title: Economic analysis of step-wise treatment of gastro-oesophageal reflux disease.
abstract: BACKGROUND
  To expose patients with gastro-oesophageal reflux disease (GERD) to the least amount of medication and to reduce health expenditures, it is recommended that their treatment is started with a small dose of an antisecretory or prokinetic medication. If patients fail to respond, the dose is increased in several consecutive steps or the initial regimen is changed to a more potent medication until the patients become asymptomatic. Although such treatment strategy is widely recommended, its impact on health expenditures has not been evaluated.
  
  
  METHODS
  The economic analysis compares the medication costs of competing medical treatment strategies, using two different sets of cost data. Medication costs are estimated from the average wholesale prices (AWP) and from the lowest discount prices charged to governmental health institutions. A decision tree is used to model the step-wise treatment of GERD. In a Monte Carlo simulation, all transition probabilities built into the model are varied over a wide range. A threshold analysis evaluates the relationship between the cost of an individual medication and its therapeutic success rate.
  
  
  RESULTS
  In a governmental health care system, a step-wise strategy saves on average $916 per patient every 5 years (range: $443-$1628) in comparison with a strategy utilizing only the most potent medication. In a cost environment relying on AWP, the average savings amount to $256 (-$206 to +$1561). The smaller the cost difference between two consecutive treatment steps, the longer one needs to follow the patients to reap the benefit of the small cost difference. However, even a small cost difference can turn into tangible cost savings, if a large enough fraction of GERD patients responds to the initial step of a less potent but also less expensive medication.
  
  
  CONCLUSIONS
  The economic analysis suggests that a step-wise utilization of increasingly more potent and more expensive medications to treat GERD would result in appreciable cost savings.
authors.affiliation: The Department of Veterans Affairs Medical Center and The University of New Mexico, Albuquerque, New Mexico 87108, USA. sonnbrg@unm.edu
authors.forename: A
authors.initials: A
authors.lastname: Sonnenberg
authors.forename: J M
authors.initials: JM
authors.lastname: Inadomi
authors.forename: L A
authors.initials: LA
authors.lastname: Becker
mesh_terms: D000465:Algorithms; D017281:Cost of Illness; D003661:Decision Support Techniques; D016527:Drug Costs; D005764:Gastroesophageal Reflux / Q000188:drug therapy* / Q000191:economics*; D005765:Gastrointestinal Agents / Q000191:economics* / Q000627:therapeutic use*; D006801:Humans; D009010:Monte Carlo Method
chemical_list: D005765:Gastrointestinal Agents