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Cost-Effectiveness of Histamine Receptor-2 Antagonist Versus Proton Pump Inhibitor for Stress Ulcer Prophylaxis in Critically Ill Patients*

MacLaren, Robert PharmD, MPH, FCCM, FCCP; Campbell, Jon PhD

doi: 10.1097/CCM.0000000000000032
Clinical Investigations

Objective: To examine the cost-effectiveness of using histamine receptor-2 antagonist or proton pump inhibitor for stress ulcer prophylaxis.

Design: Decision analysis model examining costs and effectiveness of using histamine receptor-2 antagonist or proton pump inhibitor for stress ulcer prophylaxis. Costs were expressed in 2012 U.S. dollars from the perspective of the institution and included drug regimens and the following outcomes: clinically significant stress-related mucosal bleed, ventilator-associated pneumonia, and Clostridium difficile infection. Effectiveness was the mortality risk associated with these outcomes and represented by survival. Costs, occurrence rates, and mortality probabilities were extracted from published data.

Setting: A simulation model.

Patients: A mixed adult ICU population.

Interventions: Histamine receptor-2 antagonist or proton pump inhibitor for 9 days of stress ulcer prophylaxis therapy.

Main Measurements and Results: Output variables were expected costs, expected survival rates, incremental cost, and incremental survival rate. Univariate sensitivity analyses were conducted to determine the drivers of incremental cost and incremental survival. Probabilistic sensitivity analysis was conducted using second-order Monte Carlo simulation. For the base case analysis, the expected cost of providing stress ulcer prophylaxis was $6,707 with histamine receptor-2 antagonist and $7,802 with proton pump inhibitor, resulting in a cost saving of $1,095 with histamine receptor-2 antagonist. The associated mortality probabilities were 3.819% and 3.825%, respectively, resulting in an absolute survival benefit of 0.006% with histamine receptor-2 antagonist. The primary drivers of incremental cost and survival were the assumptions surrounding ventilator-associated pneumonia and bleed. The probabilities that histamine receptor-2 antagonist was less costly and provided favorable survival were 89.4% and 55.7%, respectively. A secondary analysis assuming equal rates of C. difficile infection showed a cost saving of $908 with histamine receptor-2 antagonists, but the survival benefit of 0.0167% favored proton pump inhibitors.

Conclusions: Histamine receptor-2 antagonist therapy appears to reduce costs with survival benefit comparable to proton pump inhibitor therapy for stress ulcer prophylaxis. Ventilator-associated pneumonia and bleed are the variables most affecting these outcomes. The uncertainty in the findings justifies a prospective trial.

Both authors: Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO.

* See also p. 979.

This work was performed at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences.

Submitted for presentation, in part, at the Society of Critical Care Medicine Congress, San Francisco, CA, January, 2014.

Dr. MacLaren consulted for Kennedy Childs Law and Rutherford Moore Law, lectured for American Society of Health-System Pharmacists (ASHP) Advantage (continuing education symposia at pharmacy conference), and received support for development of educational presentations from ASHP Advantage. His institution received grant support from Hospira (for investigator-initiated study of dexmedetomidine in alcohol withdraw). Dr. Campbell consulted for Amgen and PEcon LLC (consulting on cost-effectiveness analyses in chronic diseases).

For information regarding this article, E-mail: rob.maclaren@ucdenver.edu

© 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins