The budget impact of endoscopic screening for esophageal varices in cirrhosis

BackgroundThe cost-effectiveness of screening for esophageal varices in cirrhosis remains uncertain. Previous analyses found that screening with upper endoscopy (EGD) may not be cost effective versus empiric beta-blocker (BB) therapy. However, these models were conducted before advances in variceal screening, including capsule endoscopy (CE), and they did not measure the budget impact (vs cost-effectiveness) of variceal screening.ObjectiveTo compare the managed care budget impact of variceal screening strategies.DesignBudget impact model.SettingHypothetical managed care organization with 1 million covered lives.PatientsPatients with compensated cirrhosis.InterventionsCompared 5 strategies: (1) empiric BB, (2) screening EGD followed by BB if varices present (EGD → BB), (3) EGD followed by endoscopic band ligation if varices present (EGD → EBL), (4) CE followed by BB if varices present (CE → BB), and (5) CE followed by EBL if varices present (CE → EBL).Main Outcome MeasurementPer-member per-month cost.ResultsBB was the least expensive, and CE → EBL was the most expensive. Substituting CE → BB in lieu of BB cost each member an additional $0.20 per month to subsidize. Compared with CE → BB, both EGD-based strategies were more expensive. However, CE was not viable in managed care organizations capable of reducing the cost of endoscopy below $410, unless the cost of CE was reduced in lockstep.LimitationsData on CE remain limited.ConclusionsScreening for varices may have an acceptable budget impact but is highly sensitive to local costs of EGD and CE. In managed care organizations willing to subsidize EBL for variceal prophylaxis, it is inefficient to screen with CE compared with EGD.