Endoscopic Management for Non-Variceal Upper Gastrointestinal Bleeding: A Network Meta-Analysis of Randomized Controlled Trials and Cost-Effectiveness Analyses of 2 Health Care Systems

INTRODUCTION: 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. METHODS: 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 health care settings: the United States, 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 of $100,000 per quality-adjusted life year for the US model and THB 150,000 per quality-adjusted life year for the TH-BOS and TH-CHN models. RESULTS: Ten randomized controlled trials with 1,120 patients with NVGIB were included in the network meta-analysis. 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 cost-effective analysis, the US model reported OTSC as a dominant approach compared with HP (ICER: -$314) and ST (-$3,112). In the TH model, OTSC still dominated ST (ICER: -THB 28,423 for TH-BOS and -22,858 for TH-CHN) and was more cost-effective than HP (THB 1,833 for TH-BOS and THB 2,026 for TH-CHN). DISCUSSION: OTSC was superior to HP and ST in efficacy and cost-effectiveness, favoring its use as a first-line endoscopic hemostasis intervention for NVGIB.