A cost-effectiveness analysis of prescribing strategies in the management of gastroesophageal reflux disease.
OBJECTIVE
Patients who have uncomplicated gastroesophageal-reflux disease (GERD) typically present with heartburn and acid regurgitation. We sought to determine the cost-effectiveness of H2-receptor antagonists (H2RAs) and proton-pump inhibitors (PPIs) as first-line empiric therapy for patients with typical symptoms of GERD.


METHODS
Decision analysis comparing costs and benefits of empirical treatment with H2RAs and PPIs for patients presenting with typical GERD was employed. The six treatment arms in the model were: 1) Lifestyle therapy, including antacids; 2) H2RA therapy, with endoscopy performed if no response to H2RAs; 3) Step up (H2RA-PPI) Arm: H2RA followed by PPI therapy in the case of symptomatic failure; 4) Step down arm: PPI therapy followed by H2RA if symptomatic response to PPI, and antacid therapy if response to H2RA therapy; 5) PPI-on-demand therapy: 8 wk of treatment for symptomatic recurrence, with no more than three courses per year; and 6) PPI-continuous therapy. Measurements were lifetime costs, quality-adjusted life years (QALYs) gained, and incremental cost effectiveness.


RESULTS
Initial therapy with PPIs followed by on-demand therapy was the most cost-effective approach, with a cost-effectiveness ratio of $20,934 per QALY gained for patients with moderate to severe GERD symptoms, and $37,923 for patients with mild GERD symptoms. This therapy was also associated with the greatest gain in discounted QALYs. The PPI-on-demand strategy was more effective and less costly than the H2RA followed by PPI strategy or the other treatment arms. The results were not highly sensitive to cost of therapy, QALY adjustment from GERD symptoms, or the success rate of the lifestyle arm. However, when the success rate of the PPI-on-demand arm was < or =59%, the H2RA-PPI arm was the preferred strategy.


CONCLUSIONS
For patients with moderate to severe symptoms of GERD, initial treatment with PPIs followed by on-demand therapy is a cost-effective approach.
Gerson
L B
LB
Department of Medicine, Stanford University School of Medicine, California, USA.
Robbins
A S
AS
Garber
A
A
Hornberger
J
J
Triadafilopoulos
G
G
D000328:Adult; D000863:Antacids / Q000191:economics / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D003365:Costs and Cost Analysis; D003661:Decision Support Techniques; D003663:Decision Trees; D011307:Drug Prescriptions / Q000191:economics; D004791:Enzyme Inhibitors / Q000191:economics / Q000627:therapeutic use*; D004945:Esophagoscopy; D005764:Gastroesophageal Reflux / Q000188:drug therapy*; D006356:Heartburn / Q000188:drug therapy; D006635:Histamine H2 Antagonists / Q000191:economics / Q000627:therapeutic use*; D006801:Humans; D008019:Life Style; D054328:Proton Pump Inhibitors; D019057:Quality-Adjusted Life Years; D012008:Recurrence; D012074:Remission Induction; D013997:Time Factors; D016896:Treatment Outcome
D000863:Antacids; D004791:Enzyme Inhibitors; D006635:Histamine H2 Antagonists; D054328:Proton Pump Inhibitors