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Prevention of Complicated Ulcer Disease Among Chronic Users of Nonsteroidal Anti-inflammatory Drugs
The Use of a Nomogram in Cost-effectiveness Analysis
Hashem B. El-Serag, MD, MPH;
David Y. Graham, MD;
Peter Richardson, PhD;
John M. Inadomi, MD
Arch Intern Med. 2002;162:2105-2110.
Background Nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with an
increased risk of clinical upper gastrointestinal tract (UGI) events, namely,
symptomatic ulcer, perforation, bleeding, and obstruction. Our objective in
this study was to compare the cost-effectiveness of several strategies aimed
at reducing the risk of clinical UGI events in NSAID users.
Methods A decision tree model was used for patients requiring long-term treatment
with NSAIDs to compare conventional NSAID therapy alone with 7 other treatment
strategies to reduce the risk of NSAID-related clinical UGI events (cotherapy
with proton-pump inhibitor, cotherapy with misoprostol, cyclooxygenase [COX]-2–selective
NSAID therapy, or Helicobacter pylori treatment followed
by each of the previous strategies, including conventional NSAID treatment,
respectively). The outcome measure is the incremental cost per clinical UGI
event prevented compared with conventional NSAID treatment over 1 year.
Results The use of a COX-2–selective NSAID and cotherapy with proton-pump
inhibitors were the 2 most cost-effective strategies. However, the incremental
cost associated with these strategies was high (>$35 000) in persons
with a low risk of clinical UGI event with conventional NSAIDs (eg, 2.5% per
year). If the baseline risk of clinical UGI events is moderately high (eg,
6.5%), using a COX-2–selective NSAID becomes the most effective and
least costly (dominant) treatment strategy, followed closely by cotherapy
with a daily proton-pump inhibitor. Because small changes in costs or assumed
efficacy of these drugs could change the conclusions, the incremental cost-effectiveness
ratios between any 2 strategies were presented in a nomogram that allows the
flexible use of a wide range of values for costs and rates of clinical UGI
events.
Conclusions The risk of clinical UGI events in NSAID users depends on their baseline
risk, the added risk associated with the individual NSAID, and the protection
conferred by cotherapy. A nomogram can be used to incorporate these factors
and derive estimates regarding cost-effectiveness of competing strategies
aimed at reducing the risk of clinical UGI events.
From the Health Services Research Sections, Houston Center for Quality
of Care & Utilization Studies (Drs El-Serag and Richardson), and the Gastroenterology
Section (Dr Graham), The Houston Department of Veterans Affairs Medical Center
and Baylor College of Medicine, Houston, Tex; the Department of Veterans Affairs
Medical Center & Health Services Research and Development Service and
the University of Michigan, Ann Arbor (Dr Inadomi).
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