Endoscopic Management for Non-variceal Upper Gastrointestinal Bleeding: A Network Meta-analysis of Randomized Controlled Trials and Cost-Effectiveness Analyses of Two Healthcare Systems.

Abstract

Non-variceal upper gastrointestinal bleeding (NVGIB) represents an urgent medical condition with high mortality. Standard endoscopic therapies (ST) still carry a high rebleeding rate. Novel modalities such as the over-the-scope clip (OTSC) and hemostatic powder (HP) could be promising alternatives, but their efficacy and cost-effectiveness remain to be explored. A network meta-analysis and cost-effectiveness analyses were conducted to compare OTSC vs. HP vs. ST. Primary endpoints include 30-day rebleeding and 30-day further bleeding. Markov models with a 12-month time horizon were created across 3 different healthcare settings: the United States (US), Thailand with Boston Scientific products (TH-BOS), and Thailand with China-manufactured alternatives (TH-CHN). Incremental cost-effectiveness ratio (ICER) was evaluated at a willingness-to-pay (WTP) of $100,000 per quality-adjusted life year (QALY) for the US model and THB150,000 per QALY for the TH-BOS and TH-CHN models. Ten RCTs with 1,120 NVGIB patients were included in the NMA. Lowest 30-day rebleeding was seen in OTSC (P-score:0.996), followed by ST (0.296) and HP (0.208). Similarly, OTSC also achieved lowest 30-day further bleeding (0.906), followed by HP (0.570) and ST (0.024). In CEA, the US model reported OTSC as a dominant approach compared to HP (ICER: -$314) and ST (-$3,112). In the TH model, OTSC still dominated ST (ICER:-THB28,423 for TH-BOS and -22,858 for TH-CHN) and was more cost-effective than HP (THB1,833 for TH-BOS and THB2,026 for TH-CHN). OTSC was superior to HP and ST in terms of efficacy and cost-effectiveness, favoring its use as a first-line endoscopic hemostasis intervention for NVGIB.