title: Cost-effectiveness analysis: stress ulcer bleeding prophylaxis with proton pump inhibitors, H2 receptor antagonists.
abstract: OBJECTIVE
  Proton pump inhibitors (PPIs) and H2-receptor antagonists (H2RAs) present varying pharmacological efficacy in preventing stress ulcer bleeding (SUB) in intensive care units. The literature also reports disparate rates of ventilator-assisted pneumonia (VAP) as side effects of these treatments. We compared the cost-effectiveness of these two prophylactic pharmacological options.
  
  
  METHODS
  We constructed a decision tree with a 60-day time horizon for patients at high risk for developing SUB, receiving either PPIs or H2RAs. For each treatment strategy, patients could be in one of three states of health: SUB, VAP, or no complication. Contemporary, clinically relevant probabilities were obtained from a broad literature search. Costs were estimated by using a representative US countrywide database. A third-party payer perspective was adopted. Cost-effectiveness and univariate and multivariate sensitivity analyses were performed.
  
  
  RESULTS
  Probabilities of SUB and VAP were 1.3% and 10.3% for PPIs versus 6.6% and 10.3% for H2RAs, respectively. Lengths of stay and per diem costs were 24 days and US $2764 for SUB, 42 days and US $3310 for VAP, and 14 days and US $2993 for patients without complications. Average costs per no complication were US $58,700 for PPIs and US $63,920 for H2RAs. The H2RA strategy was dominated by PPIs. Sensitivity analysis showed that these findings were sensitive to VAP rates but PPIs remain cost-effective. The acceptability curve shows the stability of the probabilistic results according to varying willingness-to-pay values.
  
  
  CONCLUSIONS
  PPI prophylaxis is the most efficient prophylactic strategy in patients at high risk of developing SUB when compared with using H2RAs.
authors: Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada. alan.barkun@muhc.mcgill.ca
authors: Alan N
authors: AN
authors: Barkun
authors: Viviane
authors: V
authors: Adam
authors: Myriam
authors: M
authors: Martel
authors: Marc
authors: M
authors: Bardou
mesh_terms: D000897:Anti-Ulcer Agents / Q000191:economics / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D016208:Databases, Factual; D003663:Decision Trees; D006471:Gastrointestinal Hemorrhage / Q000191:economics / Q000209:etiology / Q000517:prevention & control*; D017048:Health Care Costs; D006635:Histamine H2 Antagonists / Q000191:economics / Q000627:therapeutic use*; D006801:Humans; D007902:Length of Stay; D015999:Multivariate Analysis; D010437:Peptic Ulcer / Q000150:complications / Q000188:drug therapy* / Q000191:economics; D054328:Proton Pump Inhibitors / Q000191:economics / Q000627:therapeutic use*; D014481:United States
chemical_list: D000897:Anti-Ulcer Agents; D006635:Histamine H2 Antagonists; D054328:Proton Pump Inhibitors