Minimizing recurrent peptic ulcer hemorrhage after endoscopic hemostasis: the cost-effectiveness of competing strategies.
OBJECTIVE
Controversy exists regarding the optimal strategy to minimize recurrent ulcer hemorrhage after successful endoscopic hemostasis. Our objective was to evaluate the cost-effectiveness of competing strategies for the posthemostasis management of patients with high risk ulcer stigmata.


METHODS
Through decision analysis, we calculated the cost-effectiveness of four strategies: 1) follow patients clinically after hemostasis and repeat endoscopy only in patients with evidence of rebleeding (usual care); 2) administer intravenous proton pump inhibitors (i.v. PPIs) after hemostasis and repeat endoscopy only in patients with clinical signs of rebleeding; 3) perform second look endoscopy at 24 h in all patients with successful endoscopic hemostasis; and 4) perform selective second look endoscopy at 24 h only in patients at high risk for rebleeding as identified by the prospectively validated Baylor Bleeding Score. Probability estimates were derived from a systematic review of the medical literature. Cost estimates were based on Medicare reimbursement. Effectiveness was defined as the proportion of patients with rebleeding, surgery, or death prevented.


RESULTS
The selective second look endoscopy strategy was the most effective and least expensive of the four competing strategies, and therefore dominated the analysis. The i.v. PPI strategy required 50% fewer endoscopies than the competing strategies, and became the dominant strategy when the rebleed rate with i.v. PPIs fell below 9% and when the cost of i.v. PPIs fell below 10 dollars/day.


CONCLUSIONS
Compared with the usual practice of "watchful waiting," performing selective second look endoscopy in high risk patients may prevent more cases of rebleeding, surgery, or death at a lower overall cost. However, i.v. PPIs are likely to reduce the need for second look endoscopy and may be preferred overall if the rebleed rate and cost of i.v. PPIs remains low.
Spiegel
Brennan M R
BM
Department of Digestive Diseases, University of California at Los Angeles School of Medicine, Los Angeles, California, USA.
Ofman
Joshua J
JJ
Woods
Karen
K
Vakil
Nimish B
NB
D000328:Adult; D000368:Aged; D003362:Cost-Benefit Analysis; D016099:Endoscopy, Gastrointestinal / Q000191:economics*; D006489:Hemostatic Techniques / Q000191:economics*; D006801:Humans; D008875:Middle Aged; D010438:Peptic Ulcer Hemorrhage / Q000628:therapy*; D054328:Proton Pump Inhibitors; D012008:Recurrence; D012307:Risk Factors; D012680:Sensitivity and Specificity
D054328:Proton Pump Inhibitors