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Ad hoc cost analysis of the new gastrointestinal bleeding algorithm in patients with ventricular assist device

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Gastrointestinal bleed (GIB) is a known complication in patients receiving nonpulsatile ventricular assist devices (VAD). Previously, we reported a new algorithm for the workup of GIB in VAD patients using deep bowel enteroscopy. In this new
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  351 ASAIO Journal 2014 Gastrointestinal bleed (GIB) is a known complication in patients receiving nonpulsatile ventricular assist devices (VAD). Previously, we reported a new algorithm for the workup of GIB in VAD patients using deep bowel enteros-copy. In this new algorithm, patients underwent fewer proce-dures, received less transfusions, and took less time to make the diagnosis than the traditional GIB algorithm group. Con-currently, we reviewed the cost-effectiveness of this new algo-rithm compared with the traditional workup. The procedure charges for the diagnosis and treatment of each episode of GIB was ~ $2,902 in the new algorithm group versus   ~ $9,013 in the traditional algorithm group ( p   < 0.0001). Following the new algorithm in VAD patients with GIB resulted in fewer transfusions and diagnostic tests while attaining a substantial cost savings per episode of bleeding . ASAIO Journal   2014; 60:351–352.Key Words: gastrointestinal bleeding, ventricular assist device, deep bowel enteroscopy, cost V entricular assist devices (VAD) therapy is an established treatment of choice for patients with advanced heart failure. Currently, nonpulsatile VADs are preferred device of choice because of smaller sizes and proven longevity. One of the complications of nonpulsatile VADs is the high incidence of gastrointestinal bleeding (GIB). Previously, we studied GIB after VAD placement and reported 1 : 1) GIB in the patients with a VAD was most commonly associated with nonpulsa-tile VAD (we have not observed any GIB on pulsatile VADs in our study); 2) GIB occurred in 23% of the patients who received nonpulsatile device; 3) if GIB occurred within 1 year after VAD placement, the recurrence rate was 72%; 4) 67% of GIB lesions were located in the duodenum or the  jejunum; 5) the majority of lesions were arteriovenous mal-formations (92%); and 6) 64% of GIB occurred even with subtherapeutic international normalized ratios.Routine workup and management of each episode of GIB requires discontinuation of anticoagulation, which carries a potential risk of pump thrombosis and subsequent emboli-zation. Thus, we advocated our proposed new GIB workup algorithm, which focused on of early utilization of the deep bowel enteroscopy (DBE). In this report, we analyzed the cost-effectiveness of the new GIB workup algorithm compared with the traditional GIB workup algorithm.Between 2004 and 2012, a total of 84 patients underwent VAD placement. Among them, 14 patients developed at least one episode of GIB during mean follow-up period of 34 ± 20 months. All 14 patients with GIB had recurrent GIB events; a total 45 individual episodes of GIB were identified. One episode treated without any gastrointestinal intervention was excluded from the analysis, giving a total of 44 episodes that were eligible for this cost study. The hospital procedural charges from the gas-troenterology department for GIB workups were analyzed after institutional review board approval.Twenty-seven episodes were evaluated with the traditional GIB workup algorithm; this included a digital rectal examina-tion, anoscopy, and nasogastric lavage to differentiate upper versus  lower GIB. If nasogastric lavage or rectal examination was positive, upper or lower endoscopy, respectively, was scheduled at a later date. If nasogastric lavage and upper and lower endoscopy were negative, red blood cell scan or capsule study was performed to rule out small intestinal bleeding. Per-sistent small intestinal bleeding might require angiography or surgical intervention. The new GIB workup algorithm was used in 17 episodes. The new GIB workup included early utilization of DBE for every patients except those who had previous his-tory of or obvious lower GIB (these individuals were primarily evaluated by colonoscopy).The patients evaluated with new GIB algorithm had fewer procedures per episode (1.1 procedures in the new algorithm group versus  3.0 procedures for the traditional algorithm group,  p  < 0.0001) and less red blood cell transfusions per episode (2.1 units in the new algorithm group versus  5.9 units in the Brief Communication Ad Hoc Cost Analysis of the New Gastrointestinal Bleeding Algorithm in Patients With Ventricular Assist Device H ITOSHI  H IROSE , K ONRAD  S AROSIEK , AND  N ICHOLAS  C. C AVAROCCHI Copyright © 2014 by the American Society for Artificial Internal Organs DOI: 10.1097/MAT.0000000000000052 From the Department of Surgery, Thomas Jefferson University, Phila-delphia, Pennsylvania.Submitted for consideration December 2013; accepted for publica-tion in revised form January 2014.Disclosure: The authors have no conflicts of interest to report.Reprint Requests: Hitoshi Hirose, MD, Department of Surgery, Thomas Jefferson University Hospital, 1025 Walnut Street, Room 605, Philadelphia, PA 19107. Email: Hitoshi.Hirose@jefferson.edu Table 1. Hospital Procedural Charges for Various Diagnosis and Treatment for Gastrointestinal Bleeding ProcedureChargeEndoscopy with control of bleeding$3,613Colonoscopy$2,360Computed tomography angiography$4,145Capsule endoscopy$3,464Bleeding scan in nuclear medicine$1,674Deep bowel enteroscopy$2,310  352  HIROSE ET AL. traditional algorithm group,  p  < 0.0001). Hospital procedural charges were obtained from the department of gastroenterol-ogy ( Table 1 ). The total procedural charges for the patients who followed the new GIB algorithm were significantly smaller than those following the traditional algorithm ($2,801 in the new algorithm group versus  $9,112 in the traditional algorithm group,  p  < 0.0001, Table 2 )In reviewing our results, the cost saving from the new GIB algorithm was at least $6,000/episode. The increased num-ber of transfusions and additional hospital stay in the patients evaluated by the traditional GIB workup resulted in further increases in the overall hospital cost, which was not taken into account in this analysis. One of the immense benefits of the new algorithm is its ability to diagnose and treat GIB of the entire upper gastrointestinal tract, from the stomach through the entire small intestine using DBE. The new GIB algorithm not only optimizes resource utilization, but also contributes to cost reduction in VAD patients, although DBE may require additional equipment and technical skills. The GIB events after nonpulsatile VAD placement remain an on-going, unresolved issue. This new GIB workup algorithm using DBE provides rapid diagnosis and treatment of the GIB and is markedly more cost-effective in these particular patients with nonpulsatile VAD. Reference  1. Sarosiek K, Bogar L, Conn MI, O’Hare B, Hirose H, Cavarocchi NC: An old problem with a new therapy: Gastrointestinal bleeding in ventricular assist device patients and deep overtube-assisted enteroscopy.  ASAIO J   59: 384–389, 2013. Table 2. Comparison of the Number of Procedures Performed, Transfusions Received, and Charges per Episode of Gastrointestinal Bleed in Groups 1 and 2 Traditional Workup (n = 27)New Workup (n = 17)  p  Average number of procedures3.0 ± 0.21.1 ± 0.1< 0.0001 Average number of transfusions5.9 ± 0.62.1 ± 0.5< 0.0001 Average GI procedure charges per GIB episode$9,112 ± 520$2,801 ± 258< 0.0001Data are expressed with mean ± standard deviation. GI, gastroin-testinal; GIB, gastrointestinal bleeding
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