Related Experiment Videos
Test sequence in the management of gastrointestinal bleeding
1Portland VA Medical Center and Oregon Health & Science University, Portland, Oregon 97239, USA. sonnenbe@ohsu.edu
Insights
This study determined the optimal sequence for diagnostic tests in gastrointestinal bleeding. Procedures with lower success probability thresholds, like esophagogastroduodenoscopy (EGD) and colonoscopy, should be considered earlier in patient management.
Area of Science:
- Gastroenterology
- Medical Diagnostics
- Health Economics
Background:
- Numerous diagnostic and therapeutic procedures exist for suspected gastrointestinal bleeding.
- Selecting the most effective test sequence is crucial for efficient patient management.
Purpose of the Study:
- To identify the optimal sequence of diagnostic tests for managing gastrointestinal bleeding.
- To compare the cost-effectiveness of different test sequences.
Main Methods:
- Estimated professional fees and facility costs using US Medicare data (FY 2010).
- Employed threshold analysis to compare costs across various clinical scenarios and test sequences.
- Calculated thresholds representing the minimum success probability for test indication.
Main Results:
- Thresholds varied by procedure: laboratory tests/gastric lavage (1%), esophagogastroduodenoscopy (EGD) (8%), colonoscopy (9%), CT angiography (14%), capsule endoscopy (23%), angiography/embolization (25%).
- EGD and colonoscopy consistently showed low thresholds across most scenarios.
- Increased complication risk or cost elevated a procedure's threshold, potentially making it less viable.
Conclusions:
- Low thresholds indicate preferred management options that should be prioritized early in the diagnostic workup for gastrointestinal bleeding.
- This approach aids in optimizing the sequence of tests for gastrointestinal bleeding.
Background And Study Aim:
A large variety of test procedures is available to diagnose and treat patients with suspected gastrointestinal bleeding. The aim of the study was to investigate which test sequence should be utilized in managing gastrointestinal bleeding.
Methods:
For each endoscopic, radiologic, or laboratory test procedure, professional fees and facility costs were estimated based on payments allowed by the US Centers for Medicare and Medicaid Services during the fiscal year 2010. A threshold analysis was used to compare the costs associated with different test sequences of varying clinical scenarios.
Results:
A threshold represents the lowest expected probability of success, for which a test would still be indicated. In a work-up including all possible management options, the threshold associated with laboratory tests and gastric lavage was 1 %, esophagogastroduodenoscopy (EGD) 8 %, colonoscopy 9 %, nuclear scan 9 %, enteroscopy 11 %, computed tomography (CT) angiography 14 %, capsule endoscopy 23 %, and angiography with transcatheter embolization 25 %. Varying sets of thresholds were calculated for different clinical scenarios. The thresholds of EGD and colonoscopy remained low in most scenarios. In sensitivity analysis, rising risk of complications or costs of a procedure also lead to rising threshold values for it, potentially rendering the particular procedure untenable.
Conclusions:
A low threshold indicated a preferred management option that should be used early rather than late in a sequence of multiple possible test procedures to work up instances of gastrointestinal bleeding.
Related Concept Videos
01:28Esophageal Varices-II: Clinical Features and Management
In the initial assessment, a thorough review of the patient's medical history is vital to identify risk factors such as liver disease, alcohol abuse, or...
01:30Serum Laboratory Studies, Stool Test, Breath Test
01:23Gastritis III: Clinical Manifestations and Management
Clinical manifestations of acute gastritis
The patient with acute gastritis may have a rapid onset of symptoms, such as epigastric pain or discomfort, dyspepsia, anorexia, hiccups, or nausea and vomiting, which can last from a few hours to a few days. Erosive or hemorrhagic gastritis may cause bleeding, which may manifest as blood in vomit or as...
01:28Peptic Ulcer Disease III: Clinical Manifestations and Diagnostic Studies
Few clinical manifestations differentiate gastric ulcers from duodenal ulcers. Distinctions in the location, timing, and pain relief are crucial for healthcare providers in differentiating between gastric and duodenal ulcers during clinical assessments.
01:23Lower GI Series: Barium Enema
Procedure Details
The examination begins by inserting a lubricated rectal tube into the patient's rectum to administer a radiopaque barium solution. The barium flow is carefully...
01:29Endoscopic Procedures I: Esophagogastroduodenoscopy
During an EGD, the endoscope can be used to: