title: Cost-saving approach to patients on long-term anticoagulation who need endoscopy: a decision analysis.
abstract: OBJECTIVE
  The management strategies used when patients requiring long-term anticoagulation need endoscopic procedures vary considerably. Two commonly used approaches are a "heparin window" strategy in the inpatient setting and, more recently, a "switch to low molecular weight heparin (LMWH)" strategy for elective procedures. The aim of this study was to determine whether an initial diagnostic endoscopy (visualization only) is a cost-effective strategy in these patients.
  
  
  METHODS
  Decision analysis was performed for two scenarios using probability estimates from our retrospective study. Scenario 1: Patients with any (urgent and elective) indication for endoscopy while on anticoagulation. A decision tree was made outlining two strategies: 1) a diagnostic endoscopy on full anticoagulation followed by therapeutic endoscopy if needed using standard practice; and 2) standard approach. Scenario 2: Patients requiring elective endoscopy. Here, the decision tree outlined three strategies: 1) initial diagnostic endoscopy on full anticoagulation followed by a therapeutic endoscopy if needed using a "heparin window"; 2) initial diagnostic endoscopy followed by therapeutic endoscopy if needed using "switch to LMWH" strategy; and 3) "direct switch to LMWH strategy."
  
  
  RESULTS
  Initial diagnostic endoscopy is the preferred strategy when patients requiring anticoagulation need endoscopy. In scenario 1 (all patients), the diagnostic endoscopy approach will reduce need for hospital stay and save $85,006 per 100 patients when a therapeutic impact is not predictable before endoscopy. Similarly, in scenario 2, an initial diagnostic endoscopy followed by switch to LMWH strategy is the most cost saving.
  
  
  CONCLUSIONS
  In anticoagulated patients, an initial diagnostic endoscopy approach on anticoagulation is the most cost-saving strategy, when a direct therapeutic impact is not predictable.
authors.affiliation: Departments of Medicine, Milton S. Hershey Medical Center, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033-0850, USA.
authors.forename: Abraham
authors.initials: A
authors.lastname: Mathew
authors.forename: Thomas R
authors.initials: TR
authors.lastname: Riley
authors.forename: Mark
authors.initials: M
authors.lastname: Young
authors.forename: Ann
authors.initials: A
authors.lastname: Ouyang
mesh_terms: D000925:Anticoagulants / Q000009:adverse effects* / Q000627:therapeutic use; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D004724:Endoscopy / Q000009:adverse effects* / Q000191:economics*; D006471:Gastrointestinal Hemorrhage / Q000139:chemically induced / Q000209:etiology* / Q000517:prevention & control; D006801:Humans; D012189:Retrospective Studies
chemical_list: D000925:Anticoagulants