Analysis of the use and cost of stress ulcer prophylaxis for surgical inpatients.

Background Stress ulcer is a superficial and asymptomatic lesion and causes bleeding. As many as 50% of death cases are reported as the result of stress ulcer bleeding. Stress ulcer prophylaxis (SUP) is a drug used to prevent gastrointestinal tract injuries due to stress ulcers. The inappropriate use of SUP drugs can cause adverse drug reactions, and thus SUP drugs are only given to patients in accordance with guidelines in order to avoid the overuse of SUP drugs. The aim of this present study is to analyse the suitability of SUP drug usage based on the criteria from the American Society of Health-System Pharmacists (ASHP) and the drug costs of SUP overuse. Methods An observational descriptive study was conducted from April 24, 2019, to May 17, 2019, in the inpatient surgical ward of Dr. Soetomo General Hospital. Data were obtained from patient medical health records. Results One hundred fifty-two patients used 1404 SUP drugs. Approximately 48% of usage did not suit the ASHP criteria and was considered as medication overuse. The cost of excessive SUP usage during the study period was more than US $65, which is 30.08% of the total drug cost of prescribed stress ulcer drugs. Conclusions The present study suggests that the relatively high excessive drug costs for SUP show a need for monitoring of the application of SUP therapy guidelines.

A Successful Pharmacist-Based Quality Initiative to Reduce Inappropriate Stress Ulcer Prophylaxis Use in an Academic Medical Intensive Care Unit.

Stress ulcer prophylaxis (SUP) is often inappropriately utilized, particularly in critically ill patients. The objective of this study is to find an effective way of reducing inappropriate SUP use in an academic medical intensive care unit (ICU). Medical ICU patients receiving SUP were identified over a 1-month period, and their charts were reviewed to determine whether American Society of Health-System Pharmacists guidelines were followed. Inappropriate usage was calculated as inappropriate patient-days and converted to incidence per 100 patient-days. Two interventions were implemented: (1) Pharmacists reviewed indications for SUP on each patient during daily team rounds and daily medication reconciliation and (2) residents rotating on ICU services were educated on a bimonthly basis. Postintervention data were obtained in a similar fashion. Prior to intervention, the incidence of inappropriate SUP usage was calculated to be 26.75 per 100 patient-days (n = 1099 total patient-days). Total cost attributable to the inappropriate use was $2433. Post intervention, we were able to decrease the inappropriate incidence of SUP usage to 7.14 per 100 patient-days (n = 1149 total patient-days). In addition, total cost of inappropriate use was reduced to $239.80. Our study highlights an effective multidisciplinary approach to reduce the inappropriate use of SUP in an academic medical ICU. We were able to reduce the incidence of inappropriate use of SUP by 73.31% ( P < .001). Furthermore, we were able to decrease the costs by approximately $2200/month.

Risk Factors Associated with Mortality and Increased Drug Costs in Nonvariceal Upper Gastrointestinal Bleeding.

BACKGROUND/AIMS: To determine risk factors associated with mortality and increased drug costs in patients with nonvariceal upper gastrointestinal bleeding. METHODOLOGY: We retrospectively analyzed data from patients hospitalized with nonvariceal upper gastrointestinal bleeding between January 2001-December 2011. Demographic and clinical characteristics and drug costs were documented. Univariate analysis determined possible risk factors for mortality. Statistically significant variables were analyzed using a logistic regression model. Multiple linear regression analyzed factors influencing drug costs. p < 0.05 was considered statistically significant. RESULTS: The study included data from 627 patients. Risk factors associated with increased mortality were age > 60, systolic blood pressure<100 mmHg, lack of endoscopic examination, comorbidities, blood transfusion, and rebleeding. Drug costs were higher in patients with rebleeding, blood transfusion, and prolonged hospital stay. CONCLUSION: In this patient cohort, re-bleeding rate is 11.20% and mortality is 5.74%. The mortality risk in patients with comorbidities was higher than in patients without comorbidities, and was higher in patients requiring blood transfusion than in patients not requiring transfusion. Rebleeding was associ-ated with mortality. Rebleeding, blood transfusion, and prolonged hospital stay were associated with increased drug costs, whereas bleeding from lesions in the esophagus and duodenum was associated with lower drug costs.

Evidence-based therapy according to the guideline for gastric ulcers is cost-effective in Japan.

Helicobacter pylori (H. pylori) infection is a major cause of gastric ulcers (GU) and eradication of the infection controls the ulcer with no requirement for maintenance therapy. In Japan, an evidence-based guideline (GL) was first published in 2003 (1(st) version) and then again in 2007 (2(nd) version) with a minor revision under support of the Japanese Ministry of Health, Labor and Welfare (GUGLJ). Adherence to its standards is high, estimated at 80%. GU patients aged 18 or older with active ulcers at the time of diagnosis by an endoscopic examination at National Hospital Organization (NHO) hospitals of Japan were enrolled between September 2004 and April 2005. Subjective and endoscopic outcome, medical treatments and medical costs during the following nine months were analyzed, retrospectively. As a result, 935 patients and 270 doctors in charge from 62 NHO hospitals were analyzed. Among H. pylori-positive GU patients, the endoscopic recurrence rate of 24 patients with failure of eradication was 29.2%, which was significantly higher than 8.8% of 194 patients with successful eradication. Successful eradication of H. pylori resulted in significantly lower endoscopic recurrence rates for GU patients either with or without administration of non-steroidal anti-inflammatory drugs (NSAID). GUGLJ adherence scores were significantly related to the specialty or knowledge on the GUGLJ of doctors in charge, and the total medical cost consumed. These results suggest that the therapy of GU along with an evidence-based GL is essential to implement cost-effective treatment and the GI experts or the doctors that understand the GUGLJ very well should perform it.

Cost-effectiveness of endoscopic surveillance of gastric ulcers to improve survival.

BACKGROUND: Endoscopic surveillance of presumed-benign gastric ulcers may detect missed malignancy, but its impact on long-term outcomes is uncertain. OBJECTIVE: To estimate the clinical benefits and cost-effectiveness of follow-up surveillance. DESIGN: State-transition model. SETTING: To simulate the clinical course of presumed-benign gastric ulcers, we estimated prevalence and incidence of undetected gastric cancer, surveillance effectiveness, stage-specific disease mortality rates, and costs from clinical studies and databases. PATIENTS: This study involved 60-year-old men diagnosed with presumed-benign gastric ulcers. INTERVENTION: Follow-up endoscopic surveillance. MAIN OUTCOME MEASUREMENTS: Lifetime gastric cancer risk, life expectancy, quality-adjusted life expectancy, lifetime costs, and incremental cost-effectiveness ratios. RESULTS: For a cohort of 60-year-old men with presumed-benign gastric ulcers and a 2.6% prevalence of undetected malignancy, the lifetime gastric cancer risk was 4.4%. Surveillance improved (undiscounted) life expectancy by 10.0 days and increased discounted quality-adjusted life expectancy by 3.4 days at a cost of $146,700 per quality-adjusted life year (QALY). Surveillance cost less than $50,000 per QALY if the undetected gastric cancer prevalence was 6.5%, and it cost less than $100,000 per QALY if the prevalence was greater than 3.5%, endoscopy costs were 40% lower, or the disutility associated with gastric cancer was 30% lower. Probabilistic sensitivity analysis suggested that at a willingness-to-pay threshold of $100,000 per QALY, the probability that surveillance was cost effective was 25.2%. LIMITATIONS: Data from multiple sources with varied study designs were used. CONCLUSION: Endoscopic surveillance of presumed-benign gastric ulcers may improve overall survival. However, unless the prevalence of having undetected malignancy exceeds 6%, surveillance is unlikely to be cost-effective.

Patient and physician predictors of inappropriate acid-suppressive therapy (AST) use in hospitalized patients.

BACKGROUND: The use of acid suppressive therapy (AST) in prevention of stress ulcers has been well defined in critical care patients, though its use has become increasingly common in general medicine patients, with little to no supportive evidence. None of the previous studies has examined the patient and physician characteristics of inappropriate AST initiation and use in hospitalized patients. The aim of our study was to identify: (1) the appropriateness of AST in hospitalized patients and the cost associated with inappropriate use; and (2) patient and physician characteristics predicting inappropriate initiation and use of AST. METHODS: All discharges over a period of 8 consecutive days were selected. RESULTS: There were 207 patients discharged over a period of 8 days. AST was inappropriately initiated in 92 of 133 (69.2%) patients included in our study. On univariate analysis, higher hemoglobin value, postgraduate year 1 (PGY-1) residents, physicians with an MD degree, international medical graduates (IMGs), and internal medicine physicians were more likely to prescribe AST inappropriately. On multivariate analysis, a higher hemoglobin value, PGY-1 residents, and MD physicians were factors associated with inappropriate AST use. The total direct patient cost for this inappropriate use was $8026, with an estimated annual cost of approximately $366,000. CONCLUSIONS: AST was inappropriately initiated in 69.2% of patients with increased direct costs of $8026. Residents in their first year of training as well physicians with a MD degree are more likely to initiate AST inappropriately. Curtailing the inappropriate use of AST therapy may reduce overall costs for the patient and institution.

Cost of detecting malignant lesions by endoscopy in 2741 primary care dyspeptic patients without alarm symptoms.

BACKGROUND & AIMS: Current guidelines recommend empirical, noninvasive approaches to manage dyspeptic patients without alarm symptoms, but concerns about missed lesions persist; the cost savings afforded by noninvasive approaches must be weighed against treatment delays. We investigated the prevalence of malignancies and other serious abnormalities in patients with dyspepsia and the cost of detecting these by endoscopy. METHODS: We studied 2741 primary-care outpatients, 18-70 years in age, who met Rome II criteria for dyspepsia. Patients with alarm features (dysphagia, bleeding, weight loss, etc) were excluded. All patients underwent endoscopy. The cost and diagnostic yield of an early endoscopy strategy in all patients were compared with those of endoscopy limited to age-defined cohorts. Costs were calculated for a low, intermediate, and high cost environment. RESULTS: Endoscopies detected abnormalities in 635 patients (23%). The most common findings were reflux esophagitis with erosions (15%), gastric ulcers (2.7%), and duodenal ulcers (2.3%). The prevalence of upper gastrointestinal malignancy was 0.22%. If all dyspeptic patients 50 years or older underwent endoscopy, 1 esophageal cancer and no gastric cancers would have been missed. If the age threshold for endoscopy were set at 50 years, at a cost of $500/endoscopy, it would cost $82,900 (95% CI, $35,714-$250,000) to detect each case of cancer. CONCLUSIONS: Primary care dyspeptic patients without alarm symptoms rarely have serious underlying conditions at endoscopy. The costs associated with diagnosing an occult malignancy are large, but an age cut-off of 50 years for early endoscopy provides the best assurance that an occult malignancy will not be missed.

[Analysis of the clinical benefits and cost-effectiveness of performing a systematic second-look gastroscopy in benign gastric ulcer]. / Estudio del beneficio clínico y de coste-efectividad tras efectuar sistemáticamente una segunda gastroscopia en la úlcera gástrica benigna.

INTRODUCTION: We analyzed the need to routinely perform a second gastroscopy after an initial diagnosis of benign gastric ulcer. METHOD: A total of 226 consecutive cases of gastric ulcer were reviewed. Sensitivity (S), specificity (Sp), positive and negative predictive value (PPV and NPV) and the accuracy of the initial gastroscopy plus biopsy were analyzed, both overall and according to the initial endoscopist's experience (attending or resident physician). The diagnostic accuracy of the initial and second-look gastroscopies was compared. The number of second endoscopies required to diagnose a new case of malignant gastric ulcer and their cost was calculated, both overall and according to the endoscopist's experience. RESULTS: There were 178 benign ulcers (79%) and 48 malignant ulcers (21%). The initial gastroscopy (S: 87.2%; Sp: 100%; PPV: 100%; PNV: 96.7%; accuracy: 96.7%) was performed by an attending physician in 74% of the patients and by a resident physician in the remaining 26%. Diagnostic accuracy was higher for attending physicians than for residents (98.2% vs. 94.8%; p=0.18). The accuracy of second-look endoscopy was 100%, with a significant improvement when compared with the initial procedure (p=0.035). Three new cases of MALT lymphoma and three new cases of gastric adenocarcinoma were diagnosed and could be treated with curative intent. The number of second gastroscopies required to diagnose a new case of malignant gastric ulcer and their economic cost was: 37.3 (4,675 Euros) for the whole group, 55.2 (6,845 Euros) for attending physicians and 19.3 (2,393 Euros) for residents. CONCLUSIONS: Initial gastroscopy showed high diagnostic accuracy, which was slightly lower when performed by resident physicians. Second-look gastroscopy significantly improved the results, confirming the clinical benefit of this procedure in diagnosing potentially curable malignant lesions. The mean cost of each new diagnosis of malignancy was 4,675 Euros, which was three times lower if the initial gastroscopy was performed by a less experienced endoscopist.

Incremental cost effectiveness of proton pump inhibitors for the prevention of non-steroidal anti-inflammatory drug ulcers: a pharmacoeconomic analysis linked to a case-control study.

INTRODUCTION: We estimated the cost effectiveness of concomitant proton pump inhibitors (PPIs) in relation to the occurrence of non-steroidal anti-inflammatory drug (NSAID) ulcer complications. METHODS: This study was linked to a nested case-control study. Patients with NSAID ulcer complications were compared with matched controls. Only direct medical costs were reported. For the calculation of the incremental cost effectiveness ratio we extrapolated the data to 1,000 patients using concomitant PPIs and 1,000 patients not using PPIs for 1 year. Sensitivity analysis was performed by 'worst case' and 'best case' scenarios in which the 95% confidence interval (CI) of the odds ratio (OR) and the 95% CI of the cost estimate of a NSAID ulcer complication were varied. Costs of PPIs was varied separately. RESULTS: In all, 104 incident cases and 284 matched controls were identified from a cohort of 51,903 NSAID users with 10,402 NSAID exposition years. Use of PPIs was associated with an adjusted OR of 0.33 (95% CI 0.17 to 0.67; p = 0.002) for NSAID ulcer complications. In the extrapolation the estimated number of NSAID ulcer complications was 13.8 for non-PPI users and 3.6 for PPI users. The incremental total costs were euro 50,094 higher for concomitant PPIs use. The incremental cost effectiveness ratio was euro 4,907 per NSAID ulcer complication prevented when using the least costly PPIs. CONCLUSIONS: Concomitant use of PPIs for the prevention of NSAID ulcer complications costs euro 4,907 per NSAID ulcer complication prevented when using the least costly PPIs. The price of PPIs highly influenced the robustness of the results.

A prospective randomized trial of either famotidine or omeprazole for the prevention of bleeding after endoscopic mucosal resection and the healing of endoscopic mucosal resection-induced ulceration.

BACKGROUND: It has been reported that inhibitors of gastric acid secretion prevent bleeding after endoscopic mucosal resection for mucosal gastric neoplasm. However, uncertain whether an histamine2-receptor antagonist or proton-pump inhibitor is more effective. AIM: To evaluate prospectively the effectiveness of famotidine or omeprazole for ulcer management after endoscopic mucosal resection. METHODS: From July 2003 to October 2004, 57 patients were randomly assigned to famotidine or omeprazole for the management of endoscopic mucosal resection. Both drugs were given intravenously for the first 2 days, thereafter by mouth. The bleeding rates after endoscopic mucosal resection, the effects on the healing of endoscopic mucosal resection-induced ulceration, and cost-benefits were compared. RESULTS: Twenty-eight patients received famotidine and 29 received omeprazole. No significant difference was observed between the two groups in patient characteristics. The bleeding rates after endoscopic mucosal resection were not significantly different (18% vs. 14%) between the groups. Similarly, no differences were seen in the size of the endoscopic mucosal resection-induced ulceration at 1, 30 and 60 days after resection between groups. The total costs of anti-secretory agents demonstrated a significant cost-benefit to those treated with famotidine (10,420 yen vs. 17,782 yen). CONCLUSIONS: Famotidine is suggested as a better alternative to omeprazole for the management of endoscopic mucosal resection, as it showed a clear cost-benefit, and the healing results after endoscopic mucosal resection were similar for the two treatment strategies.

Upper GI risks of NSAIDs and antiplatelet agents: key issues for the cardiologist.

The use of antiplatelet/antithrombotic agents (eg, low-dose aspirin or clopidogrel) in primary or secondary intervention treatment strategies for cardiovascular disease is a common practice among cardiologists. Furthermore, these agents frequently are used concomitantly with other nonsteroidal anti-inflammatory drugs (NSAIDs) that patients are taking for a wide array of rheumatologic- or orthopedic-related complaints. These therapies, however, have defined upper gastrointestinal (UGI) risks for ulcer-related injury and complications. It is important for the cardiologist to fully understand the UGI risk profiles so that each patient is evaluated as a candidate for possible preventive co-therapy with appropriate anti-ulcer medication.

Does seropositivity for Helicobacter pylori antibodies increase outpatient costs for gastric and duodenal ulcer or inflammation?

BACKGROUND: Helicobacter pylori is regarded as an important cause of both peptic ulcer and chronic gastritis. In particular, seropositivity is highest in patients with duodenal ulcer. No studies have determined whether there are differences in the direct medical costs associated with gastric/duodenal ulcer or inflammation, between seropositive and seronegative patients. OBJECTIVE: To examine the relationship between seropositivity for H. pylori and outpatient visits and direct medical costs for gastric/duodenal ulcer or inflammation in Japan from the perspective of the payor and patients. METHODS: Participants were males (n = 653) who worked for an agricultural co-operative in Fukuoka Prefecture, attended an annual health examination (including a written lifestyle and medical survey), belonged to the same health insurance society consistently for 4 years from April 1996 to March 2000, and provided a blood sample. The survey asked about lifestyle, including smoking and drinking, and past medical history. We retrospectively analysed the annual number of outpatient visits per person and outpatient medical cost (Yen, 2000 values) per person for visits relating to gastric or duodenal ulcer or inflammation using International Classification of Diseases (9th edition) -- Clinical Modification codes. We assessed for potential confounding factors using analysis of covariance and the chi-square test. RESULTS: The annual outpatient incidence of disease, the number of visits to physicians, and the medical costs for gastric or duodenal ulcer or inflammation were about 2-fold greater in individuals with antibodies to H. pylori compared with those without antibodies. CONCLUSION: Population-based studies and/or randomised controlled clinical trials that target high-risk groups and account for the unique way in which data are collected in Japan are needed to determine whether medical costs for gastric and duodenal ulcer might be reduced by treating asymptomatic patients who have antibodies to H. pylori.

Role of initial NSAID choice and patient risk factors in the prevention of NSAID gastropathy: a decision analysis.

OBJECTIVE: To investigate the role of initial nonsteroidal antiinflammatory drug (NSAID) choice in the prevention of NSAID gastropathy, based on relative clinical and economic effects. METHODS: To mimic clinical practice, a symptom-driven decision analytic model was constructed to compare 2 treatment strategies for long-term users of NSAIDs over a 1-year period: Strategy 1-generic NSAID used initially, and safer, more expensive NSAID reserved for treatment failures due to symptomatic gastropathy; and Strategy 2-safer, more expensive NSAID used in all instances. The only distinction between the strategies was the choice of initial NSAID. NSAIDs differed in gastrointestinal safety profiles and acquisition costs. The use and impact of antisecretory medications were included in the model. Because published data on patients' ulcer risk and relative NSAID safety show considerable variability, sensitivity analyses were used to evaluate the key clinical outcomes and costs. RESULT: For patients without risk factors for NSAID ulcers (average risk), the model estimated that the strategy restricting use of the safer NSAID resulted in more symptomatic ulcers (Strategy 1, 2.58; Strategy 2, 0.73) and ulcer-related complications (Strategy 1, 1.18; Strategy 2, 0.23) per 100 patient years. The restricted strategy led to a significantly lower cost per patient treated (Strategy 1, $239; Strategy 2, $831 per year). In the principal analysis, the incremental costs to prevent symptomatic and complicated ulcers were $31,900 and $56,700, respectively. The estimated incremental cost per ulcer avoided was sensitive to the relative protection provided by the safer NSAID and fell dramatically as the patients' ulcer risk was increased above average risk. CONCLUSION: Unrestricted use of NSAIDs that reduce the risk of symptomatic ulcers has the potential to produce important clinical benefits at incremental cost. The impressive impact of ulcer risk on the incremental cost per ulcer prevented warrants increased attention to risk factor identification when NSAIDs are prescribed.

Incremental cost-effectiveness analysis comparing rofecoxib with nonselective NSAIDs in osteoarthritis: Ontario Ministry of Health perspective.

BACKGROUND: Clinical trials have shown rofecoxib, a selective inhibitor of cyclo-oxygenase-2, to be associated with fewer gastrointestinal complications than non-selective nonsteroidal anti-inflammatory drugs (NSAIDs). OBJECTIVE: To evaluate the potential clinical and economic consequences of rofecoxib prescription in Ontario, Canada, for patients with osteoarthritis (OA) aged >65 years who did not respond to paracetamol (acetaminophen) therapy. DESIGN: Decision analytic modelling study. METHODS: A model was constructed to compare rofecoxib and nonselective NSAIDs with respect to their gastrointestinal complications in patients with OA. The model had a 1-year horizon and considered direct medical costs from the perspective of the Ontario Ministry of Health. Event rates were estimated from a pooled analysis of 8 phase IIb/Ill clinical trials. The number of perforations, ulcers and bleeds (PUBs) with each strategy was used as the primary measure of effectiveness. RESULTS: In the base-case scenario, the expected total cost per patient-day on nonselective NSAIDs was 1.60 Canadian dollars (Can dollars) versus 1.67 Can dollars on rofecoxib (1999 values). Rofecoxib was associated with 0.0109 fewer PUBs per patient per year. The incremental cost to avoid 1 additional PUB by substituting rofecoxib for nonselective NSAIDs was 2247 Can dollars. The rofecoxib strategy became dominant if a gastroprotective agent was prescribed to more than 27.5% of the patients receiving nonselective NSAIDs. CONCLUSION: For patients with OA aged >65 years in whom paracetamol therapy has failed, rofecoxib may represent a cost-effective alternative to nonselective NSAIDs. Increased costs for drug acquisition are offset, in part. by avoidance of gastrointestinal complications and reduced use of gastroprotective agents. Rofecoxib may offer increased benefit among patients at a higher risk of serious gastrointestinal events.

Evaluation of the cost-effectiveness of Helicobacter pylori eradication triple therapy vs. conventional therapy for ulcers in Japan.

BACKGROUND: Helicobacter pylori eradication triple therapy with a combination of lansoprazole, amoxicillin and clarithromycin was approved in Japan in September 2000. AIM: To compare the cost-effectiveness of this eradication therapy with conventional histamine-2 receptor antagonist therapy in Japan. METHODS: We established two Markov models for gastric and duodenal ulcers. The model design was based on the Japanese H. pylori eradication guideline and a specialist's opinions, and the model inputs were obtained from a literature review. The models predict the direct medical costs, number of disease-free days and cost per disease-free day for 5 years. RESULTS: In the gastric ulcer model, the expected total costs of eradication and conventional therapies per patient were yen169 719 and yen390 921, respectively; the expected numbers of disease-free days were 1454 days and 1313 days, respectively. In the duodenal ulcer model, the expected total costs were yen134 786 and yen324 689, respectively; the expected numbers of disease-free days were 1503 days and 1387 days, respectively. The sensitivity analyses showed that the results of the base case analysis were robust. CONCLUSIONS: This eradication therapy is less costly and more effective than conventional therapy for the treatment of gastric and duodenal ulcers in a Japanese medical setting.