Fully Covered Metal Stents Are the Most Cost-Effective Option for Benign Biliary Strictures in Chronic Pancreatitis
Bret T. Petersen, MD, MASGE, reviewing Thiruvengadam NR, et al. Clin Gastroenterol Hepatol 2022 Feb 15.
Benign distal biliary strictures (BBS) are common sequelae of chronic pancreatitis. The usual treatment involves prolonged maximal-caliber stenting, using either serial exchange of multiple plastic stents (MPS) or one or two cycles of large-caliber fully covered self-expanding metal stents (FCSEMS). The authors of this study used a Markov model to estimate the incremental cost-effectiveness ratios of these approaches, assuming MPS exchange every 3 months and FCSEMS remained in place for 6 or 12 months, with 5 years of follow-up and the potential for additional remedial care.
Treatment with 12 months of FCSEMS, with a cost of $10,938 and effectiveness of 4.58 quality-adjusted life-years (QALYs), was less costly and more effective than therapy with either the shorter indwell time of 6 months ($13,846 and 4.57 QALYs) or serial placement of MPS ($28,587 and 4.53 QALYs). FCSEMS for 12 months remained the most cost-effective option for stricture resolution rates higher than approximately 60%. FCSEMS for 6 months was most cost-effective for resolution rates between 14.75% and 60%. MPS was the preferred strategy in only about 5% of iterations.
COMMENTIn this Markov model of stent therapy for BBS in chronic pancreatitis, FCSEMS for 6 or 12 months were the dominant cost-effective alternatives in 95% of repetitions; therefore, they should be preferred (by payors) in most instances. For providers and sites of care, the lost revenue from serial procedures usually exceeds the expense of FCSEMS. Further analysis by the authors demonstrated that applying existing cost-sharing measures, such as pass-through codes designated by the Centers for Medicare & Medicaid Services, could incentivize best practices by distributing the savings to physicians, payors, and patients.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
CITATION(S)
Thiruvengadam NR, Saumoy M, Schneider Y, Kochman ML. Fully covered self-expanding stents are cost-effective at remediating biliary strictures in patients with chronic pancreatitis. Clin Gastroenterol Hepatol 2022 Feb 15. (Epub ahead of print) (https://doi.org/10.1016/j.cgh.2022.02.019)
