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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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