Journal: Endoscopy
Study type
- Decision-analytic, state-transition Markov model over 1 year
- US healthcare payer perspective
- Population modeled: 70-year-old with locally advanced, unresectable pancreatic cancer, malignant distal biliary obstruction, and common bile duct dilation >15 mm
Interventions compared
- Endoscopic ultrasound–guided choledochoduodenostomy (EUS-CDS) using a lumen‑apposing metal stent (LAMS)
- Endoscopic retrograde cholangiopancreatography–guided transpapillary biliary drainage (ERCP-BD) using a self‑expandable metal stent (SEMS)
Data sources and outcomes
- Transition probabilities: from meta-analyses of randomized trials
- Main outcome: incremental cost-effectiveness ratio (ICER), expressed as cost per quality-adjusted life year (QALY) gained
- Willingness‑to‑pay threshold: $100,000 per QALY
- Sensitivity analyses: one-way and probabilistic sensitivity analyses performed
Key results
- EUS‑CDS with LAMS was cost-effective versus ERCP‑BD with SEMS, with an ICER of $47,711/QALY.
- One-way sensitivity analyses:
- EUS‑CDS remained cost-effective if its cost was < $15,502 or if ERCP‑BD cost > $11,174.
- ERCP‑BD could become cost-effective if:
- Technical success > 91%, or
- Reintervention rate < 11%, or
- Post-procedural pancreatitis rate < 4%.
- Probabilistic sensitivity analysis: EUS‑CDS was cost-effective in 74.1% of simulations at the chosen threshold.
Conclusions and implications for practice
- For patients with malignant distal biliary obstruction and significant biliary dilation (>15 mm), EUS‑CDS with LAMS appears not only clinically favorable (based on prior trials) but also economically attractive as a primary palliative drainage strategy.
- Wider adoption may be supported by further reducing LAMS costs, optimizing stent performance (less dysfunction/reintervention), and refining anatomic selection criteria.