Prevention of recurrences of erosive reflux esophagitis: a cost-effectiveness analysis of maintenance proton pump inhibition.
OBJECTIVE
To determine the cost-effectiveness of three management strategies for healed erosive reflux esophagitis: maintenance therapy with a proton pump inhibitor (PPI) from the outset; no maintenance therapy unless a patient's symptoms recur once over a year; and no maintenance therapy unless a patient's symptoms recur twice over a year.


METHODS
Decision analysis using data from randomized trials of lansoprazole, case series, and expert opinion.


RESULTS
For patients with grade 4 esophagitis, maintenance from the outset is the most efficient approach. For all other patients, providing maintenance PPI after a patient experiences two recurrences is the least costly but least effective approach. The other two approaches prevent more recurrences: waiting to initiate maintenance therapy until symptoms recur once requires an additional $73 for each recurrence prevented whereas maintenance PPI from the outset requires an additional $819 for each recurrence prevented. Maintenance therapy from the outset is cost effective if symptoms of esophagitis cause a 22% or greater decrement in quality of life (using $50,000 per quality-adjusted life year gained as a cost-effectiveness definition). However, withholding maintenance until the time of a first recurrence is cost effective if symptoms cause a 2% or greater decrement in quality of life.


CONCLUSIONS
For grades 2 and 3 esophagitis, providing maintenance therapy after a patient experiences a further recurrence is a preferred option that appears cost-effective across a wide array of assumptions. Maintenance therapy from the outset, however, appears cost-effective only for those patients who report a significant decline in quality of life associated with esophagitis or for those patients with baseline grade 4 esophagitis.
Harris
R A
RA
Technology Assessment Group San Francisco, California 94107, USA.
Kuppermann
M
M
Richter
J E
JE
D053799:2-Pyridinylmethylsulfinylbenzimidazoles; D000897:Anti-Ulcer Agents / Q000191:economics* / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D004942:Esophagitis, Peptic / Q000191:economics* / Q000517:prevention & control*; D006801:Humans; D064747:Lansoprazole; D009853:Omeprazole / Q000031:analogs & derivatives* / Q000191:economics / Q000627:therapeutic use; D054328:Proton Pump Inhibitors; D011788:Quality of Life; D012008:Recurrence; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index
D053799:2-Pyridinylmethylsulfinylbenzimidazoles; D000897:Anti-Ulcer Agents; D054328:Proton Pump Inhibitors; D064747:Lansoprazole; D009853:Omeprazole