Roy Ann, Kim Micheline, Hawes Robert, Varadarajulu Shyam
Health Economics and Reimbursement, Boston Scientific Corporation, Natick, MA, USA.
Center for Interventional Endoscopy, Florida Hospital, Orlando, FL, USA.
United European Gastroenterol J. 2017 Apr;5(3):359-364. doi: 10.1177/2050640616663570. Epub 2016 Aug 2.
The aim of this article is to evaluate the clinical and cost implications of failed endoscopic hemostasis in patients with gastroduodenal ulcer bleeding.
A retrospective claims analysis of the Medicare Provider Analysis and Review (MedPAR) file was conducted to identify all hospitalizations for gastroduodenal ulcer bleeding in the year 2012. The main outcome measures were to compare all-cause mortality, total length of hospital stay (LOS), hospital costs and payment between patients managed with one upper gastrointestinal (UGI) endoscopy versus more than one UGI endoscopy or requiring interventional radiology-guided hemostasis (IRH) or surgery after failed endoscopic attempt.
The MedPAR claims data evaluated 13,501 hospitalizations, of which 12,242 (90.6%) reported one UGI endoscopy, 817 (6.05%) reported >1 UGI endoscopy, 303 (2.24%) reported IRH after failed endoscopy and 139 (1.03%) reported surgeries after failed endoscopy. All cause-mortality was significantly lower for patients who underwent only one UGI endoscopy (3%) compared to patients requiring >1 endoscopy (6%), IRH (9%) or surgery (14%), < 0.0001. The median LOS was significantly lower for patients who underwent only one UGI endoscopy (four days) compared to patients requiring >1 endoscopy (eight days), IRH (nine days) or surgery (15 days), < 0.0001. The median hospital costs were significantly lower for patients who underwent one UGI endoscopy ($10,518) compared to patients requiring >1 endoscopy ($20,055), IRH ($34,730) or surgery ($47,589), < 0.0001.
Failure to achieve hemostasis at the index endoscopy has significant clinical and cost implications. When feasible, a repeat endoscopy must be attempted followed by IRH. Surgery should preferably be reserved as a last resort for patients who fail other treatment measures.
本文旨在评估胃十二指肠溃疡出血患者内镜止血失败的临床及成本影响。
对医疗保险提供者分析与审查（MedPAR）文件进行回顾性索赔分析，以确定2012年所有因胃十二指肠溃疡出血而住院的病例。主要结局指标是比较接受一次上消化道（UGI）内镜检查的患者与接受一次以上UGI内镜检查、内镜检查失败后需要介入放射学引导下止血（IRH）或手术的患者之间的全因死亡率、住院总时长（LOS）、住院费用及支付情况。
MedPAR索赔数据评估了13501例住院病例，其中12242例（90.6%）报告进行了一次UGI内镜检查，817例（6.05%）报告进行了一次以上UGI内镜检查，303例（2.24%）报告内镜检查失败后进行了IRH，139例（1.03%）报告内镜检查失败后进行了手术。仅接受一次UGI内镜检查的患者全因死亡率（3%）显著低于需要进行一次以上内镜检查（6%）、IRH（9%）或手术（14%）的患者，P＜0.0001。仅接受一次UGI内镜检查的患者中位住院时长（4天）显著低于需要进行一次以上内镜检查（8天）、IRH（9天）或手术（15天）的患者，P＜0.0001。接受一次UGI内镜检查的患者中位住院费用（10518美元）显著低于需要进行一次以上内镜检查（20055美元）、IRH（34730美元）或手术（47589美元）的患者，P＜0.0001。
初次内镜检查未能实现止血具有重大的临床及成本影响。在可行的情况下，必须尝试重复内镜检查，随后进行IRH。对于其他治疗措施失败的患者，手术最好作为最后手段保留。
