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Cost‐Effectiveness of Histamine 2 Receptor Antagonists Versus Proton Pump Inhibitors for Stress Ulcer Prophylaxis in Critically Ill Patients
Author(s) -
Hammond Drayton A.,
Kathe Niranjan,
Shah Anuj,
Martin Bradley C.
Publication year - 2017
Publication title -
pharmacotherapy: the journal of human pharmacology and drug therapy
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.227
H-Index - 109
eISSN - 1875-9114
pISSN - 0277-0008
DOI - 10.1002/phar.1859
Subject(s) - stress ulcer , medicine , histamine , critically ill , histamine h2 receptor , intensive care medicine , histamine receptor , pharmacology , anesthesia , receptor , antagonist
Study Objective To determine the cost‐effectiveness of stress ulcer prophylaxis with histamine 2 receptor antagonists (H2 RAs ) versus proton pump inhibitors ( PPIs ) in critically ill and mechanically ventilated adults. Design A decision analytic model estimating the costs and effectiveness of stress ulcer prophylaxis (with H2 RA s and PPI s) from a health care institutional perspective. Patients Adult mixed intensive care unit ( ICU ) population who received an H2 RA or PPI for up to 9 days. Measurements and Main Results Effectiveness measures were mortality during the ICU stay and complication rate. Costs (2015 U.S. dollars) were combined to include medication regimens and untoward events associated with stress ulcer prophylaxis (pneumonia, Clostridium difficile infection, and stress‐related mucosal bleeding). Costs and probabilities for complications and mortality from complications came from randomized controlled trials and observational studies. A base case scenario was developed with pooled data from an observational study and meta‐analysis of randomized controlled trials. Scenarios based on observational and meta‐analysis data alone were evaluated. Outcomes were expected and incremental costs, mortalities, and complication rates. Univariate sensitivity analyses were conducted to determine the influence of inputs on cost, mortality, and complication rates. Monte Carlo simulations evaluated second‐order uncertainty. In the base case scenario, the costs, complication rates, and mortality rates were $9039, 17.6%, and 2.50%, respectively, for H2 RA s and $11,249, 22.0%, and 3.34%, respectively, for PPI s, indicating that H2 RA s dominated PPI s. The observational study–based model provided similar results; however, in the meta‐analysis–based model, H2 RA s had a cost of $8364 and mortality rate of 3.2% compared with $7676 and 2.0%, respectively, for PPI s. At a willingness‐to‐pay threshold of $100,000/death averted, H2 RA therapy was superior or preferred 70.3% in the base case and 97.0% in the observational study–based scenario. PPI therapy was preferred 87.2% in the meta‐analysis–based scenario. Conclusion Providing stress ulcer prophylaxis with H2 RA therapy may reduce costs, increase survival, and avoid complications compared with PPI therapy. This finding is highly sensitive to the pneumonia and stress‐related mucosal bleeding rates and whether observational data are used to inform the model.