title: Determining an appropriate threshold for referral to surgery for gastroesophageal reflux disease.
abstract: BACKGROUND
  Persistent symptomatic gastroesophageal reflux disease (GERD) can be treated with medication or surgery. The purposes of this study were (1) to determine how poor the quality of life on medication would need to be to justify assuming the risks of surgery, and (2) to estimate the proportion of patients currently on medication whose quality of life is below this value.
  
  
  METHODS
  We developed a Markov decision analysis model to simulate health outcomes (measured in quality adjusted life years [QALY]) over 10 years for medication and surgery in patients with typical GERD symptoms. We included probabilities of events obtained from a systematic literature review. Quality of life adjustments, expressed as utilities, were drawn from a survey of 131 patients 1 to 5 years after antireflux surgery. By using this model, we calculated what quality of life on medications would change the optimal strategy from medication to surgery (threshold). To determine the proportion of patients below this value, we prospectively surveyed 40 medically treated GERD patients at our hospital.
  
  
  RESULTS
  Surgery resulted in more QALYs than medical therapy when the utility with medication use was below 0.90. Sensitivity analysis showed this value to be relatively insensitive to reasonable variations in surgical risks (mortality, failures, reoperation) and quality of life after surgery. Among those surveyed on medications, 48% fell below this threshold and would be predicted to benefit from surgery.
  
  
  CONCLUSIONS
  Our model suggests that surgery would likely benefit a high proportion of medically treated GERD patients. Individual assessment of quality of life with GERD should be considered to aid clinical decision making.
authors.affiliation: Department of Surgery, VA Medical Center, White River Junction, VT, USA.
authors.forename: Jean Y
authors.initials: JY
authors.lastname: Liu
authors.forename: Samuel R G
authors.initials: SR
authors.lastname: Finlayson
authors.forename: William S
authors.initials: WS
authors.lastname: Laycock
authors.forename: Richard I
authors.initials: RI
authors.lastname: Rothstein
authors.forename: Thadeus L
authors.initials: TL
authors.lastname: Trus
authors.forename: Heiko
authors.initials: H
authors.lastname: Pohl
authors.forename: John D
authors.initials: JD
authors.lastname: Birkmeyer
mesh_terms: D003625:Data Collection; D003657:Decision Making; D005764:Gastroesophageal Reflux / Q000601:surgery* / Q000628:therapy*; D006801:Humans; D010535:Laparoscopy; D008390:Markov Chains; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D019057:Quality-Adjusted Life Years; D012017:Referral and Consultation