Cost-effectiveness analysis of management strategies for obscure GI bleeding

doi:10.1016/j.gie.2008.01.035

Gastrointestinal Endoscopy

Volume 68, Issue 5, November 2008, Pages 920-936

https://doi.org/10.1016/j.gie.2008.01.035 Get rights and content

Background and Aims

Of patients who are seen with GI hemorrhage, approximately 5% will have a small-bowel source. Management of these patients entails considerable expense. We performed a decision analysis to explore the optimal management strategy for obscure GI hemorrhage.

Methods

We used a cost-effectiveness analysis to compare no therapy (reference arm) to 5 competing modalities for a 50-year-old patient with obscure overt bleeding: (1) push enteroscopy, (2) intraoperative enteroscopy, (3) angiography, (4) initial anterograde double-balloon enteroscopy (DBE) followed by retrograde DBE if the patient had ongoing bleeding, and (5) small-bowel capsule endoscopy (CE) followed by DBE guided by the CE findings. The model included prevalence rates for small-bowel lesions, sensitivity for each intervention, and the probability of spontaneous bleeding cessation. We examined total costs and quality-adjusted life years (QALY) over a 1-year time period.

Results

An initial DBE was the most cost-effective approach. The no-therapy arm cost $532 and was associated with 0.870 QALYs compared with $2407 and 0.956 QALYs for the DBE approach, which resulted in an incremental cost-effectiveness ratio of $20,833 per QALY gained. Compared to the DBE approach, an initial CE was more costly and less effective. The initial DBE arm resulted in an 86% bleeding cessation rate compared to 76% for the CE arm and 59% for the no-therapy arm. The model results were robust to a wide range of sensitivity analyses.

Limitations

The short time horizon of the model, because of the lack of long-term data about the natural history of rebleeding from small-intestinal lesions.

Conclusions

An initial DBE is a cost-effective approach for patients with obscure bleeding. However, capsule-directed DBE may be associated with better long-term outcomes because of the potential for fewer complications and decreased utilization of endoscopic resources.

Section snippets

Patients and methods

Cost-effectiveness analysis is a quantitative method used to evaluate the outcomes and costs of interventions designed to improve health.²¹ We used decision analysis software (TreeAge Pro 2005 Suite; TreeAge Software, Boston, Mass) to create a decision tree to compare no therapy (reference arm) to 5 competing modalities for a 50-year-old patient with obscure overt bleeding: (1) push enteroscopy, (2) intraoperative enteroscopy, (3) angiography, (4) initial anterograde DBE, followed by a

Results

By using the base-case probabilities shown in Table 1, the no-therapy arm was the least expensive and was associated with the lowest fraction of QALYs. The initial DBE arm was the most effective but more expensive than the no-therapy arm, whereas all of the other strategies (except for a push enteroscopy, which was less costly) were less effective than the DBE arm and more expensive. The no-therapy arm cost $532 and was associated with 0.870 QALYs, whereas the DBE arm cost $2407 and was

Discussion

Approximately 5% of patients with GI bleeding will have a source localized to the small intestine. Before the advent of CE, the primary tools available for diagnosis and treatment of small-bowel lesions included push enteroscopy, which could primarily detect lesions just distal to the ligament of Treitz, or intraoperative enteroscopy, which had a high success rate for treatment of small-bowel lesions but also carried a high morbidity and mortality rate. With the advent of CE in 2000, the entire

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Original articleClinical endoscopyCost-effectiveness analysis of management strategies for obscure GI bleeding

Background and Aims

Methods

Results

Limitations

Conclusions

Section snippets

Patients and methods

Results

Discussion

Gastroenterology

Gastrointest Endosc Clin N Am

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Lancet

Gastrointest Endosc

Am J Gastroenterol

Gastrointest Endosc

Gastrointest Endosc

Gastroenterol Clin Biol

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Gastroenterology

Am J Surg

J Gastrointest Surg

Gastrointest Endosc

J Vasc Interv Radiol

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Lancet

Am J Surg

Gastrointest Endosc

Gastrointest Endosc

Am J Surg

Gastrointest Endosc

Gastrointest Endosc

Clin Gastroenterol Hepatol

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Surgical approach to occult gastrointestinal bleeding

Am J Surg

Clinical evaluation of push-type enteroscopy

Endoscopy

Small bowel push-type fiberoptic enteroscopy for patients with occult gastrointestinal bleeding or suspected small bowel pathology

Am J Gastroenterol

Diagnostic and therapeutic push type enteroscopy in clinical use

Gut

Obscure gastrointestinal haemorrhage of small-bowel origin

Br Med J (Clin Res Ed)

Does hormonal therapy have any benefit for bleeding angiodysplasia?

J Clin Gastroenterol

Diagnostic efficacy of push-enteroscopy and long-term follow-up of patients with small bowel angiodysplasias

Dig Dis Sci

“Missed” upper gastrointestinal tract lesions may explain “occult” bleeding

Endoscopy

The first prospective controlled trial comparing wireless capsule endoscopy with push enteroscopy in chronic gastrointestinal bleeding

Endoscopy

Wireless capsule endoscopy in patients with obscure gastrointestinal bleeding: a comparative study with push enteroscopy

Aliment Pharmacol Ther

Role of intraoperative enteroscopy in obscure gastrointestinal bleeding of small bowel origin

Br J Surg

Efficacy of intraoperative enteroscopy in diagnosis and prevention of recurrent, occult gastrointestinal bleeding

Am J Surg

Influence of patient selection on the outcome of capsule endoscopy in patients with chronic gastrointestinal bleeding

J Clin Gastroenterol

Push-and-pull enteroscopy in the small bowel using the double-balloon technique: results of a prospective European multicenter study

Endoscopy

Diagnostic and therapeutic impact of double-balloon enteroscopy

Endoscopy

ICCE consensus for obscure gastrointestinal bleeding

Endoscopy

Original article
Clinical endoscopy
Cost-effectiveness analysis of management strategies for obscure GI bleeding