Economic analysis of step-wise treatment of gastro-oesophageal reflux disease

Background: To expose patients with gastro-oesophageal reflux disease (GERD ) to the least amount of medication and to reduce health expenditures, it i s recommended that their treatment is started with a small dose of an antis ecretory or prokinetic medication, If patients fail to respond, the dose is increased in several consecutive steps or the initial regimen is changed t o a more potent medication until the patients become asymptomatic. Although such treatment strategy is widely recommended, its impact on health expend itures has not been evaluated. Methods: The economic analysis compares the medication costs of competing m edical treatment strategies, using two different sets of cost data. Medicat ion costs are estimated from the average wholesale prices (AWP) and from th e lowest discount prices charged to governmental health institutions. A dec ision tree is used to model the step-wise treatment of GERD, In a Monte Car lo simulation, all transition probabilities built into the model are varied over a wide range. A threshold analysis evaluates the relationship between the cost of an individual medication and its therapeutic success rate, Results: In a governmental health care system, a stepwise strategy saves on average $916 per patient every 5 years (range: $443-$1628) in comparison w ith a strategy utilizing only the most potent medication, In a cost environ ment relying on AWP, the average savings amount to $256 (-$206 to +$1561). The smaller the cost difference between two consecutive treatment steps, th e longer one needs to follow the patients to reap the benefit of the small cost difference. However, even a Small cost difference can turn into tangib le cost savings, if a large enough fraction of GERD patients responds to th e initial step of a less potent but also less expensive medication. Conclusions: The economic analysis suggests that a stepwise utilization of increasingly more potent and more expensive medications to treat GERD would result in appreciable cost savings.