Cost effectiveness of follow-up endoscopy for bleeding gastric ulcers

Introduction: It is estimated that the incidence of gastric ulcers is approximately 87,000 per year, with bleeding occurring in 25%, Follow-up endoscopy has been suggested for these patients to exclude gastric carcinoma, however, the cost of this strategy has not been assessed. Aim: To evaluate the cost effectiveness of follow-up endoscopy in patients with gastric ulcer who presented with upper GI bleeding. Methods: The Bleeding Team data base, which has been created to prospectively collect information on all patients in our institution with gastrointestinal hemorrhage, was used to identify cases of bleeding gastric ulcers between 1988-1995. This information included clinical presentation, endoscopic assessment on presentation and follow-up, use of NSAIDS and pathology. National cost estimates were based on standard 1995 Medicare charges for gastroscopy and biopsy ($672). Results: 204 pts presented with bleeding gastric ulcer and were recommended to have follow-up endoscopy. 10.5% of the ulcers were in the cardia and fundus, 17.5% in the body and 72% in the antrum. Mean ulcer size was 13±9 mm (range 3-60). Eighty nine pts (48F, 41M; mean age 67±12, range 35-87 yrs) returned for endoscopy. Sixty one pts (69%) were taking NSAIDS at the time of presentation. Mean follow-up interval was 66±32 days (range 12-242). Ninety seven follow-up endoscopies were performed. Sixty pts (67%) had biopsies at follow-up. Two patients were diagnosed with gastric malignancy at the time of follow-up. In one the initial ulcer was thought to be malignant. In the second the initial ulcer (15mm) was not clearly seen but was thought to be benign. At follow-up the ulcer did demonstrate healing (8mm) but biopsies revealed signet cell carcinoma. The cost of screening this group was $64,512 per cancer found not inclusive of work days lost. Conclusions: 1. Prevalence of gastric malignancy at follow-up endoscopy in patients presenting with a bleeding ulcer was low (1.1%). 2. Nationally, annual costs are estimated at $14,616,000. 3. The low compliance rate (43%) of these patients further diminishes the efficacy of any bleeding gastric ulcer follow-up strategy. 4. Endoscopic follow-up for bleeding gastric ulcers appears to be expensive and may not be a reasonable use of limited medical resources.