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The clinical and economic impact of competing management strategies for gastro‐oesophageal reflux disease
Background: Gastro‐oesophageal reflux disease (GERD) is a common disorder in the primary care setting. Traditional management strategies consist of sequentially intensive therapeutic trials followed by invasive diagnostic testing for nonresponders. A high dose proton pump inhibitor trial (the ‘proto...
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| Published in: | Alimentary pharmacology & therapeutics 2002-02, Vol.16 (2), p.261-273 |
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| Main Authors: | , , , |
| Format: | Article |
| Language: | English |
| Subjects: | |
| Citations: | Items that this one cites Items that cite this one |
| Online Access: | Get full text |
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| Summary: | Background:
Gastro‐oesophageal reflux disease (GERD) is a common disorder in the primary care setting. Traditional management strategies consist of sequentially intensive therapeutic trials followed by invasive diagnostic testing for nonresponders. A high dose proton pump inhibitor trial (the ‘proton pump inhibitor test’) has been shown to be an accurate diagnostic alternative, and may be an efficient initial approach to patients with GERD symptoms.
Aim:
To examine the clinical, economic and policy implications of alternative management strategies for GERD.
Methods:
Decision analysis was used to calculate the clinical and economic outcomes of competing management strategies. The traditional strategy incorporates sequential therapeutic trials with more intensive therapy (‘step‐up’ approach) followed by sequential invasive diagnostic testing of nonresponders. The ‘proton pump inhibitor test’ strategy includes an initial ‘proton pump inhibitor test’ (7 days of omeprazole; 40 mg AM + 20 mg PM daily) followed by less intensive therapeutic trials in those testing positive (‘step‐down’ approach) with sequential invasive diagnostic testing as needed. Cost estimates were based on Medicare reimbursement and average wholesale drug prices. Probability estimates were derived from a systematic review of the published medical literature. Model results are reported as the average and incremental cost‐per‐symptom free patient and cost‐per‐quality‐adjusted life‐years (QALYs) gained.
Results:
The average cost per patient was $1045 for the traditional step‐up management strategy, compared to $1172 for the ‘proton pump inhibitor test’ and step‐down strategy. The percentage of patients who were symptom‐free at 1 year was 50% for the traditional management strategy compared to 75% for the ‘proton pump inhibitor test’ strategy. The ‘proton pump inhibitor test’ strategy results in QALY gains of 0.01–0.05 depending on the utility estimate employed. The incremental cost‐effectiveness ratio for the ‘proton pump inhibitor test’ strategy is $510 per additional symptomatic cure over 1 year, and between $2822–$10 160 per QALY gained. The traditional management strategy resulted in a greater than 5‐fold increase in the utilization of upper endoscopy, which was partially offset by a 47% reduction in the use of ambulatory 24‐h oesophageal pH monitoring. The reduced effectiveness of the traditional management strategy may be attributed in part to a 118% increase in the use of ‘high‐dose’ H2R |
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| ISSN: | 0269-2813 1365-2036 |
| DOI: | 10.1046/j.1365-2036.2002.01167.x |