Background & Aims

Post–endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is the most common adverse event after endoscopic retrograde cholangiopancreatography, and is responsible for substantial morbidity and health care expenditures of at least $200 million. Therapies for PEP prevention include pancreatic stent placement (PSP), rectal indomethacin, sublingual nitrates, and aggressive lactated Ringer’s hydration. Our objective was to determine which PEP prophylactic strategies are cost effective.

Methods

We developed 2 separate decision trees to evaluate PEP prophylactic strategies. The first, in high-risk patients, compared rectal indomethacin, PSP, PSP with indomethacin, sublingual nitrates, aggressive hydration with lactated Ringer’s, and no prophylaxis. The second, in average-risk patients, compared rectal indomethacin, sublingual nitrates, aggressive hydration, and no prophylaxis. We used incidence rates, transition probabilities, and costs from publications and public data sources. Outcome measures were reported as incremental cost-effectiveness ratios, with a willingness-to-pay (WTP) threshold of $100,000/quality-adjusted life years (QALYs).

Results

Compared with no prophylaxis, all strategies were cost effective at a WTP of $100,000 in preventing PEP in high-risk patients. When directly compared with each other, rectal indomethacin was the cost-effective strategy in high-risk patients ($31,589/QALYs). In average-risk patients, indomethacin and sublingual nitrates were cost effective at a WTP of $100,000/QALYs compared with no prophylaxis. When directly compared with each other, rectal indomethacin was the cost-effective strategy ($53,016/QALYs).

Conclusions

Rectal indomethacin was the cost-effective strategy for preventing PEP in both average-risk and high-risk patients undergoing endoscopic retrograde cholangiopancreatography. All strategies were cost effective when compared with no prophylaxis in high-risk patients, whereas all strategies except for aggressive hydration with lactated Ringer’s were cost effective in average-risk patients. Further studies are needed to improve the utilization of PEP prevention strategies.

中文翻译：

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美国内镜逆行胰胆管造影术后胰腺炎预防的成本效益分析

背景与目标

内镜逆行胰胆管造影术后胰腺炎 (PEP) 是内镜逆行胰胆管造影后最常见的不良事件，导致大量发病率和至少 2 亿美元的医疗保健支出。预防 PEP 的疗法包括胰腺支架置入 (PSP)、直肠消炎痛、舌下硝酸盐和积极的乳酸林格水合作用。我们的目标是确定哪些 PEP 预防策略具有成本效益。

方法

我们开发了 2 个独立的决策树来评估 PEP 预防策略。首先，在高危患者中，比较了直肠消炎痛、PSP、PSP 与吲哚美辛、舌下硝酸盐、乳酸林格氏液的积极补液，以及无预防。第二，在平均风险患者中，比较了直肠消炎痛、舌下硝酸盐、积极补水和不预防。我们使用了来自出版物和公共数据源的发病率、转换概率和成本。结果测量报告为增量成本效益比，支付意愿 (WTP) 阈值为 100,000 美元/质量调整生命年 (QALYs)。

结果

与不采取预防措施相比，在 WTP 为 100,000 美元的情况下，所有策略在预防高危患者 PEP 方面都具有成本效益。当直接相互比较时，直肠消炎痛是高风险患者的成本效益策略（31,589 美元/QALYs）。在平均风险患者中，消炎痛和舌下硝酸盐在 WTP 为 100,000 美元/QALYs 时具有成本效益，而没有预防。当直接相互比较时，直肠消炎痛是具有成本效益的策略（53,016 美元/QALYs）。

结论

在接受内镜逆行胰胆管造影的中等风险和高风险患者中，直肠消炎痛是预防 PEP 的具有成本效益的策略。与在高危患者中不采取预防措施相比，所有策略都具有成本效益，而除了乳酸林格氏液的积极补液外，所有策略在平均风险患者中都是具有成本效益的。需要进一步的研究来提高 PEP 预防策略的利用率。