCP was the more effective and cost-effective initial test in postcholecystectomy patients with a low to moderate probability of CBDS.

Keywords

EconomicsMagnetic resonance imagingCholangiopancreatographyEndoscopic retrogradeBiliary tract disease
Type
GENERAL ESSAYS
Information
International Journal of Technology Assessment in Health Care , Volume 22 , Issue 1 , January 2006 , pp. 109 - 118
Copyright
© 2006 Cambridge University Press

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References

Angulo P, Pearce DH, Johnson CD, et al. 2000 Magnetic resonance cholangiography in patients with biliary disease: Its role in primary sclerosing cholangitis. J Hepatol. 33: 520– 527.Google Scholar
Arguedas MR, Dupont AW, Wilcox CM. 2001 Where do ERCP, endoscopic ultrasound, magnetic resonance cholangiopancreatography, and intraoperative cholangiography fit in the management of acute biliary pancreatitis? A decision analysis model. Am J Gastroenterol. 96: 2892– 2899.Google Scholar
Barish MA, Yucel EK, Ferrucci JT. 1999 Magnetic resonance cholangiopancreatography. N Engl J Med. 341: 258– 264.Google Scholar
Bass EB, Pitt HA, Lillemoe KD. 1993 Cost-effectiveness of laparoscopic cholecystectomy versus open cholecystectomy. Am J Surg. 165: 466– 471.Google Scholar
Bass EB, Steinberg EP, Pitt HA, et al. 1991 Cost-effectiveness of extracorporeal shock-wave lithotripsy versus cholecystectomy for symptomatic gallstones. Gastroenterology. 101: 189– 199.Google Scholar
Cook J, Richardson J, Street A. 1994 A cost utility analysis of treatment options for gallstone disease: Methodological issues and results. Health Econ. 3: 157– 168.Google Scholar
Department of Health and Ageing. 2004. Manual of Resource Items and their Associated Costs for use in submissions to the Pharmaceutical Benefits Advisory Committee involving economic evaluation. Canberra, Australia: Department of Health and Ageing, Commonwealth of Australia;
Department of Health and Ageing. 2004. Medicare Benefits Schedule (from November 1, 2004). Canberra, Australia: Department of Health and Ageing, Commonwealth of Australia;
Department of Health and Ageing. 2004. National Hospital Cost Data Collection. Public Sector Cost Weights for AR-DRG version 4.2 Round 6 (2001–2002). Canberra, Australia: Department of Health and Ageing, Commonwealth of Australia;
Department of Health and Ageing. 2004. Schedule of pharmaceutical benefits for approved pharmacists and medical practitioners. Canberra, Australia: Department of Health and Ageing, Commonwealth of Australia;
Flamm CR, Mark DH, Aronson N. 2002 Evidence-based review of ERCP: Introduction and description of systematic review methods. Gastrointest Endosc. 56 (Suppl 6): S161– S164.Google Scholar
Freeman ML. 2003 Adverse outcomes of endoscopic retrograde cholangiopancreatography: Avoidance and management. Gastrointest Endosc Clin North Am. 13: 775– 798.Google Scholar
Freeman ML, Disario JA, Nelson DB, et al. 2001 Risk factors for post-ERCP pancreatitis: A prospective, multicenter study. Gastrointest Endosc. 54: 425– 434.Google Scholar
Freeman ML, Nelson DB, Sherman S, et al. 1996 Complications of endoscopic biliary sphincterotomy. N Engl J Med. 335: 909– 918.Google Scholar
Gregor JC, Ponich TP, Detsky AS. 1996 Should ERCP be routine after an episode of “idiopathic” pancreatitis? A cost-utility analysis. [see comment]. Gastrointest Endosc. 44: 118– 123.Google Scholar
Groeneveld PW, Lieu TA, Fendrick AM, et al. 2001 Quality of life measurement clarifies the cost-effectiveness of Helicobacter pylori eradication in peptic ulcer disease and uninvestigated dyspepsia. Am J Gastroenterol. 96: 338– 347.Google Scholar
Kaltenthaler E, Vergel YB, Chilcott J, et al. 2004 A systematic review and economic evaluation of magnetic resonance cholangiopancreatography compared with diagnostic endoscopic retrograde cholangiopancreatography. Health Technol Assess. 8: iii– 89.Google Scholar
Loperfido S, Angelini G, Benedetti G, et al. 1998 Major early complications from diagnostic and therapeutic ERCP: A prospective multicenter study. Gastrointest Endosc. 48: 1– 10.Google Scholar
Masci E, Toti G, Mariani A, et al. 2001 Complications of diagnostic and therapeutic ERCP: A prospective multicenter study. Am J Gastroenterol. 96: 417– 423.Google Scholar
Medical Services Advisory Committee. 2005. Magnetic resonance cholangiopancreatography: Assessment report. Canberra, Australia: Commonwealth of Australia; Report No.: MSAC Reference 25.
Romagnuolo J, Bardou M, Rahme E, et al. 2003 Magnetic resonance cholangiopancreatography: A meta-analysis of test performance in suspected biliary disease. Ann Intern Med. 139: 547– 557.Google Scholar
Scheiman JM, Carlos RC, Barnett JL, et al. 2001 Can endoscopic ultrasound or magnetic resonance cholangiography replace ERCP in patients with suspected biliary disease? A prospective trial and cost analysis. Am J Gastroenterol. 96: 2900– 2904.Google Scholar
Tillinger W, Mittermaier C, Lochs H, Moser G. 1999 Health-related quality of life in patients with Crohn's disease: Influence of surgical operation–a prospective trial. Dig Dis Sci. 44: 932– 938.Google Scholar
Tranter SE, Thompson MH. 2002 Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct. Br J Surg. 89: 1495– 1504.Google Scholar