Cost-Effectiveness of Pantoprazole to Prevent Upper Gastrointestinal Bleeding in Mechanically Ventilated Patients

Importance: Pantoprazole reduces clinically important upper gastrointestinal bleeding in critically ill patients. However, the cost-effectiveness of this strategy is unclear. Objective: To assess the cost-effectiveness of daily intravenous pantoprazole vs no pantoprazole for preventing upper gastrointestinal bleeding in mechanically ventilated patients. Design, Setting, and Participants: This prospective health economic evaluation was conducted alongside the Reevaluating the Inhibition of Stress Erosions (REVISE) trial over a time horizon of intensive care unit (ICU) admission to hospital discharge or death from a public health care payer's perspective. The REVISE trial included critically ill adults from Canada, Australia, the US, England, Saudi Arabia, Brazil, Kuwait, and Pakistan receiving invasive ventilation. Interventions: Daily intravenous pantoprazole (40 mg) or placebo (0.9% sodium chloride). Main Outcomes and Measures: The primary outcome was the incremental cost per clinically important upper gastrointestinal bleed prevented. The base-case analysis included all study site-specific resource utilization. Canadian costs were applied to measured resource uses across sites. Sensitivity analyses were conducted across cost ranges and using US-based cost estimates. Uncertainty was assessed using nonparametric bootstrapping simulations. All costs are presented in 2025 US dollars. Results: 4821 invasively ventilated critically ill patients (mean [SD] age, 58.2 [16.4] years; 1752 female [36.3%]) were enrolled from 68 ICUs. For pantoprazole, the mean (SD) stay was 12.4 (11.7) days in the ICU and an additional 14.8 (28.0) days in the hospital, as compared with 13.3 (13.3) days in the ICU and 16.5 (42.9) days in the hospital for no pantoprazole. Mean (SD) total per-patient costs were $60 466 ($58 546) for pantoprazole vs $65 423 ($75 661) for no pantoprazole. The incremental cost per patient was -$4957 (95% CI, -$8777 to -$1136). In a sensitivity analysis, US costs were applied for pantoprazole, bleeding, and ICU and hospital stay to all patients; mean (SD) total per-patient costs were $130 179 ($123 456) for pantoprazole vs $140 770 ($153 195) for no pantoprazole (incremental cost: -$10 591; 95% CI, -$18 448 to $-2735). When excluding top 10% of patients in terms of ICU days, ward days, and total costs, the incremental costs were -$1151, -$3388, and -$1356, respectively. In 99% of simulations, the strategy of using pantoprazole was more effective and less costly than no pantoprazole. Conclusions and Relevance: In this economic evaluation, daily pantoprazole for invasively mechanically ventilated patients was less costly and more effective than care without pantoprazole, indicating both clinical benefits and economic value for the health care system.

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