Cost-effectiveness analysis of management strategies for obscure GI bleeding.
OBJECTIVE
Of patients who are seen with GI hemorrhage, approximately 5% will have a small-bowel source. Management of these patients entails considerable expense. We performed a decision analysis to explore the optimal management strategy for obscure GI hemorrhage.


METHODS
We used a cost-effectiveness analysis to compare no therapy (reference arm) to 5 competing modalities for a 50-year-old patient with obscure overt bleeding: (1) push enteroscopy, (2) intraoperative enteroscopy, (3) angiography, (4) initial anterograde double-balloon enteroscopy (DBE) followed by retrograde DBE if the patient had ongoing bleeding, and (5) small-bowel capsule endoscopy (CE) followed by DBE guided by the CE findings. The model included prevalence rates for small-bowel lesions, sensitivity for each intervention, and the probability of spontaneous bleeding cessation. We examined total costs and quality-adjusted life years (QALY) over a 1-year time period.


RESULTS
An initial DBE was the most cost-effective approach. The no-therapy arm cost $532 and was associated with 0.870 QALYs compared with $2407 and 0.956 QALYs for the DBE approach, which resulted in an incremental cost-effectiveness ratio of $20,833 per QALY gained. Compared to the DBE approach, an initial CE was more costly and less effective. The initial DBE arm resulted in an 86% bleeding cessation rate compared to 76% for the CE arm and 59% for the no-therapy arm. The model results were robust to a wide range of sensitivity analyses.


CONCLUSIONS
The short time horizon of the model, because of the lack of long-term data about the natural history of rebleeding from small-intestinal lesions.


CONCLUSIONS
An initial DBE is a cost-effective approach for patients with obscure bleeding. However, capsule-directed DBE may be associated with better long-term outcomes because of the potential for fewer complications and decreased utilization of endoscopic resources.
Gerson
Lauren
L
Division of Gastroenterology and Hepatology Stanford University School of Medicine, Stanford, California 94305-5202, USA.
Kamal
Ahmad
A
D053704:Capsule Endoscopy / Q000191:economics; D003362:Cost-Benefit Analysis; D003365:Costs and Cost Analysis; D016099:Endoscopy, Gastrointestinal / Q000191:economics* / Q000379:methods; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis / Q000191:economics* / Q000209:etiology / Q000601:surgery; D006801:Humans; D007421:Intestine, Small / Q000473:pathology; D008297:Male; D008875:Middle Aged; D019057:Quality-Adjusted Life Years; D012680:Sensitivity and Specificity