Cost-effectiveness of the evaluation of a suspicious biliary stricture Joseph B. Oliver, MD, MPH, a, * Atuhani S. Burnett, MD, PhD, a Sushil Ahlawat, MD, b and Ravi J. Chokshi, MD a a Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey b Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey article info Article history: Received 25 September 2014 Received in revised form 21 November 2014 Accepted 17 December 2014 Available online xxx Keywords: Bile duct ERCP EUS Stricture Whipple Cost-effectiveness abstract Background: Biliary stricture without mass presents diagnostic and therapeutic challenges because the poor sensitivity of the available tests and significant mortality and cost with operation. Methods: A decision model was developed to analyze costs and survival for 1) investigation first with endoscopic ultrasound (EUS) and fine needle aspiration, 2) investigation first with endoscopic retrograde cholangiopancreatography (ERCP) and brushing, or 3) surgery on every patient. The average age of someone with a biliary stricture was found to be 62-y-old and the rate of cancer was 55%. Incremental cost-effectiveness ratios (ICER) were calcu- lated based on the change in quality adjusted life years (QALYs) and costs (US$) between the different options, with a threshold of $150,000 to determine the most cost-effective strategy. One-way, two-way, and probabilistic-sensitivity analysis were performed to validate the model. Results: ERCP results in 9.05 QALYs and a cost of $34,685.11 for a cost-effectiveness ratio of $3832.33. EUS results in an incremental increase in 0.13 QALYs and $2773.69 for an ICER of $20,840.28 per QALY gained. Surgery resulted in a decrease of 1.37 QALYs and increased cost of $14,323.94 (ICER-$10,490.53). These trends remained within most sensitivity ana- lyses; however, ERCP and EUS were dependent on the test sensitivity. Conclusions: In patients with a biliary stricture with no mass, the most cost-effective strategy is to investigate the patient before operation. The choice between EUS and ERCP should be institutionally dependent, with EUS being more cost-effective in our base case analysis. ª 2015 Elsevier Inc. All rights reserved. 1. Introduction The patient presenting with a biliary stricture without obvious tumor on standard radiographic imaging (ultrasound, computed tomography [CT], or magnetic resonance imaging) presents a difficult diagnostic and therapeutic challenge. The risk of cancer is believed to be approximately 55% [1]. Benign conditions such as chronic pancreatitis, primary sclerosing cholangitis, choledocholithiasis, and postoperative strictures can present in a similar fashion. Furthermore, those with * Corresponding author. Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, 185 South Orange Ave, MSB G-595, Newark, NJ 07101 1709. Tel.: þ1 570 460 8124; fax: þ1 973 302 7156. E-mail address: oliverjo@njms.rutgers.edu (J.B. Oliver). Available online at www.sciencedirect.com ScienceDirect journal homepage: www.JournalofSurgicalResearch.com journal of surgical research xxx (2015) 1 e9 0022-4804/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2014.12.037