Researchers from the USA examined the clinical, economic, and policy implications of alternative management strategies for gastroesophageal reflux disease (GERD).
Decision analysis was used to calculate the clinical and economic outcomes of competing management strategies.
The traditional strategy incorporated sequential therapeutic trials with more intensive therapy ('step-up' approach), followed by sequential invasive diagnostic testing of nonresponders.
The 'proton pump inhibitor test' strategy included an initial proton pump inhibitor test (7 days of omeprazole; 40 mg a.m., 20 mg p.m. daily). This was followed by less intensive therapeutic trials in those testing positive ('step-down' approach) with sequential invasive diagnostic testing as needed.
The average cost per patient was found to be $1045 for the traditional step-up management strategy, compared to $1172 for the proton pump inhibitor test and step-down strategy.
|Patients symptom-free at 1 year:|
Traditional management: 50%
Proton pump inhibitor test: 75%
| Alimentary Pharmacology & Therapeutics |
The percentage of patients who were symptom-free at 1 year was 50% for the traditional management strategy, compared to 75% for the proton pump inhibitor test strategy.
The proton pump inhibitor test strategy resulted in quality-adjusted life-year (QALY) gains of 0.01-0.05, depending on the utility estimate employed.
The team found that the incremental cost-effectiveness ratio for the proton pump inhibitor test strategy was $510 per additional symptomatic cure over 1 year, and between $2822-$10,160 per QALY gained.
The traditional management strategy resulted in a greater than 5-fold increase in the utilization of upper endoscopy. This was partially offset by a 47% reduction in the use of ambulatory 24-hour esophageal pH monitoring.
The authors note that the reduced effectiveness of the traditional management strategy may be attributed in part to a 118% increase in the use of high-dose H2Ras, while reducing the use of standard dose proton pump inhibitors by only 42% and high-dose proton pump inhibitors by 57%.
Joshua J. Ofman, of the Cedars-Sinai Health System, California, commented on behalf of his colleagues, "Based on the results of this analysis, strategies utilizing the initial PPI test followed by a step-down approach may result in improved symptom relief and quality of life over 1 year.
"They may also result in more appropriate utilization of invasive diagnostic testing at a small marginal increase in total costs."
"These findings warrant a prospective trial comparing these competing management strategies," he concluded.