Cost‐effectiveness in Canada of intravenous proton pump inhibitors for all patients presenting with acute upper gastrointestinal bleeding

Abstract

SUMMARYBackground: The administration of proton pump inhibitors intravenously after endoscopic treatment of peptic ulcers significantly reduces the recurrence of bleeding. Aim: To evaluate the incremental cost-effectiveness in Canada of intravenous proton pump inhibitor before endoscopic therapy to patients presenting with acute upper gastrointestinal bleeding, compared with endoscopic treatment alone. Methods: From a third-party payer perspective, we modelled the costs and effectiveness over 60 days of the two approaches using decision analysis. The probabilities of various outcomes, such as re-bleeding and the need for surgery, were taken from the published literature. We included the costs of intravenous proton

Description of Prescribing Practices in Patients with Upper Gastrointestinal Bleeding Receiving Intravenous Proton-Pump Inhibitors: A Multicentre Evaluation

“…Recently, we have developed a statistical model using a hypothetical cohort of 1000 patients comparing a strategy of empirically treating all patients presenting to the emergency department with IV PPI infusion and endoscopic treatment versus endoscopic treatment alone (12). Based on the expected frequencies of endoscopically treatable ulcers and the efficacy of IV PPI from the study by Lau et al (6), significant cost savings can be realized with the use of IV PPI.…”

“…In most studies, IV PPI was administered after endoscopic assessment with or without endoscopic therapy. Recently, cost analysis has suggested that IV PPI may be cost-effective if given before the endoscopic examination (12). Additionally, other Canadian National Registry studies have suggested that other patient groups may benefit from IV PPI.…”

Cost-effectiveness of proton pump inhibitor therapy for acute peptic ulcer-related bleeding*

“…Of the three cost-effectiveness investigations evaluating the use of high-dose intravenous PPI therapy for acute peptic ulcer bleeding (11)(12)(13), only one was conducted from the perspective of a health care system in the United States (13). The latter study evaluated two scenarios involving second-look endoscopy (reendoscopy in all patients vs. re-endoscopy in patients at high risk for rebleeding), a scenario in which high-dose intravenous PPI therapy was given as an adjunct to therapeutic endoscopy and a usual care scenario in which patients only had a second endoscopy if signs of rebleeding occurred (no high-dose PPI) (13).…”

“…The three published cost-effectiveness studies that included at least one scenario involving PPI therapy used episodes of bleeding averted (11)(12), or in one case episodes of bleeding, surgery, or death averted (13), as the primary effectiveness outcome. In this investigation, effectiveness was primarily evaluated in terms of episodes of bleeding averted based on the studies underlying the clinical scenarios (14,15,17).…”

“…The earliest of these economic evaluations was designed to compare endoscopic treatment regimens, so the value of adjunctive PPI therapy was not addressed (10). Of the recent investigations that have evaluated the cost-effectiveness of adjunctive PPI therapy, one was conducted from the perspective of a public health organization in Hong Kong (11) and the other from a third-party payer perspective in Canada (12). The only investigation conducted from the perspective of a third party payer in the United States evaluated four competing strategies: usual care (repeat endoscopy only if clinical evidence of recurrent bleeding), usual care plus highdose intravenous PPI therapy, repeat endoscopy in all patients at 24 hrs, and selective endoscopy at 24 hrs based on a validated scoring system relative to risk of recurrent bleeding (13).…”