Results
There were a total of 150 TIPS procedures performed in the study period. Of these, 28 (19%) were primarily for the treatment of refractory ascites (including one patient who had a recurrent hepato-hydrothorax: the cost for this procedure was considered equivalent to an ascitic drain). Nine of these were performed in patients referred from surrounding secondary care institutions and of these four did not have sufficient notes available for a full data set and are subsequently excluded in the study. The remaining 24 cases are subsequently described (86% of potentially eligible patients within study period) with full data on hospital length of stay and resource use.
Patient characteristics: 62.5% of patients were male. Mean age at TIPS procedure was 57.1 (33.3–78.6). The mean MELD score at this time was 13.1 (6–26). Alcoholic cirrhosis was the most common aetiology. There was a mean of 8.5 (1–26) ascitic drains per patient performed in the year proceeding TIPS, 30 units of Human Albumin Solution (HAS) used (1–104) and 30.3 inpatient hospital days (6–78) per patient.
In addition to admissions and hospital days for paracentesis (ie, independent of number of drains performed), on average patients had two admissions before TIPS and a mean length of stay of 19.8 hospital days relating to chronic liver disease (21.5 for all admissions). After TIPS the mean number of admissions was 1.3 with a mean number of 10.8 hospital days secondary to chronic liver disease (13.8 days spent in hospital for any cause). The difference in the number of hospital days excluding those for paracentesis was not significant (p=0.19). However, when including hospital days for paracentesis, the difference was highly significant (p=0.01), mostly reflecting the success in reducing ascites after TIPS (number of ascitic drains 8.5 vs 1.0; p=0.00).
The number of days spent in hospital where the primary indication for admission was encephalopathy increased after procedure from a mean of 2.0 (0–27) to a mean of 7.0 (0–117). Five patients had admissions for encephalopathy prior to TIPS which increased to nine after (38%). Seven patients developed new encephalopathy after TIPS and interestingly three patients who had admissions for encephalopathy preprocedure did not have any post-TIPS.
All TIPS procedures were technically successful at the time of the index procedure with reductions in the porto-systemic gradient for all (mean reduction 15.0 mm Hg). There were no immediate complications. All patients received covered stents. One patient required their TIPS narrowing for refractory encephalopathy but otherwise no reintervention was required. There were no episodes of TIPS blockage during the follow-up period.
The mean TIPS survival to the end of study period was 25.9 months but there was a wide distribution (5 days to 5 years; SD 18.7). In all, 65% survived at least 1 year. One patient only survived for 5 days due to her liver disease being more severe than initially appreciated.
The majority of patients had no clinical or radiological evidence of ascites after their procedures (77% at 28 days). This progressively improved throughout the study period. At 6 months, only 12% of patients required ascitic drainage and at 1 year no patients who survived this long had detectable ascites. The incidence of clinically evident encephalopathy was 15% at 1 month, 20% at 6 months and 12% at 1 year.
The compound cost of their care is illustrated in Table 1. The average net saving was £2759 for an individual patient as compared with the costs involved in their care in the year preceding TIPS. This number includes the cost of the procedure itself and the management of any complications requiring hospital admission.
In patients who required six or less drains in the year preceding TIPS (n=13), the net average saving was £995 per patient. In patients requiring 6–12 drains in the year preceding TIPS (n=6), the average saving was £9203.68 per patient. In patients requiring more than 12 drains (n=5) in the year preceding, there was a net cost of £1409.83 but this figure was heavily influenced by one patient who had a 106-day hospital admission (total net cost £24 258.85) after the procedure mainly due to a considerable delay in discharge while suitable accommodation was found, and unrelated to the TIPS procedure or liver disease directly. With this patient excluded as an outlier, the average net saving was £4569.86.