Cost-saving approach to patients on long-term anticoagulation who need endoscopy: a decision analysis

OBJECTIVES: The management strategies used when patients requiring long-term anticoagulation need endoscopic procedures vary considerably. Two commonly used approaches are a "heparin window" strategy in the inpatient setting and, more recently, a "switch to low molecular weight heparin (LMWH)" strategy for elective procedures. The aim of this study was to determine whether an initial diagnostic endoscopy (visualization only) is a cost-effective strategy in these patients. METHODS: Decision analysis was performed for two scenarios using probability estimates from our retrospective study. Scenario 1: Patients with any (urgent and elective) indication for endoscopy while on anticoagulation. A decision tree was made outlining two strategies: 1) a diagnostic endoscopy on full anticoagulation followed by therapeutic endoscopy if needed using standard practice; and 2) standard approach. Scenario 2: Patients requiring elective endoscopy. Here, the decision tree outlined three strategies: 1) initial diagnostic endoscopy on full anticoagulation followed by a therapeutic endoscopy if needed using a "heparin window"; 2) initial diagnostic endoscopy followed by therapeutic endoscopy if needed using "switch to LMWH" strategy; and 3) "direct switch to LMWH strategy." RESULTS: Initial diagnostic endoscopy is the preferred strategy when patients requiring anticoagulation need endoscopy. In scenario 1 (all patients), the diagnostic endoscopy approach will reduce need for hospital stay and save $85,006 per 100 patients when a therapeutic impact is not predictable before endoscopy. Similarly, in scenario 2, an initial diagnostic endoscopy followed by switch to LMWH strategy is the most cost saving. CONCLUSIONS: In anticoagulated patients, an initial diagnostic endoscopy approach on anticoagulation is the most cost-saving strategy, when a direct therapeutic impact is not predictable.