A cost analysis based on mathematic modelling determined the average cost of repeating standard treatment in patients with persistent/recurrent peptic ulcer bleeding ($ 6,578) and the average cost of second-line OTSC treatment after failed standard therapy, which was lower (at average $ 6,298). The average cost of standard treatment was based on the cost of one hemoclip and a gold probe. However, many patients treated with standard endoscopy receive more than one hemoclip, which would make the cost of repeat standard treatment even higher.
J. X. Yu et al., Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA, evaluated by mathematic modelling the cost-effectiveness of OTSC clips for the treatment of peptic ulcer bleeding as first-line and second-line therapy. A decision tree was used to model the cost, effectiveness, and rates of persistent/recurrent bleeding of OTSC versus standard treatment (ST) for the management of peptic ulcer bleeding.
Three possible treatment strategies were modeled for a patient with peptic ulcer bleeding: OTSC clipping after first line standard therapy, a repeat of standard therapy after first-line standard therapy, and standard therapy after first-line OTSC clipping. It was assumed that if the second-line therapy remained unsuccessful, the patient would undergo interventional radiology or surgery.
The average cost of standard treatment was based on the cost of one hemoclip and a gold probe. The cost of an esophagogastroduodenoscopy and for hospitalization were estimated from Medicare and Medicaid data, the probability of persistent/recurrent bleeding with standard therapy and OTSC therapy was obtained through review of the literature.
Results showed that the first treatment strategy of first-line ST followed by OTSC was the most cost-effective strategy, costing $ 6,298 per patient and resulting in 0.0686 QALYs. The second strategy with ST followed by ST cost $ 6,576 and resulted in 0.0659 QALYs. The third strategy with OTSC as first-line treatment and second-line ST cost $ 6,490 and resulted in 0.0687 QALYs. As the probability of persistent/recurrent bleeding following ST increases, OTSC treatment becomes preferred in more scenarios. Specifically, for medium- or high-risk ulcer with Rockall ≥ 4, OTSC as first line therapy followed by ST is preferred.
The authors concluded that in patients with persistent/recurrent peptic ulcer bleeding after standard endoscopic treatment a repeat of the standard approach is not cost-effective. Instead, OTSC clipping should be used. For first-line therapy, OTSC clipping should be considered for patients with intermediate or high-risk ulcers as determined by the Rockall score.
Clipping Over the Scope for Recurrent Peptic Ulcer Bleeding is Cost-Effective as Compared to Standard Therapy: An Initial Assessment
Yu JX, Russell WA, Asokkumar R, Kaltenbach T, Soetniko R
Gastrointest Endoscopy Clin N Am 30 (2020) 91-97. https://doi.org/10.1016/j.giec.2019.09.004