Presentation (CTI)

OBJECTIVES: Indeterminate biliary strictures can have many underlying benign and malignant causes, including infections, pancreatitis, or cancer. Endoscopic retrograde cholangiopancreatography (ERCP) brushing and biopsy is the standard of care for the diagnosis of indeterminate biliary strictures in Saudi Arabia. Utilizing direct visualization single-operator cholangioscopy guided biopsy (SOC) improves the quality of the biopsy due to advanced visualization. In this study the cost-consequence of utilizing SOC compared to ERCP for the diagnosis of biliary strictures was evaluated.
METHODS: A health-economic model was developed in Excel® comparing SOC to ERCP-based biopsy and brushing for indeterminate biliary strictures from the Saudi Arabian public payer perspective. A decision-tree was utilized to model the initial cancer diagnosis of cholangiocarcinoma, followed by a Markov model exploring the disease-progression over a lifetime horizon. Model inputs were sourced from peer-reviewed literature as well as expert-interview derived micro-costing. Costs were reported in 2023 Saudi Arabian Riyals (SAR). Sensitivity analyses were run and presented at the range of the 95% credible interval.
RESULTS: The use of SOC for the diagnosis of indeterminate biliary strictures resulted in fewer biopsies performed as well as a reduced time to correct diagnosis by -6.6 weeks. Compared to ERCP-based biopsy, SOC reduced costs of care by 5,135 SAR (93,389 to 88,254) per patient and increased quality-adjusted life years (+0.8 QALYs) over the patient’s lifetime. An ICER was not calculated as SOC dominated ERCP. Outcomes were driven by early cancer detection and management. Sensitivity analyses found that SOC dominated ERCP in 95% of simulations.
CONCLUSIONS: Switching from ERCP to SOC for diagnosing cancer in patients with indeterminate biliary strictures reduces the number of biopsies required per patient and offers cost savings from the perspective of the Saudi Arabian public payer.