Mathew Abraham, Riley Thomas R, Young Mark, Ouyang Ann
Departments of Medicine, Milton S. Hershey Medical Center, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033-0850, USA.
Am J Gastroenterol. 2003 Aug;98(8):1766-76. doi: 10.1111/j.1572-0241.2003.07594.x.
The management strategies used when patients requiring long-term anticoagulation need endoscopic procedures vary considerably. Two commonly used approaches are a "heparin window" strategy in the inpatient setting and, more recently, a "switch to low molecular weight heparin (LMWH)" strategy for elective procedures. The aim of this study was to determine whether an initial diagnostic endoscopy (visualization only) is a cost-effective strategy in these patients.
Decision analysis was performed for two scenarios using probability estimates from our retrospective study. Scenario 1: Patients with any (urgent and elective) indication for endoscopy while on anticoagulation. A decision tree was made outlining two strategies: 1) a diagnostic endoscopy on full anticoagulation followed by therapeutic endoscopy if needed using standard practice; and 2) standard approach. Scenario 2: Patients requiring elective endoscopy. Here, the decision tree outlined three strategies: 1) initial diagnostic endoscopy on full anticoagulation followed by a therapeutic endoscopy if needed using a "heparin window"; 2) initial diagnostic endoscopy followed by therapeutic endoscopy if needed using "switch to LMWH" strategy; and 3) "direct switch to LMWH strategy."
Initial diagnostic endoscopy is the preferred strategy when patients requiring anticoagulation need endoscopy. In scenario 1 (all patients), the diagnostic endoscopy approach will reduce need for hospital stay and save $85,006 per 100 patients when a therapeutic impact is not predictable before endoscopy. Similarly, in scenario 2, an initial diagnostic endoscopy followed by switch to LMWH strategy is the most cost saving.
In anticoagulated patients, an initial diagnostic endoscopy approach on anticoagulation is the most cost-saving strategy, when a direct therapeutic impact is not predictable.
对于需要长期抗凝治疗的患者在进行内镜检查时所采用的管理策略差异很大。两种常用方法分别是住院环境下的“肝素窗”策略，以及最近用于择期手术的“换用低分子量肝素（LMWH）”策略。本研究的目的是确定初始诊断性内镜检查（仅观察）在这些患者中是否是一种具有成本效益的策略。
使用我们回顾性研究中的概率估计值，针对两种情况进行决策分析。情况1：正在接受抗凝治疗且有任何（紧急和择期）内镜检查指征的患者。绘制了决策树，概述了两种策略：1）在全量抗凝状态下进行诊断性内镜检查，如有必要则根据标准操作进行治疗性内镜检查；2）标准方法。情况2：需要进行择期内镜检查的患者。在此，决策树概述了三种策略：1）在全量抗凝状态下进行初始诊断性内镜检查，如有必要则使用“肝素窗”进行治疗性内镜检查；2）初始诊断性内镜检查，如有必要则使用“换用LMWH”策略进行治疗性内镜检查；3）“直接换用LMWH策略”。
当需要抗凝治疗的患者需要进行内镜检查时，初始诊断性内镜检查是首选策略。在情况1（所有患者）中，当内镜检查前治疗效果不可预测时，诊断性内镜检查方法将减少住院需求，每100例患者可节省85,006美元。同样，在情况2中，初始诊断性内镜检查后换用LMWH策略是最节省成本的。
在抗凝患者中，当直接治疗效果不可预测时，在抗凝状态下进行初始诊断性内镜检查是最节省成本的策略。
