Economic Evaluation and Budget Impact Analysis of Indocyanine Green Test for Preoperative Liver Function in Patients with Major Hepatectomy in Thailand

Abstract

Introduction: Post-hepatectomy liver failure (PHLF) remains a significant cause of morbidity and mortality following liver resections. Indocyanine green (ICG) clearance testing provides quantitative liver function assessment to improve perioperative risk stratification. However, its cost poses a concern in resource-limited settings like Thailand. This study aimed to evaluate the cost-utility and budget impact of adding ICG testing to standard diagnosis compared to standard diagnosis alone in patients undergoing first major hepatectomy. Methods: A hybrid model combining a decision tree and Markov model was developed from a societal perspective over a lifetime horizon. Clinical data and cancer treatment costs were derived from 400 real-world patients admitted to four university hospitals. PHLF costs were sourced from the National Health Security Office and utility values were directly collected from patients admitted for major hepatectomy. Primary outcomes included total costs, life years, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER). A 3% annual discount rate was applied. A variety of sensitivity analyses were conducted to test parameter uncertainty. A 5-year budget impact analysis was also performed from a payer’s perspective, calculating the net budget impact (NBI) between both strategies. Results: Compared to standard diagnosis alone, adding ICG testing increased costs by 3600 Thai baht (THB) [102 US dollars ($)] and gained 0.001 QALYs, yielding an ICER of 2,763,973 THB/QALY ($78,321). The probability of cost-effectiveness at the ceiling threshold of 160,000 THB/QALY ($4,534) was 6.3%. The ICER would fall below this threshold if PHLF risk exceeded 10.1% or if ICG test cost decreased by at least 88%. The 5-year NBI was 39.5 million THB ($1.1 million), reduced by 47.3% with dose-sharing. Conclusion: Although not cost-effective at current thresholds, ICG reduces PHLF-related costs and maintains an acceptable NBI per year.