Prophylaxis for stress-related gastrointestinal hemorrhage: A cost effectiveness analysis

Objective: To assess the cost-effectiveness of prophylaxis for stress-related gastrointestinal hemorrhage in patients admitted to the intensive care unit. Design: Decision model of the cost and efficacy of sucralfate and cimetidine, two commonly used drugs for prophylaxis of stress related hemorrhage. Outcome estimates were based on data from published studies. Cost data were based on cost of medications and costs of treatment protocols at our institution. Measurements and Main Results: The marginal cost-effectiveness of prophylaxis, as compared with no prophylaxis, was calculated separately for sucralfate and cimetidine and expressed as cost per bleeding episode averted. An incremental cost-effectiveness analysis was subsequently employed to compare the two agents, Sensitivity analyses of the effects of the major clinical outcomes on the cost per bleeding episode averted were performed, At the base-case assumptions of 6% risk of developing stress-related hemorrhage and 50% risk-reduction due to prophylaxis, the cost of sucralfate was $1,144 per bleeding episode averted. The cost per bleeding episode averted was highly dependent on the risk of hemorrhage and, to a lesser degree, on the efficacy of sucralfate prophylaxis, ranging from a cost per bleeding episode averted of $103,725 for low risk patients to cost savings for very high risk patients. The cost per bleeding episode averted increased significantly if the risk of nosocomial pneumonia was included in the analysis. The effect of pneumonia was greater for populations at low risk of hemorrhage. Assuming equal efficacy, the cost per bleeding episode averted of cimetidine was 6.5-fold greater than the cost per bleeding episode averted of sucralfate. Conclusions: The cost of prophylaxis in patients at low risk of stress-related hemorrhage is substantial, and may be prohibitive. Further research is needed to identify patient populations that are at high risk of developing stress-related hemorrhage, and to determine whether prophylaxis increases the risk of nosocomial pneumonia.