title: Cost-effectiveness of histamine receptor-2 antagonist versus proton pump inhibitor for stress ulcer prophylaxis in critically ill patients*.
abstract: OBJECTIVE
  To examine the cost-effectiveness of using histamine receptor-2 antagonist or proton pump inhibitor for stress ulcer prophylaxis.
  
  
  METHODS
  Decision analysis model examining costs and effectiveness of using histamine receptor-2 antagonist or proton pump inhibitor for stress ulcer prophylaxis. Costs were expressed in 2012 U.S. dollars from the perspective of the institution and included drug regimens and the following outcomes: clinically significant stress-related mucosal bleed, ventilator-associated pneumonia, and Clostridium difficile infection. Effectiveness was the mortality risk associated with these outcomes and represented by survival. Costs, occurrence rates, and mortality probabilities were extracted from published data.
  
  
  METHODS
  A simulation model.
  
  
  METHODS
  A mixed adult ICU population.
  
  
  METHODS
  Histamine receptor-2 antagonist or proton pump inhibitor for 9 days of stress ulcer prophylaxis therapy.
  
  
  RESULTS
  Output variables were expected costs, expected survival rates, incremental cost, and incremental survival rate. Univariate sensitivity analyses were conducted to determine the drivers of incremental cost and incremental survival. Probabilistic sensitivity analysis was conducted using second-order Monte Carlo simulation. For the base case analysis, the expected cost of providing stress ulcer prophylaxis was $6,707 with histamine receptor-2 antagonist and $7,802 with proton pump inhibitor, resulting in a cost saving of $1,095 with histamine receptor-2 antagonist. The associated mortality probabilities were 3.819% and 3.825%, respectively, resulting in an absolute survival benefit of 0.006% with histamine receptor-2 antagonist. The primary drivers of incremental cost and survival were the assumptions surrounding ventilator-associated pneumonia and bleed. The probabilities that histamine receptor-2 antagonist was less costly and provided favorable survival were 89.4% and 55.7%, respectively. A secondary analysis assuming equal rates of C. difficile infection showed a cost saving of $908 with histamine receptor-2 antagonists, but the survival benefit of 0.0167% favored proton pump inhibitors.
  
  
  CONCLUSIONS
  Histamine receptor-2 antagonist therapy appears to reduce costs with survival benefit comparable to proton pump inhibitor therapy for stress ulcer prophylaxis. Ventilator-associated pneumonia and bleed are the variables most affecting these outcomes. The uncertainty in the findings justifies a prospective trial.
authors.affiliation: Both authors: Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO.
authors.forename: Robert
authors.initials: R
authors.lastname: MacLaren
authors.forename: Jon
authors.initials: J
authors.lastname: Campbell
mesh_terms: D003015:Clostridium Infections / Q000453:epidemiology; D003362:Cost-Benefit Analysis; D016638:Critical Illness; D003661:Decision Support Techniques; D006471:Gastrointestinal Hemorrhage / Q000453:epidemiology; D006635:Histamine H2 Antagonists / Q000008:administration & dosage / Q000191:economics*; D006801:Humans; D007362:Intensive Care Units; D010437:Peptic Ulcer / Q000517:prevention & control*; D053717:Pneumonia, Ventilator-Associated / Q000453:epidemiology; D017494:Proton Pumps / Q000008:administration & dosage / Q000191:economics*; D013312:Stress, Physiological
chemical_list: D006635:Histamine H2 Antagonists; D017494:Proton Pumps