A comparison of the cost effectiveness of pharmacotherapy or surgery (laparoscopic fundoplication) in the treatment of GORD.
BACKGROUND
Gastro-oesophageal reflux disease (GORD) causes some of the most frequently seen symptoms in both primary and secondary care. An estimated 4-5 patients (age range 18-60 years) per 10,000 (0.045% of the general population) are receiving maintenance proton pump inhibitors (PPIs) for oesophagitis and reflux. The treatment of reflux disease represents significant prescription drug costs to the UK NHS. An alternative to lifelong pharmacotherapy is surgical treatment of reflux using the laparoscopic fundoplication technique to effect a cure. A multicentre study (REFLUX trial) comparing laparoscopic fundoplication with medical management (PPIs) among patients with GORD is currently underway in the UK. This study includes data collection to contribute to a cost-effectiveness analysis.


OBJECTIVE
To generate some preliminary estimates of the cost effectiveness of surgical and medical management of GORD to guide UK NHS decision making before the REFLUX trial reports.


METHODS
A Markov model was developed in Excel. Probabilistic sensitivity analysis was employed to assess the uncertainty associated with the point estimates. Two strategies were compared: long-term medical management or immediate laparoscopic surgery for GORD. Health outcomes were expressed in terms of QALYs with a lifetime time horizon (30 years) for a patient aged 45 years at commencement of treatment. Costs (pound, 2004 values) of drugs and costs associated with surgery were obtained from five of the REFLUX study centres. Costs and outcomes were discounted by 3.5% per anum. Value of information analysis was used to quantify the cost of uncertainty associated with the decision about which therapy to adopt, indicating the maximum value of future research.


RESULTS
Treatment with laparoscopic fundoplication is the most costly strategy but is also associated with more QALYs. The incremental cost per additional QALY for surgery versus medical management was 180 pounds. However, the cost effectiveness of surgery was uncertain, and the probability that it is cost effective at the threshold of 30,000 pounds per QALY was 0.639. Value of information analysis suggests that further research in this area could be potentially worthwhile. Specifically, this research should focus on the health-related quality of life of patients on medical management or post-surgery.


CONCLUSIONS
The results of the model suggest that, on the basis of current evidence, laparoscopic fundoplication represents a cost effective means of treating GORD rather than lifelong medical management.
Bojke
Laura
L
Centre for Health Economics, University of York, York, UK. lg116@york.ac.uk
Hornby
Edward
E
Sculpher
Mark
M
D000293:Adolescent; D000328:Adult; D003362:Cost-Benefit Analysis; D004358:Drug Therapy / Q000191:economics*; D018662:Fundoplication / Q000191:economics*; D005764:Gastroesophageal Reflux / Q000188:drug therapy* / Q000191:economics / Q000601:surgery*; D017048:Health Care Costs / Q000706:statistics & numerical data; D006801:Humans; D010535:Laparoscopy / Q000191:economics; D008390:Markov Chains; D008875:Middle Aged; D015233:Models, Statistical; D019057:Quality-Adjusted Life Years; D012984:Software; D006113:United Kingdom