title: Should noncardiac chest pain be treated empirically? A cost-effectiveness analysis.
abstract: BACKGROUND
  Chest pain is a common clinical problem, but up to 30% of patients who present with chest pain lack coronary disease. Subsequent investigation often reveals an esophageal source for the pain, with gastroesophageal reflux disease identified most frequently. Controversy exists regarding whether to establish the cause or to empirically treat as reflux.
  
  
  OBJECTIVE
  To assess the cost-effectiveness of empirical treatment in patients with noncardiac chest pain.
  
  
  METHODS
  Decision analysis was used to compare a strategy of empirical treatment as reflux using an H-blocker or proton pump inhibitor with initial investigation for gastrointestinal causes over a period of up to 16 weeks and over a period of more than a year. The prototype patient was an outpatient with chest pain and a normal coronary angiogram. Gastrointestinal investigations included an upper gastrointestinal tract series, endoscopy, manometry, 24-hour pH monitoring, and provocation tests. The main outcome measure was direct medical costs per case treated from a third-party payer perspective.
  
  
  RESULTS
  Total medical costs were $2,187 per case treated for the initial investigation arm and $849 for the empirical treatment arm in the 8- to 16-week model. One-way sensitivity analyses revealed that the model was robust; the treatment arm was less expensive in all cases. At just over a year empirical treatment remained dominant.
  
  
  CONCLUSIONS
  An initial therapeutic trial with antisecretory agents for patients with noncardiac chest pain is cost-effective compared with investigation for gastrointestinal causes in the short term of weeks, with cost savings persisting beyond a year.
authors.affiliation: Dalhousie University School of Medicine, Halifax, Nova Scotia, Canada. borzecki@is.dal.ca
authors.forename: A M
authors.initials: AM
authors.lastname: Borzecki
authors.forename: M C
authors.initials: MC
authors.lastname: Pedrosa
authors.forename: M J
authors.initials: MJ
authors.lastname: Prashker
mesh_terms: D000328:Adult; D000368:Aged; D002637:Chest Pain / Q000000981:diagnostic imaging / Q000191:economics* / Q000209:etiology / Q000628:therapy*; D003327:Coronary Disease / Q000175:diagnosis / Q000191:economics; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D003663:Decision Trees; D003937:Diagnosis, Differential; D005260:Female; D005764:Gastroesophageal Reflux / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000191:economics*; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012680:Sensitivity and Specificity; D014481:United States