The Charlson Comorbidity Index Is Predictive of Mortality Following Percutaneous Endoscopic Gastrostomy (PEG) Placement in Noncancer Medicare Patients (1992-2003)

Abstracts

W1421 The Charlson Comorbidity Index Is Predictive of Mortality Following Percutaneous Endoscopic Gastrostomy (PEG) Placement in Noncancer Medicare Patients (1992-2003) Richard C. Wong, Doug Kuo, Gregory D. Olds, Gregory S. Cooper

triple therapy required to meet the cost-effectiveness threshold remained %10% even in the worst-case scenario. Conclusions: To meet traditional criteria for costeffectiveness, triple therapy need only demonstrate a small incremental reduction in rebleeding risk over traditional dual therapy. In the future, adequately powered studies should compare triple therapy to dual therapy in patients with high-risk bleeding peptic ulcers.

Background: PEG placement is an increasingly common means of providing artificial nutrition and hydration (ANH) in patients who are unable to swallow because of conditions such as dementia and stroke. Its use is recommended for those patients who will require ANH for at least one month. However, mortality rates at 1 and 12 months following PEG placement have been previously reported to be as high as 33 and 66%, respectively. The Charlson index is a validated scoring system of comorbidity that has been used for predicting patient mortality. Identification of predictive markers of mortality could allow for improved patient selection for ANH. Objective: Analysis of the Charlson comorbidity index as a predictor of patient mortality following PEG placement in noncancer patients. Methods: All inpatient claims from 1992 to 2003 from a 5% random sample of cancer-free Medicare beneficiaries age 66 years and older were examined. Patients who were enrolled in Medicare Part A and were in fee-for-service arrangements were included. All comorbid conditions within a year prior to PEG placement were used to calculate the Charlson index. Survival was measured from the date of PEG placement and through a 3-year follow-up period. Kaplan-Meier analysis was used to compare differences in mortality. Results: 7,437 noncancer patients received a PEG tube. Of these, overall mortality at 30 days, 1 year, and 3 years was 20.7%, 54.8%, and 74.6%, respectively, with the greatest hazard of death within the first year in all Charlson groups. Patients with Charlson index R 4 have the highest mortality (27.2% vs. 19.4%, p ! 0.0001) at one month (Table 1). Conclusions: Patients with a Charlson index of R 4 have a significantly higher mortality throughout the follow-up period of 3 years after PEG placement. In a noncancer population, the Charlson comorbidity index can be used to predict patient mortality following PEG placement. The Charlson comorbidity index should be used to counsel patients and/or their caregivers in the decision-making process regarding PEG placement. Table 1 Charlson index 0-3 R4

n

%

Median survival (month)

6468 969

87.0 13.0

6.01 2.98

Adjusted risk

1 month mortality

1 year mortality

3 year mortality

1.00 1.45

19.4 27.2

52.2 66.4

72.6 83.2

W1422 The Clinical and Economic Effects of Hemo-Clips for High-Risk Bleeding Ulcers: Are They Likely to Be Worth the Money? Sameer D. Saini, James Scheiman Background: Data suggest that dual therapy with epinephrine and bipolar electrocoagulation is superior to epinephrine alone in high-risk bleeding peptic ulcers. In the last several years, however, mechanical hemostasis with endoscopic clipping devices has become increasingly popular. Yet, the added cost of widespread use of clips can only be justified if they also provide added benefit to patients by reducing ulcer rebleeding risk. The purpose of this study was to quantify the minimum incremental reduction in ulcer rebleeding risk needed to make a triple therapy approach with epinephrine, bipolar electrocoagulation, and clipping, cost-effective by traditional standards (!$50,000 per life-year saved). Methods: A simple mathematical model was developed to compare triple therapy to traditional dual therapy for high-risk bleeding peptic ulcers. The published literature was used to estimate risks, benefits, and costs. The model assumed that: (1) the rebleeding risk for high-risk lesions was 12% (range 5%-20%); (2) the risk of mortality from rebleeding was 12% (5%-20%); (3) the added cost of clip-based therapy was $600 per endoscopy ($300-$900); and, (4) the cost of ulcer rebleeding was $4000 ($1,000-$20,000). We calculated the minimum incremental relative risk reduction (RRR) required for triple therapy to cost less than $50,000 per life-year saved (LYS). Results: In the base-case analysis, the cost-effectiveness threshold (!$50,000 per LYS) for the triple therapy approach was achieved at a RRR for rebleeding of 5% or greater. In sensitivity analysis, this result proved to be sensitive to the overall rebleeding risk and the mortality from rebleeding, though the RRR of

AB362 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007

W1423 T Staging Accuracy of Esophageal Cancers By Endoscopic Ultrasound: A Meta-Analysis and Systematic Review Srinivas R. Puli, Jyotsna Bk Reddy, Matthew L. Bechtold, Mainor R. Antillon, Jamal A. Ibdah Background: Prognosis and treatment of patients with Esophageal cancers (ECA) depends largely on the T staging of the tumor. The published data on accuracy of Endoscopic Ultrasound (EUS) for T staging in ECA patients has varied. Aim: To evaluate the accuracy of EUS in T staging of ECA cancers. Methods:Study Selection Criteria: Only EUS studies confirmed by surgery were selected. EUS criteria used for T staging were: T1-tumor invades the lamina propria or submucosa but doesn’t invade the muscularis propria, T2-tumor invades but doesn’t extend beyond the muscularis propria, T3-tumor invades the periesophageal tissues but does not invade adjacent organs, and T4-tumor invades adjacent structures. Only studies from which a 2  2 table could be constructed for true positive, false negative, false positive and true negative values were included. Data collection & extraction: Articles were searched in Medline, Pubmed, Ovid journals, CINH, International pharmaceutical abstracts, and Cochrane control trial registry. Two reviewers independently searched and extracted data. The differences were resolved by mutual agreement. Statistical Method: Meta-analysis for the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratio. Pooling was conducted by both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity of studies was tested using Cochran’s Q test based upon inverse variance weights. Results: Initial search identified 3730 reference articles, of these 389 relevant articles were selected and reviewed. 36 studies (N Z 2558) which met the inclusion criteria were included in this analysis. Pooled accuracy data for T staging is shown in table 1. The pooled estimated by fixed and random effect models were similar. The p for chi-squared heterogeneity for all the pooled accuracy estimates was O0.05. Conclusion: As a result of excellent sensitivity and specificity, EUS can accurately diagnose T staging in a patient with ECA. EUS performs better with advanced disease than early disease. If EUS says that a patient has advance disease i.e. T4, the odds are 250 times higher to have the correct anatomic stage of the disease. EUS should be strongly considered for T staging of ECA. Table 1. Shows the accuracy of EUS with confidence intervals to diagnose T stages in ECA patients. Pooled sensitivity T1 T2 T3 T4

81.6% 81.4% 91.4% 92.4%

(77.8-84.9) (77.5-84.8) (89.5-93.0) (89.2-95.0)

Pooled specificity 99.4% 96.3% 94.4% 97.4%

(99.0-99.7) (95.4-97.1) (93.1-95.5) (96.6-98.0)

Pooled LRD 44.4 16.6 12.5 25.4

(15.5-127.4) (9.3-29.7) (7.7-20.3) (13.7-47.0)

Pooled LRL 0.2 0.2 0.1 0.1

(0.2-0.4) (0.2-0.3) (0.1-0.2) (0.1-0.2)

Pooled DOR 221.5 90.7 145.2 250.0

(118.5-413.9) (48.3-170.5) (90.3-233.4) (145.2-430.5)

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