A comparative cost analysis of TIPS and BRTO for secondary prophylaxis in gastric variceal bleeding.

BACKGROUND: After a gastric variceal rupture, clinical practice guidelines recommend either transjugular intrahepatic portosystemic shunt (TIPS) or balloon-occluded retrograde transvenous obliteration (BRTO) as interventional options for secondary prevention. This study aimed to generate and compare TIPS and BRTO costing data to calculate the secondary prevention cost following gastric variceal bleeding, to encourage consideration of resource cost within decision-making. METHODS: All costs were included for patients treated between 1 January 2017 and 1 January 2024. Data on procedure, non-procedure, and ward costs were collected. Ward costs were only calculated for elective admissions to reduce bias from inpatient emergency procedures. All costs were measured from a healthcare system perspective and included direct and indirect expenses where relevant. A 5% indexation for inflation was applied to non-fixed costs from 2017 to the 2024 cost year. The cost to prevent gastric re-bleeding was then calculated by adjusting the costing data generated based on existing outcome data in the literature, utilising the largest existing meta-analysis on the efficacy of TIPS and BRTO in preventing re-bleeding. RESULTS: There were 38 patients in the study cohort, with a mean age 56.8 years (SD 12.0), and 25 patients (66%) were male. TIPS was performed in 27 patients (71%). The TIPS and BRTO groups had similar mean age, proportion of male sex, CP grading, and proportions of elective admissions. The median total cost for TIPS was AUD$11,922 (range $6307-$53,432), while the median total cost for BRTO was AUD$3632 (range $1818-$5174), p < 0.001. The adjusted cost to prevent future gastric re-bleed using TIPS was AUD$14,803, while the cost to prevent re-bleed using BRTO was AUD$3896. CONCLUSION: The cost magnitude of both TIPS and BRTO was both low in an Australian model, and both remain good options for patients. However, the use of BRTO was associated with significantly lower upfront procedural costs than for TIPS for secondary prevention of gastric variceal bleeding. Costs should form a key component of the value of IR to modern healthcare.