title: Cost-effectiveness of proton-pump inhibition before endoscopy in upper gastrointestinal bleeding.
abstract: OBJECTIVE
  Randomized trials suggest high-dose proton-pump inhibitors (PPIs) administered before gastroscopy in suspected upper gastrointestinal bleeding downstage bleeding ulcer stigmata. We assessed the cost-effectiveness of this approach.
  
  
  METHODS
  A decision model compared high-dose IVPPI initiated while awaiting endoscopy with IVPPI administration on the basis of endoscopic findings. IVPPIs were given to all patients undergoing endoscopic hemostasis for 72 hours thereafter. Once the IV regimen was completed or for patients with low-risk endoscopic lesions, an oral daily PPI was given for the remainder of the time horizon (30 days after endoscopy). The unit of effectiveness was the proportion of patients without rebleeding, representing the denominator of the cost-effectiveness ratio (cost per no rebleeding). Probabilities and costs were derived from the literature and national databases.
  
  
  RESULTS
  IVPPIs before endoscopy were both slightly more costly and effective than after gastroscopy in the U.S. and Canadian settings, with cost-effectiveness ratios of US$5048 versus $4933 and CAN$6064 versus $6025 and incremental costs of US$45,673 and CAN$19,832 to prevent one additional rebleeding episode, respectively. Sensitivity analyses showed robust results in the US In Canada, intravenous proton-pump inhibitors (IVPPIs) before endoscopy became more effective and less costly (dominant strategy) when the uncomplicated stay for high-risk patients increased above 6 days or that of low-risk patients decreased below 3 days.
  
  
  CONCLUSIONS
  With conservative estimates and high-quality data, IVPPIs given before endoscopy are slightly more effective and costly than no administration. In Canada, this approach becomes dominant as the duration of hospitalization for high-risk ulcer patients increases or that of low-risk ulcer patients decreases.
authors.affiliation: Division of General Surgery, McGill University, Montréal, Québec, Canada.
authors.forename: Salman
authors.initials: S
authors.lastname: Al-Sabah
authors.forename: Alan N
authors.initials: AN
authors.lastname: Barkun
authors.forename: Karl
authors.initials: K
authors.lastname: Herba
authors.forename: Viviane
authors.initials: V
authors.lastname: Adam
authors.forename: Carlo
authors.initials: C
authors.lastname: Fallone
authors.forename: Serge
authors.initials: S
authors.lastname: Mayrand
authors.forename: Gilles
authors.initials: G
authors.lastname: Pomier-Layrargues
authors.forename: Wendy
authors.initials: W
authors.lastname: Kennedy
authors.forename: Marc
authors.initials: M
authors.lastname: Bardou
mesh_terms: D053799:2-Pyridinylmethylsulfinylbenzimidazoles / Q000008:administration & dosage / Q000191:economics*; D002170:Canada; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D004305:Dose-Response Relationship, Drug; D004932:Esophageal and Gastric Varices / Q000150:complications; D006471:Gastrointestinal Hemorrhage / Q000209:etiology / Q000517:prevention & control*; D005773:Gastroscopy; D006801:Humans; D007262:Infusions, Intravenous; D007902:Length of Stay / Q000191:economics; D000077402:Pantoprazole; D010437:Peptic Ulcer / Q000150:complications; D011292:Premedication; D054328:Proton Pump Inhibitors / Q000008:administration & dosage / Q000191:economics*; D055502:Secondary Prevention; D014481:United States
chemical_list: D053799:2-Pyridinylmethylsulfinylbenzimidazoles; D054328:Proton Pump Inhibitors; D000077402:Pantoprazole