Should ERCP be routine after an episode of “idiopathic” pancreatitis? A cost-utility analysis,☆☆,,★★

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Abstract

Background: Patients often recover from an episode of acute pancreatitis with conservative therapy and without an identified cause. The options include proceeding with ERCP to identify and treat an occult common bile duct stone or performing the procedure only after a second episode of idiopathic pancreatitis occurs. Methods: Decision analysis (SMLTREE software) was used to determine incremental cost-utility. Variables were estimated from a search of the literature, a utility analysis involving health professionals familiar with the question, and a retrospective review of hospital charts and costs. Results: This model estimates an incremental utility gain for the prompt ERCP approach of 1.0 quality-adjusted life weeks per patient at an incremental cost of $245 (Canadian). This yields a cost-utility ratio of $12,740 (Canadian) per quality-adjusted life year. The result was highly sensitive to the probability of finding an occult common bile duct stone. Conclusion: Routine ERCP is of marginal overall benefit, but is of more substantial benefit and is more cost-effective in a subgroup of patients with a greater probability of having an occult common duct stone. (Gastrointest Endosc 1996;44:118-23.)

Section snippets

Tree structure

Using SMLTREE software (Version 2.9, Jim Hollenberg, 1989), a decision tree (Fig. 1), was constructed with dual outcomes of utility and cost.

. Decision tree to evaluate both the utility and cost of proceeding promptly with ERCP versus waiting for a second episode. The open box represents the decision node, while the open circles represent chance nodes and the solid boxes represent terminal nodes.

There is a single decision node with two options, either proceeding with an outpatient ERCP a few

RESULTS

Using the baseline values, (Table 2, left hand column) the expected utility of the ERCP option is 1146.8 QALWs, whereas that of the No ERCP is 1145.8 QALWs, yielding an incremental utility gain of 1.0 QALWs per patient. This is generally referred to as a “close call” or “toss up.”33, 34 The expected cost of the ERCP option is $2729 versus $2484 for the No ERCP option, yielding an incremental cost of $245 per patient. The cost-utility ratio is $12,740 per quality-adjusted life year (QALY) gained.

DISCUSSION

To estimate the potential benefit of the ERCP option we chose to focus therapy on the identification and removal of an occult common duct stone. We did this for two reasons. First of all, expertise in interventions for such causes as pancreas divisum and gall bladder sludge is limited to select centers. By limiting our focus to occult choledocholithiasis, we believe that our results are more generalizable to community endoscopists whose primary indication for the procedure is ruling this out.

Acknowledgements

The authors gratefully acknowledge the helpful comments provided by Dr. Peter Coyte, Dr. John Howard, and Dr. William Watson, as well as the assistance of Lynda Heckendorn and Carmela O'Reilly.

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    From the Victoria Hospital, The University of Western Ontario, London, Ontario, Canada, and the Toronto Hospital, The University of Toronto, Toronto, Ontario, Canada.

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    Dr. Detsky is supported by a National Research Scholar Award from Health and Welfare Canada.

    Reprint requests: J.C. Gregor, MD, Room N562, Victoria Hospital, 375 South St., London, Ontario, Canada, N6A 4G5.

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    37/1/72571.

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