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Second-look Endoscopy for Bleeding Peptic Ulcer Disease: A Decision-effectiveness and Cost-effectiveness Analysis

Imperiale, Thomas F. MD*,†,‡; Kong, Nan PhD§

Journal of Clinical Gastroenterology: October 2012 - Volume 46 - Issue 9 - p e71–e75
doi: 10.1097/MCG.0b013e3182410351
ONLINE ARTICLES: Original Articles

Background: Second-look endoscopy after initial therapeutic endoscopy for bleeding peptic ulcer disease may decrease the risk of rebleeding; however, it is not recommended routinely. Understanding conditions under which second-look endoscopy is beneficial might be useful for clinical decision making.

Methods: Using a decision model, literature-based probabilities, and Medicare reimbursement costs, we compared routine second-look endoscopy with no second-look endoscopy. We measured rebleeding, need for surgery, hospital mortality, and costs, and calculated the cost to avoid each outcome, expressed as the number needed to treat, along with the cost per outcome prevented.

Results: In the base case, routine second-look endoscopy reduced rebleeding from 16% to 10% (needed to treat=16) but had no effect on other outcomes. The cost to prevent 1 case of rebleeding was nearly $13,000. Threshold analysis revealed a rebleeding threshold of 31% to neutralize the cost difference between routine second-look endoscopy and no routine second-look endoscopy. If routine second-look endoscopy was 100% effective in preventing rebleeding, then the rebleeding threshold for cost neutrality would be 17.5%. When rebleeding risks after the index endoscopy and second-look endoscopy were simultaneously considered, the cost per bleed prevented ranged from a cost savings of $165 when the respective risks were 25% and 5%, to a cost of nearly $33,000 when the risks were 20% and 15%.

Conclusions: The results suggest that routine second-look endoscopy is not indicated after therapeutic endoscopy for bleeding peptic ulcer disease. However, if rebleeding risk is 31% or greater, then routine second-look endoscopy reduces this risk at no additional cost.

*Department of Medicine, Division of Gastroenterology, Indiana University School of Medicine

Regenstrief Institute Inc

Center of Excellence for Implementation of Evidence-based Practice, Roudebush VA Medical Center, Indianapolis

§Weldon School Biomedical Engineering, Purdue University, Lafayette, IN

Supported in part by NIH Grant DK 002756 (Dr Imperiale).

The study was presented in part at the 2010 Annual International Meetings of the American College of Gastroenterology, October 20, 2010, San Antonio, TX and Society for Medical Decision Making, October 24, 2010, Toronto, Ontario, Canada.

The authors declare that they have nothing to disclose.

Study concept and design, T.F.I.; acquisition of data, T.F.I.; analysis and interpretation of data, T.F.I., N.K.; drafting of the manuscript, T.F.I.; critical revision of the manuscript, N.K., T.F.I.; and statistical analysis, N.K.

Reprints: Thomas F. Imperiale, MD, Regenstrief Institute Inc., 1050 Wishard Boulevard, Indianapolis, IN 46202 (e-mail:

Received July 22, 2011

Accepted November 8, 2011

© 2012 Lippincott Williams & Wilkins, Inc.