Department of Medicine, Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA.
J Clin Gastroenterol. 2012 Oct;46(9):e71-5. doi: 10.1097/MCG.0b013e3182410351.
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.
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.
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%.
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.
初始治疗性内镜治疗消化性溃疡出血后进行再次内镜检查可能会降低再出血风险，但不推荐常规进行。了解哪些情况下再次内镜检查有益可能有助于临床决策。
使用决策模型、基于文献的概率和医疗保险报销费用，我们比较了常规再次内镜检查与不进行再次内镜检查的情况。我们测量了再出血、手术需求、住院死亡率和成本，并计算了避免每种结果所需的治疗人数，以及每个预防结果的成本，以每例需要治疗的人数和每个预防结果的成本表示。
在基础病例中，常规再次内镜检查将再出血率从 16%降低至 10%（需要治疗人数=16），但对其他结果没有影响。预防 1 例再出血的成本接近 13000 美元。阈值分析显示，再出血率为 31%时，常规再次内镜检查与不进行常规再次内镜检查的成本差异将被中和。如果常规再次内镜检查能 100%预防再出血，则成本中性的再出血阈值为 17.5%。当同时考虑索引内镜检查和再次内镜检查后的再出血风险时，预防每例出血的成本从各自风险为 25%和 5%时节省 165 美元，到风险分别为 20%和 15%时接近 33000 美元。
结果表明，在治疗性内镜治疗消化性溃疡出血后，不建议常规进行再次内镜检查。然而，如果再出血风险为 31%或更高，则常规再次内镜检查可在不增加成本的情况下降低这种风险。
