Cost and quality effects of alternative treatments for persistent gastroesophageal reflux disease.
BACKGROUND
Gastroesophageal reflux disease is commonly encountered by general internists and gastroenterologists.


METHODS
We used decision analysis to assess the clinical and economic effects of three treatments--phase 1 therapy alone or combined with omeprazole or ranitidine hydrochloride therapy--for patients with persistent, symptomatic grade 2 or higher gastroesophageal reflux disease. To the maximum extent possible, data were obtained from the published literature. We convened an expert consensus panel to estimate specific data points when they were unavailable or contradictory in the literature, including estimates of optimal and actual clinical practice patterns. A 7-month model was used to correspond to the time frame of available clinical trial data. The perspective of the analysis was that of the payer. The costs of medical care for various clinical outcomes were based on actual mean payments made by Independence Blue Cross of Philadelphia and Pennsylvania Blue Shield.


RESULTS
Although the retail payments for daily omeprazole therapy are the highest among the three interventions tested, it produced both the lowest expected overall payments for medical care and the most effective strategy for treating symptoms during the 7-month model. Omeprazole therapy was consistently approximately $1800 less costly than ranitidine therapy and $2700 less costly than phase 1 therapy alone during the period examined, regardless of whether empiric or nonempiric treatment strategies were used. Even when payments for major complications (the most important cost variable) were reduced by 80%, omeprazole therapy resulted in payments 17% and 22% lower than those associated with ranitidine therapy and phase 1 therapy alone, respectively. Omeprazole also produced the most symptom-free months during the 7-month follow-up period. The clinical and economic outcomes of performing an initial diagnostic workup, compared with treating patients empirically, were equal.


CONCLUSIONS
We conclude that omeprazole therapy is the preferred initial therapeutic approach for patients with persistent, symptomatic gastroesophageal reflux disease in whom phase 1 therapy fails. Assessment of long-term approaches must await the results of extended clinical studies.
Hillman
A L
AL
General Internal Medicine Division, University of Pennsylvania, Philadelphia.
Bloom
B S
BS
Fendrick
A M
AM
Schwartz
J S
JS
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002985:Clinical Protocols; D003365:Costs and Cost Analysis; D003663:Decision Trees; D005500:Follow-Up Studies; D005764:Gastroesophageal Reflux / Q000188:drug therapy* / Q000191:economics* / Q000601:surgery; D006801:Humans; D008875:Middle Aged; D008962:Models, Theoretical; D009853:Omeprazole / Q000191:economics* / Q000627:therapeutic use; D011899:Ranitidine / Q000191:economics* / Q000627:therapeutic use
D011899:Ranitidine; D009853:Omeprazole