The cost effectiveness of prophylaxis for stress-related gastric hemorrhage in the intensive care unit

Abstract

• THE COST EFFECTIVENESS OF PROPHYLAXIS FOR STRESSRELATED GASTRIC HEMORRHAGE IN THE INTENSIVE CARE UNIT. T B~q-Menaehem, BD McCarthy, R Brcsalier, R Fogel. Division of Gastroenterology. Henry Ford Hospital, Detroit, MI Recent clinical trials question the benefit of prophylaxis for stress-related gastric hemorrhage(SRH) for patients admitted to intensive care units(ICU). Moreover, some prophylactic agents may increase the incidence of nosocomial pneumonia. Nevertheless, some authors advocate continued use of seemingly low-cost prophylactic agents in the ICU. Our aim was to determine the cost-effectiveness of sucralfatc and cimetidine prophylaxis for SRH in patients admitted to an ICU. Methods: Estimates of SRH incidence, efficacy of prophylaxis and incidence of nosocomial pneumonia were based on data from published studies. Cost data were based on cost of medications and cost of treating SRH and pneumonia at our institution. The marginal cost-effectiveness of prophylaxis was calculated separately for sucralfate and cimetidinc and expressed as cost per bleed averted. An incremental cost-effectiveness analysis was employed to compare the two agents. Sensitivity analyses of the effect of the major clinical outcomes on the cost per bleed averted were performed. Results: At the base-case assumptions of 6% risk of developing SRH and 50% risk-reduction due to prophylaxis, the cost of sucralfate was $1,144 per bleed averted. However, it has recently been reported that the risk of SRH for the majority of patients admitted to an ICU is only 0.1%. For this population of low risk patients, the cost per bleed averted was $103,725. Conversely, cost savings as a resuh of sucralfate prophylaxis may be realized in populations with 33% risk of SRH. Including nosocomial pneumonia in the analysis significantly increased the cost per bleed averted. Each case of nosocomial pneumonia increased the cost per bleed averted by $10,062. The effect of pneumonia on the cost per bleed averted was greater for populations at low risk of SRH. Repeating the analysis for cimetidine prophylaxis showed that the cost per bleed averted Was 6.5 fold greater than that for sucralfate. Conclusions: Given the decreasing incidence of SRH and the low efficacy of prophylaxis, the cost of prophylaxis in patients at low risk of SRH is prohibitive. If prophylaxis is deemed essential for high-risk patients, sucralfate is more cost-effective than cimetidine. CONTROLLED COMPARISON OF GAS CHANGES FROM CHERRY FLAVORED AND UNFLAVORED SULFATE FREE ELECTROLYTE LAVAGE SOLUTIONS. Berry MA, DiPalma JA. University of South Alabama College of Medicine, Mobile, AL. Sulfate-free electrolyte lavage solution (SF-ELS, NuLytely, Braintree Labs Inc, Braintree, MA) is a modification of polyethylene glycol electrolyte lavage solution (PEG-ELS, GoLytely, Braintree Labs) formulated to remove sulfate and reduce sodium content. In an effort to improve taste and compliance, a new cherry flavor (Bush Boake Allen, Inc.) was developed for addition to SF-ELS (C/SF-ELS). This study was designed to evaluate the gas producing potential of C/SFELS compared to SF-ELS with lactulose as a positive control. Ten normal human volunteers received 500cc of the cleansing solutions or 20g lactulose diluted to 500cc with water. Breath samples obtained at baseline and hourly for 6 hours after challenge using an alvelor gas collection device (GaSampler; Quintron Instruments, Inc., Milwaukee, WI) were analyzed for hydrogen and methane gas with CO~ correction by chromatography (Microlyzer Model SC, Quintron). Results are expressed as the mean _+ S.D. of the area under the discontinuous curve above baseline during the testing period: Hydrogen Methane SF-ELS 23.0__+8.9* 116.3+88.4* C/SF-ELS 23.0+7.5 96.9+65.1 Lactulose 167.6+104 135.0__+107 P=0.001* P=0.33* Conclusions: There was no difference in hydrogen or methane production after SF-ELS or C/SF-ELS, and both had hydrogen levels, which are substrate-influenced, below that from lactulose. C/SF-ELS does not generate significant amounts of potentially-combustible gas.