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THE COST-EFFECTIVENESS OF HIGH DOSE ORAL VERSUS INTRAVENOUS PROTON PUMP INHIBITION IN HIGH-RISK PATIENTS WITH BLEEDING PEPTIC ULCERS HAVING UNDERGONE THERAPEUTIC ENDOSCOPY
AN Barkun1,2, V Adam2, W Kennedy3, CA Fallone1, K Herba1, M Bardou1
McGill University1, Divisions of Gastroenterology1, Epidemiology2 and the Université de Montréal, Faculty of Pharmacy3, Montréal, Québec
AIM: The management of patients with bleeding ulcers has evolved significantly over the past 5 years, partly due to the use of high dose intravenous, and more recently high dose oral proton pump inhibitors (PPI’s). We studied the comparative cost effectiveness of these two therapies.
METHODS: Patients with bleeding ulcers initially treated endoscopically for high risk stigmata of re-bleeding were considered. The model structure was defined and validated by a group of clinical experts. Probabilities were determined from published literature. Charges and length of stays (LOS) were obtained from a 20% random sample of the NIS2000 (Nation-wide Inpatient Sample) administrative database. Pharmacological costs of high dose 40mg Po BID ´ 5 days and 80 mg IV bolus followed by 8 mg/hr ´ 3 days were tabulated separately from the hospitalization costs, yielding conservative estimates. A complicated stay when a patient experienced re-bleeding. A third party payer perspective was adopted, over a 30-day time horizon. All costs were expressed in 2001 US dollars. Sensitivity and threshold analyses were carried across a broad range of clinically relevant assumptions.
RESULTS: The mean LOS and costs for patients admitted with uncomplicated and complicated ulcer bleeding were 3 and 4.7 days, and $7,993 and $11,802 respectively. Re-bleeding rates for patients receiving oral or IV therapy were 7.3% and 5.9%. In the base-case analysis, no strategy was dominated. The high dose IV PPI was $14.90 more expensive for an incremental increase in effectiveness of 1.44%. Only when the re-bleeding rate in the IV PPI group dropped below 5% or rose over 8% in the oral PPI branch did the IV PPI alternative become dominant. No differences in conclusions were noted over a wide range of cost estimates.
CONCLUSION: Based on published data, high dose IV PPI for 3 days or oral proton pump inhibition for 5 days were almost equivalent in terms of outcomes with the IV form being slightly more effective yet costly according to the base case analysis estimates. Prospective trials in Western patients are required to confirm the increased effectiveness, and subsequently, the cost-effectiveness of the high dose oral PPI approach.
The RUGBE registry was made possible through a partnership and support funding bringing together the Canadian Association of Gastroenterology and Altana Pharma Inc.
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