Minimizing recurrent peptic XXXX after endoscopic hemostasis: the cost-effectiveness of competing strategies.

@entity1 @entity204 @entity548
OBJECTIVES: Controversy exists regarding the optimal strategy to minimize recurrent @entity548 after successful endoscopic hemostasis. Our objective was to evaluate the cost-effectiveness of competing strategies for the posthemostasis management of @entity1 with high risk ulcer stigmata. METHODS: Through decision analysis, we calculated the cost-effectiveness of four strategies: 1) follow @entity1 clinically after hemostasis and repeat endoscopy only in @entity1 with evidence of rebleeding (usual care); 2) administer intravenous proton pump inhibitors (i.v. PPIs) after hemostasis and repeat endoscopy only in @entity1 with clinical signs of rebleeding; 3) perform second look endoscopy at 24 h in all @entity1 with successful endoscopic hemostasis; and 4) perform selective second look endoscopy at 24 h only in @entity1 at high risk for rebleeding as identified by the prospectively validated Baylor Bleeding Score. Probability estimates were derived from a systematic review of the medical literature. Cost estimates were based on Medicare reimbursement. Effectiveness was defined as the proportion of @entity1 with rebleeding, surgery, or @entity204 prevented. RESULTS: The selective second look endoscopy strategy was the most effective and least expensive of the four competing strategies, and therefore dominated the analysis. The i.v. PPI strategy required 50% fewer endoscopies than the competing strategies, and became the dominant strategy when the rebleed rate with i.v. PPIs fell below 9% and when the cost of i.v. PPIs fell below 10 dollars/day. CONCLUSIONS: Compared with the usual practice of "watchful waiting," performing selective second look endoscopy in high risk @entity1 may prevent more cases of rebleeding, surgery, or @entity204 at a lower overall cost. However, i.v. PPIs are likely to reduce the need for second look endoscopy and may be preferred overall if the rebleed rate and cost of i.v. PPIs remains low.
