Cost-effectiveness and cost-utility of long-term management strategies for heartburn.
OBJECTIVE
To compare the expected costs and outcomes of seven alternative long-term primary care strategies for the management of patients with moderate-to-severe heartburn over a 1-year period.


METHODS
A decision-analytic model was developed to estimate costs and effects (weeks with heartburn symptoms and quality adjusted life years [QALYs]) for each strategy. Meta-analyses were used to synthesize acute treatment and maintenance studies and physician surveys to collect information on patient management. The impact of uncertainty on the base case results was assessed using probabilistic sensitivity analysis. Probability distributions were defined for key model parameters and techniques of Monte Carlo simulation were used to draw values from these distributions. Cost-effectiveness acceptability curves (CEACs) conditional on the monetary value decision makers are willing to pay for a symptom-free day or QALY were created for each strategy.


RESULTS
In the base case, no strategy was strictly dominated by any other strategy. However, two strategies (maintenance H2-receptor antagonists H2RA] and step-down proton pump inhibitor PPI]) were dominated through principles of extended dominance. The least costly and least effective strategy was intermittent H2RA, while maintenance PPI was the most costly and most effective.


CONCLUSIONS
This analysis showed that the best way of managing patients with heartburn depends on how much society is willing to pay to achieve health improvements. Based on the commonly quoted threshold of US 50,000 dollars per QALY, the optimal primary care strategy for managing patients with moderate-to-severe heartburn symptoms is to treat the symptoms with a PPI followed by maintenance therapy with an H2RA to prevent symptomatic recurrence.
Goeree
Ron
R
Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario L8N 1G6, Canada. goereer@mcmaster.ca
O'Brien
Bernie J
BJ
Blackhouse
Gordon
G
Marshall
John
J
Briggs
Andrew
A
Lad
Rameeta
R
D002170:Canada; D003362:Cost-Benefit Analysis; D004791:Enzyme Inhibitors / Q000191:economics / Q000627:therapeutic use; D006356:Heartburn / Q000191:economics* / Q000628:therapy*; D006635:Histamine H2 Antagonists / Q000191:economics / Q000627:therapeutic use; D006801:Humans; D008134:Long-Term Care / Q000191:economics; D017059:Models, Econometric; D009010:Monte Carlo Method; D010043:Outcome and Process Assessment, Health Care; D011320:Primary Health Care / Q000191:economics* / Q000379:methods / Q000706:statistics & numerical data; D054328:Proton Pump Inhibitors; D019057:Quality-Adjusted Life Years; D055502:Secondary Prevention
D004791:Enzyme Inhibitors; D006635:Histamine H2 Antagonists; D054328:Proton Pump Inhibitors