Cost effectiveness of modalities of Palliative Biliary Drainage in Malignant Extrahepatic Biliary Obstruction

Introduction: Biliary drainage in malignant extrahepatic distal bile duct obstruction (MBO) can be achieved with Endoscopic Retrograde Cholangiopancreatography (ERCP), Percutaneous Transhepatic Biliary Drainage (PTBD) or Endoscopic Ultrasound assisted choledochoduodenostomy (EUS-CDS). The aim of our study is to evaluate all these modalities in a cost-effective model. Methods: A patient level discrete time cycle Markov model was developed using United Kingdom’s healthcare resource group (HRG) tariff costs. Health related quality of life (HRQoL) data was used to develop Quality adjusted life years (QALYs). Monte-Carlo deterministic analysis was performed. Probabilistic Sensitivity Analysis and deterministic analysis were performed. Results: EUS-CDS was the most cost-effective modality for biliary drainage in MBO, (Cost £2,116 ($2,853.99) / Effectiveness 1.35) compared to ERCP (£2,349 ($3,168.25) / 1.33) and PTBD (£3,161 ($4,263.45) / 1.31). Microsimulation over 1,000 patient iterations confirmed that EUS-CDS had the highest net monetary benefit Conclusion: EUS-CDS appears to be a cost-effective strategy for biliary drainage in malignant obstruction under a range of modelling assumptions, particularly in settings with adequate availability and expertise.